Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden.
Neurocrit Care. 2024 Oct;41(2):511-522. doi: 10.1007/s12028-024-01954-y. Epub 2024 Mar 20.
Patients with traumatic brain injury (TBI) with large contusions make up a specific TBI subtype. Because of the risk of brain edema worsening, elevated cerebral perfusion pressure (CPP) may be particularly dangerous. The pressure reactivity index (PRx) and optimal cerebral perfusion pressure (CPPopt) are new promising perfusion targets based on cerebral autoregulation, but they reflect the global brain state and may be less valid in patients with predominant focal lesions. In this study, we aimed to investigate if patients with TBI with significant contusions exhibited a different association between PRx, CPP, and CPPopt in relation to functional outcome compared to those with small/no contusions.
This observational study included 385 patients with moderate to severe TBI treated at a neurointensive care unit in Uppsala, Sweden. The patients were classified into two groups: (1) significant contusions (> 10 mL) and (2) small/no contusions (but with extra-axial or diffuse injuries). The percentage of good monitoring time (%GMT) with intracranial pressure > 20 mm Hg; PRx > 0.30; CPP < 60 mm Hg, within 60-70 mm Hg, or > 70 mm Hg; and ΔCPPopt less than - 5 mm Hg, ± 5 mm Hg, or > 5 mm Hg was calculated. Outcome (Glasgow Outcome Scale-Extended) was assessed after 6 months.
Among the 120 (31%) patients with significant contusions, a lower %GMT with CPP between 60 and 70 mm Hg was independently associated with unfavorable outcome. The %GMTs with PRx and ΔCPPopt ± 5 mm Hg were not independently associated with outcome. Among the 265 (69%) patients with small/no contusions, a higher %GMT of PRx > 0.30 and a lower %GMT of ΔCPPopt ± 5 mm Hg were independently associated with unfavorable outcome.
In patients with TBI with significant contusions, CPP within 60-70 mm Hg may improve outcome. PRx and CPPopt, which reflect global cerebral pressure autoregulation, may be useful in patients with TBI without significant focal brain lesions but seem less valid for those with large contusions. However, this was an observational, hypothesis-generating study; our findings need to be validated in prospective studies before translating them into clinical practice.
伴有大挫伤的创伤性脑损伤（TBI）患者构成了特定的 TBI 亚型。由于脑水肿恶化的风险，升高的脑灌注压（CPP）可能特别危险。压力反应指数（PRx）和最佳脑灌注压（CPPopt）是基于脑自动调节的新的有前途的灌注目标，但它们反映了整体脑状态，在以局灶性病变为主的患者中可能不太有效。在这项研究中，我们旨在研究与小/无挫伤相比，伴有明显挫伤的 TBI 患者在功能预后方面，PRx、CPP 和 CPPopt 之间的相关性是否存在差异。
这是一项观察性研究，纳入了在瑞典乌普萨拉神经重症监护病房接受治疗的 385 名中重度 TBI 患者。患者分为两组：（1）有明显挫伤（＞10mL）；（2）小/无挫伤（但有外轴或弥漫性损伤）。计算颅内压＞20mmHg 的良好监测时间百分比（%GMT）；PRx＞0.30；CPP＜60mmHg、60-70mmHg 和＞70mmHg；以及 ΔCPPopt ＜-5mmHg、±5mmHg 和＞5mmHg 的比例。6 个月后评估预后（格拉斯哥预后评分扩展）。
在 120 名（31%）有明显挫伤的患者中，CPP 在 60-70mmHg 之间的%GMT 较低与不良预后独立相关。PRx 和 ΔCPPopt±5mmHg 的%GMT 与预后无关。在 265 名（69%）小/无挫伤的患者中，PRx＞0.30 的%GMT 较高和 ΔCPPopt±5mmHg 的%GMT 较低与不良预后独立相关。
对于伴有明显挫伤的 TBI 患者，CPP 在 60-70mmHg 之间可能改善预后。PRx 和 CPPopt 反映了整体脑压力自动调节，在没有明显局灶性脑病变的 TBI 患者中可能有用，但对伴有大挫伤的患者似乎不太有效。然而，这是一项观察性的、产生假说的研究；在将这些发现转化为临床实践之前，需要在前瞻性研究中验证。
