Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany.
Neurocrit Care. 2024 Jun;40(3):879-885. doi: 10.1007/s12028-023-01822-1. Epub 2023 Sep 19.
Cerebral autoregulation is impaired early on after aneurysmal subarachnoid hemorrhage (aSAH). The study objective was to explore the pressure reactivity index (PRx) and cerebral perfusion pressure (CPP) in the earliest phase after aneurysm rupture and to address the question of whether an optimal CPP (CPPopt)-targeted management is associated with less severe early brain injury (EBI).
Patients with aSAH admitted between 2012 and 2020 were retrospectively included in this observational cohort study. The PRx was calculated as a correlation coefficient between intracranial pressure and mean arterial pressure. By plotting the PRx versus CPP, CPP correlating the lowest PRx value was identified as CPPopt. EBI was assessed by applying the Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) on day 3 after ictus. An SEBES ≥ 3 was considered severe EBI.
In 90 of 324 consecutive patients with aSAH, intracranial pressure monitoring was performed ≥ 7 days, allowing for PRx calculation and CPPopt determination. Severe EBI was associated with larger mean deviation of CPP from CPPopt 72 h after ictus (r = 0.22, p = 0.03). Progressive edema requiring decompressive hemicraniectomy was associated with larger deviation of CPP from CPPopt on day 2 (r = 0.23, p = 0.02). The higher the difference of CPP from CPPopt on day 3 the higher the mortality rate (r = 0.31, p = 0.04).
Patients with CPP near to the calculated CPPopt in the early phase after aSAH experienced less severe EBI, less frequently received decompressive hemicraniectomy, and exhibited a lower mortality rate. A prospective evaluation of CPPopt-guided management starting in the first days after ictus is needed to confirm the clinical validity of this concept.
在蛛网膜下腔出血（aSAH）后早期，脑自动调节受损。本研究的目的是探讨动脉瘤破裂后最早阶段的压力反应指数（PRx）和脑灌注压（CPP），并探讨 CPP 目标管理是否与较轻的早期脑损伤（EBI）相关。
本回顾性观察队列研究纳入了 2012 年至 2020 年间收治的 aSAH 患者。PRx 作为颅内压与平均动脉压之间的相关系数进行计算。通过绘制 PRx 与 CPP 的关系图，确定 CPP 最低 PRx 值对应的 CPPopt。EBI 通过发病后第 3 天应用蛛网膜下腔出血早期脑水肿评分（SEBES）进行评估。SEBES≥3 被认为是严重的 EBI。
在 324 例连续的 aSAH 患者中，有 90 例进行了颅内压监测≥7 天，可进行 PRx 计算和 CPPopt 确定。严重的 EBI 与发病后 72 小时 CPP 偏离 CPPopt 的平均差值较大（r=0.22，p=0.03）。需要进行减压性半脑切除术的进行性水肿与第 2 天 CPP 偏离 CPPopt 的差值较大（r=0.23，p=0.02）。第 3 天 CPP 与 CPPopt 的差值越大，死亡率越高（r=0.31，p=0.04）。
在 aSAH 后早期 CPP 接近计算的 CPPopt 的患者中，EBI 程度较轻，较少接受减压性半脑切除术，死亡率较低。需要前瞻性评估在发病后早期开始的 CPPopt 指导管理，以确认该概念的临床有效性。
