Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Neurocrit Care. 2022 Jun;36(3):1053-1070. doi: 10.1007/s12028-022-01484-5. Epub 2022 Apr 5.
Cerebral autoregulation (CA) prevents brain injury by maintaining a relatively constant cerebral blood flow despite fluctuations in cerebral perfusion pressure. This process is disrupted consequent to various neurologic pathologic processes, which may result in worsening neurologic outcomes. Herein, we aim to highlight evidence describing CA changes and the impact of CA monitoring in patients with cerebrovascular disease, including ischemic stroke, intracerebral hemorrhage (ICH), and aneurysmal subarachnoid hemorrhage (aSAH). The study was preformed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. English language publications were identified through a systematic literature conducted in Ovid Medline, PubMed, and Embase databases. The search spanned the dates of each database's inception through January 2021. We selected case-control studies, cohort observational studies, and randomized clinical trials for adult patients (≥ 18 years) who were monitored with continuous metrics using transcranial Doppler, near-infrared spectroscopy, and intracranial pressure monitors. Of 2799 records screened, 48 studies met the inclusion criteria. There were 23 studies on ischemic stroke, 18 studies on aSAH, 5 studies on ICH, and 2 studies on systemic hypertension. CA impairment was reported after ischemic stroke but generally improved after tissue plasminogen activator administration and successful mechanical thrombectomy. Persistent impairment in CA was associated with hemorrhagic transformation, malignant cerebral edema, and need for hemicraniectomy. Studies that investigated large ICHs described bilateral CA impairment up to 12 days from the ictus, especially in the presence of small vessel disease. In aSAH, impairment of CA was associated with angiographic vasospasm, delayed cerebral ischemia, and poor functional outcomes at 6 months. This systematic review highlights the available evidence for CA disruption during cerebrovascular diseases and its possible association with long-term neurological outcome. CA may be disrupted even before acute stroke in patients with untreated chronic hypertension. Monitoring CA may help in establishing individualized management targets in patients with cerebrovascular disease.
脑自动调节（CA）通过维持相对稳定的脑血流来防止脑损伤，尽管脑灌注压会波动。这个过程因各种神经病理过程而中断，这可能导致神经功能恶化。在此，我们旨在强调描述 CA 变化的证据，以及 CA 监测在脑血管疾病患者中的影响，包括缺血性脑卒中、颅内出血（ICH）和颅内动脉瘤性蛛网膜下腔出血（aSAH）。该研究根据系统评价和荟萃分析的首选报告项目进行。通过在 Ovid Medline、PubMed 和 Embase 数据库中进行系统文献检索，确定了英语文献。搜索范围为每个数据库创建日期至 2021 年 1 月。我们选择了病例对照研究、队列观察性研究和随机临床试验，纳入了使用经颅多普勒、近红外光谱和颅内压监测仪进行连续监测的成年患者（≥18 岁）。在筛选出的 2799 条记录中，有 48 项研究符合纳入标准。其中 23 项研究为缺血性脑卒中，18 项研究为 aSAH，5 项研究为 ICH，2 项研究为高血压。缺血性脑卒中后报道了 CA 损伤，但在组织型纤溶酶原激活剂给药和机械血栓切除术成功后通常会改善。CA 持续受损与出血性转化、恶性脑水肿和需要行去骨瓣减压术有关。研究大型 ICH 的文献描述了发病后 12 天内双侧 CA 受损，尤其是在小血管疾病存在的情况下。在 aSAH 中，CA 损伤与血管造影性血管痉挛、迟发性脑缺血和 6 个月时的不良功能结局有关。本系统评价强调了脑血管疾病期间 CA 中断的现有证据及其与长期神经功能结局的可能关联。未经治疗的慢性高血压患者甚至在急性脑卒中前 CA 可能已经中断。CA 监测可能有助于为脑血管疾病患者制定个体化的管理目标。
