Evaluating the Status of the Injured Brain: Cerebrovascular Reserve (CVR) Is Not Equivalent to Induced Cerebrovascular Reactivity (iCVRx) and Induced Pressure Reactivity (iPRx) in Defining the Critical Cerebral Perfusion Pressure (CPP).

4区 医学 Q2 Biochemistry, Genetics and Molecular Biology Advances in experimental medicine and biology Pub Date : 2024-01-01 DOI:10.1007/978-3-031-67458-7_15
Edwin M Nemoto, Denis E Bragin, Howard Yonas
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Abstract

Methods evaluating the status of the injured brain have evolved over the past 63 years since Lundberg first reported clinical measurement of intracranial pressure (ICP) to evaluate the status of the injured brain (Lundberg, Acta Psychiatr Scand Suppl. 36:1-193, 1960). Subsequent evaluation involved measurement of the autoregulatory capacity of the brain by measuring cerebral blood flow (CBF) with decreasing mean arterial pressure (MAP) to define the critical CPP where the vasodilatory capacity of the cerebral circulation is exceeded and CBF begins to fall (CPP of 50 mmHg). A seminal advance was made by Marmarou (Marmarou et al., J Neurosurg. 48:332-344, 1978) who measured brain compliance by injecting a bolus of saline into the intracranial catheter while measuring the rise in intracranial pressure (ICP) otherwise known as induced pressure reactivity (iPRx). Seeking to utilise continuous measurement of iPRx in traumatic brain injury (TBI) patients with continuous monitoring of ICP, the ICP response to arterial pulsations was developed to evaluate the optimal CPP patients with raised ICP by the arterial pulsations-based iPRx. A similar approach was made with Doppler measurement of CBF with arterial pulsations for iCVRx to guide optimal CPP (CPPopt). Both iPRx and iCVRx are associated with microvascular shunts (MVS) and can accurately measure the critical CPP, whereas the CBF autoregulation curve by decreasing MAP does not. Sophisticated continuous multimodal monitoring established with ICM+ algorithms successfully identifies CPPopt for ICP control and identifies CBF dysregulation as related to outcome, but does not provide insights into the mechanisms involved in the loss of CBF autoregulation as related to increased ICP and potentially effective treatments (Froese et al., Neurocrit Care. 34:325-335, 2021).

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评估受伤大脑的状态:在确定临界脑灌注压 (CPP) 时,脑血管储备 (CVR) 与诱导脑血管反应性 (iCVRx) 和诱导压力反应性 (iPRx) 并不等同。
自伦德伯格首次报告临床测量颅内压 (ICP) 以评估受伤大脑的状态以来,评估受伤大脑状态的方法已经发展了 63 年(伦德伯格,《Acta Psychiatr Scand Suppl》,36:1-193,1960 年)。随后的评估涉及通过测量脑血流量(CBF)来测量大脑的自动调节能力,并随着平均动脉压(MAP)的降低而降低,从而确定临界 CPP,在此临界点,大脑循环的血管舒张能力被超过,CBF 开始下降(CPP 为 50 mmHg)。1978 年,Marmarou(Marmarou 等人,《神经外科杂志》,48:332-344)通过向颅内导管注入生理盐水来测量脑顺应性,同时测量颅内压 (ICP) 的升高,即诱导压力反应性 (IPRx)。为了对创伤性脑损伤(TBI)患者的 ICP 进行连续监测,我们开发了 ICP 对动脉搏动的反应,通过基于动脉搏动的 iPRx 来评估 ICP 升高患者的最佳 CPP。iCVRx 也采用了类似的方法,通过多普勒测量 CBF 和动脉搏动来指导最佳 CPP (CPPopt)。iPRx 和 iCVRx 都与微血管分流(MVS)有关,能准确测量临界 CPP,而通过降低 MAP 的 CBF 自动调节曲线则不能。利用 ICM+ 算法建立的先进连续多模态监测能成功识别 ICP 控制的临界 CPPopt,并识别与预后相关的 CBF 失调,但无法深入了解与 ICP 增高相关的 CBF 自动调节功能丧失的机制以及潜在的有效治疗方法(Froese 等,Neurocrit Care.34:325-335,2021 年)。
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来源期刊
Advances in experimental medicine and biology
Advances in experimental medicine and biology 医学-医学:研究与实验
CiteScore
5.90
自引率
0.00%
发文量
465
审稿时长
2-4 weeks
期刊介绍: Advances in Experimental Medicine and Biology provides a platform for scientific contributions in the main disciplines of the biomedicine and the life sciences. This series publishes thematic volumes on contemporary research in the areas of microbiology, immunology, neurosciences, biochemistry, biomedical engineering, genetics, physiology, and cancer research. Covering emerging topics and techniques in basic and clinical science, it brings together clinicians and researchers from various fields.
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