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MINERVA ANESTESIOLOGICA

Rivista di Anestesia, Rianimazione, Terapia Antalgica e Terapia Intensiva


Official Journal of the Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care
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Minerva Anestesiologica 2017 May 12

DOI: 10.23736/S0375-9393.17.12043-2

Copyright © 2017 EDIZIONI MINERVA MEDICA

lingua: Inglese

Cerebral autoregulation monitoring in acute traumatic brain injury: what's the evidence?

Leanne A. CALVIELLO 1 , Joseph DONNELLY 1, Frederick A. ZEILER 2, 3, 4, Eric P. THELIN 1, 5, Peter SMIELEWSKI 1, Marek CZOSNYKA 1

1 Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom; 2 Division of Anesthetics, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom; 3 Section of Neurosurgery, Dept. of Surgery, University of Manitoba, Winnipeg, Canada; 4 Clinician Investigator Program, University of Manitoba, Winnipeg, Canada, 5 Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden


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Cerebral autoregulation is conceptualized as a vascular self-regulatory mechanism within the brain. Controlled by elusive relationships between various biophysical processes, it functions to protect the brain against potential damages caused by sudden changes in cerebral perfusion pressures and flow. Following events such as traumatic brain injuries (TBI), autoregulation may be compromised, potentially leading to an unfavorable outcome. In spite of its complexity, autoregulation has been able to be quantified non-invasively within the neuro-critical care setting with the aid of transcranial Doppler. This information is interpreted particularly through calculated derived indices based on commonly-monitored input signals such as arterial blood pressure and intracranial pressure (i.e. Pressure reactivity index (PRx), mean flow index (Mx), etc.). For example, PRx values that trend towards positive numbers are correlated with unfavorable outcome. These predictors are primarily surrogate markers of cerebral hemodynamic activity, although suggesting robust correlations between these indices and patient outcome. This review of the literature seeks to explain the methodology behind the calculations of various measures of autoregulation in adult patients suffering from traumatic brain injuries, and how they can interact with one another to both create larger effects on patient outcome and general outcome prediction models. Insight into the driving forces behind cerebral autoregulation is imperative for guiding both clinical decision-making and global treatment protocols for neuro-critically ill patients. The evidence that autoregulation-oriented therapy may improve outcome after TBI is still oscillating around Level III.


KEY WORDS: Cerebral autoregulation - Traumatic brain injury - Pressure reactivity index - Intracranial pressure - Cerebral perfusion pressure - Transcranial doppler - Near-infrared spectroscopy

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leannecalviello@gmail.com