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J Neurotrauma. 2018 Dec 1;35(23):2812-2819. doi: 10.1089/neu.2017.5604. Epub 2018 Aug 10.

Validation of Intracranial Pressure-Derived Cerebrovascular Reactivity Indices against the Lower Limit of Autoregulation, Part II: Experimental Model of Arterial Hypotension.

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2 Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom .
3 Section of Surgery, Rady Faculty of Health Sciences, University of Manitoba , Winnipeg, Manitoba, Canada .
4 Clinician Investigator Program, Rady Faculty of Health Science, University of Manitoba , Winnipeg, Manitoba, Canada .
1 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland.
5 Section of Brain Physics, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom .
6 Institute of Electronic Systems, Warsaw University of Technology , Warsaw, Poland .
7 Pediatric Cardiology, Texas Children's Hospital , Baylor College of Medicine, Houston, Texas.


The aim of this work was to explore the relationship between intracranial pressure (ICP)-derived indices of cerebrovascular reactivity and the lower limit of autoregulation (LLA) during arterial hypotension. We retrospectively reviewed recorded physiological data from piglets that underwent controlled hypotension. Hypotension was induced by inflation of a balloon catheter in the inferior vena cava. ICP, cortical laser Doppler flowmetry (LDF), and arterial blood pressure (ABP) monitoring was conducted. ICP-derived indices were calculated: pressure reactivity index (PRx; correlation between ICP and mean arterial pressure [MAP]); pulse amplitude index (PAx; correlation between pulse amplitude of ICP [AMP] and MAP); and RAC (correlation between AMP and cerebral perfusion pressure [CPP]). LLA was estimated by piece-wise linear regression of CPP versus LDF. We produced error bar plots for PRx, PAx, and RAC against 5-mm Hg bins of CPP, displaying the relationship with the LLA. We compared CPP values at clinically relevant thresholds of PRx, PAx, and RAC to CPP measured at the LLA. Receiver operating curve (ROC) analysis was performed for each index across the LLA using 5-mm Hg bins for CPP. Mean LLA was 36.2 ± 10.5 mm Hg. Error bar plots demonstrated that PRx, PAx, and RAC increased, with CPP decreasing below the LLA. CPP at clinically relevant thresholds for PRx, PAx, and RAC displayed weak associations with the LLA, indicating that thresholds defined in TBI may not apply to a model of arterial hypotension. ROC analysis indicated that PRx, PAx, and RAC predicted the LLA, with AUCs of: 0.806 (95% confidence interval [CI], 0.750-0.863; p < 0.0001), 0.726 (95% CI, 0.664-0.789; p < 0.0001), and 0.710 (95% CI, 0.646-0.775; p < 0.0001), respectively. Three ICP-derived continuous indices of cerebrovascular reactivity, PRx, PAx, and RAC, were validated against the LLA within this experimental model of arterial hypotension, with PRx being superior.


ICP indices; arterial hypotension; autoregulation; validation

[Available on 2019-12-01]

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