Autoregulation in the Neuro ICU

  • Anson Wang
  • Santiago Ortega-Gutierrez
  • Nils H. Petersen
Critical Care Neurology (KN Sheth, Section Editor)
  • 52 Downloads
Part of the following topical collections:
  1. Topical Collection on Critical Care Neurology

Abstract

Purpose of review

The purpose of this review is to briefly describe the concept of cerebral autoregulation, to detail several bedside techniques for measuring and assessing autoregulation, and to outline the impact of impaired autoregulation on clinical and functional outcomes in acute brain injury. Furthermore, we will review several autoregulation studies in select forms of acute brain injuries, discuss the potential for its use in patient management in the ICU, and suggest further avenues for research.

Recent findings

Cerebral autoregulation plays a critical role in regulating cerebral blood flow, and impaired autoregulation has been associated with worse functional and clinical outcomes in various acute brain injuries. There exists a multitude of methods to assess the autoregulatory state in patients using both invasive and non-invasive modalities. Continuous monitoring of patients in the ICU has yielded autoregulatory-derived optimal perfusion pressures that may prevent secondary injury and improve outcomes.

Summary

Measuring autoregulation continuously at the bedside is now a feasible option for clinicians working in the ICU, although there exists a great need to standardize autoregulatory measurement. While the clinical benefits await prospective and randomized trials, autoregulation-derived parameters show enormous potential for creating an optimal physiological environment for the injured brain.

Keywords

Cerebral autoregulation Bedside monitoring Critical care Traumatic brain injury, subarachnoid hemorrhage Ischemic stroke 

Notes

Compliance with Ethical Standards

Conflict of Interest

Anson Wang, Santiago Ortega-Gutierrez, and Nils H. Petersen each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Ursino M, Lodi CA. A simple mathematical model of the interaction between intracranial pressure and cerebral hemodynamics. J Appl Physiol. 1985), 1997;82(4):1256–69.CrossRefGoogle Scholar
  2. 2.
    Czosnyka M, et al. Contribution of mathematical modelling to the interpretation of bedside tests of cerebrovascular autoregulation. J Neurol Neurosurg Psychiatry. 1997;63(6):721–31.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Attwell D, et al. Glial and neuronal control of brain blood flow. Nature. 2010;468(7321):232–43.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Somers VK, et al. Contrasting effects of hypoxia and hypercapnia on ventilation and sympathetic activity in humans. J Appl Physiol (1985). 1989;67(5):2101–6.CrossRefPubMedGoogle Scholar
  5. 5.
    Petersen NH, et al. Dynamic cerebral autoregulation is transiently impaired for one week after large-vessel acute ischemic stroke. Cerebrovasc Dis. 2015;39(2):144–50.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Phillips AA, et al. Neurovascular coupling in humans: physiology, methodological advances and clinical implications. J Cereb Blood Flow Metab. 2016;36(4):647–64.CrossRefPubMedGoogle Scholar
  7. 7.
    Lassen NA. Cerebral blood flow and oxygen consumption in man. Physiol Rev. 1959;39(2):183–238.CrossRefPubMedGoogle Scholar
  8. 8.
    Richards HK, et al. Increase in transcranial Doppler pulsatility index does not indicate the lower limit of cerebral autoregulation. Acta Neurochir Suppl. 1998;71:229–32.PubMedGoogle Scholar
  9. 9.
    Hauerberg J, Juhler M. Cerebral blood flow autoregulation in acute intracranial hypertension. J Cereb Blood Flow Metab. 1994;14(3):519–25.CrossRefPubMedGoogle Scholar
  10. 10.
    Hauerberg J, et al. The upper limit of cerebral blood flow autoregulation in acute intracranial hypertension. J Neurosurg Anesthesiol. 1998;10(2):106–12.CrossRefPubMedGoogle Scholar
  11. 11.
    Tiecks FP, et al. Comparison of static and dynamic cerebral autoregulation measurements. Stroke. 1995;26(6):1014–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Aaslid R. Cerebral autoregulation and vasomotor reactivity. Front Neurol Neurosci. 2006;21:216–28.CrossRefPubMedGoogle Scholar
  13. 13.
    Aaslid R, et al. Cerebral autoregulation dynamics in humans. Stroke. 1989;20(1):45–52.CrossRefPubMedGoogle Scholar
  14. 14.
    Sorond FA, et al. The sit-to-stand technique for the measurement of dynamic cerebral autoregulation. Ultrasound Med Biol. 2009;35(1):21–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Brown CM, et al. Assessment of cerebrovascular and cardiovascular responses to lower body negative pressure as a test of cerebral autoregulation. J Neurol Sci. 2003;208(1–2):71–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Imholz BP, et al. Fifteen years experience with finger arterial pressure monitoring: assessment of the technology. Cardiovasc Res. 1998;38(3):605–16.CrossRefPubMedGoogle Scholar
  17. 17.
    Miller C, Armonda R, M. Participants in the International Multi-disciplinary Consensus Conference on Multimodality. Monitoring of cerebral blood flow and ischemia in the critically ill. Neurocrit Care. 2014;21(Suppl 2):S121–8.CrossRefPubMedGoogle Scholar
  18. 18.
    Jaeger M, et al. Continuous assessment of cerebrovascular autoregulation after traumatic brain injury using brain tissue oxygen pressure reactivity. Crit Care Med. 2006;34(6):1783–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Willie CK, et al. Utility of transcranial Doppler ultrasound for the integrative assessment of cerebrovascular function. J Neurosci Methods. 2011;196(2):221–37.CrossRefPubMedGoogle Scholar
  20. 20.
    Davies DJ, et al. Near-infrared spectroscopy in the monitoring of adult traumatic brain injury: a review. J Neurotrauma. 2015;32(13):933–41.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Panerai RB. Assessment of cerebral pressure autoregulation in humans—a review of measurement methods. Physiol Meas. 1998;19(3):305–38.CrossRefPubMedGoogle Scholar
  22. 22.
    van Beek AH, et al. Cerebral autoregulation: an overview of current concepts and methodology with special focus on the elderly. J Cereb Blood Flow Metab. 2008;28(6):1071–85.CrossRefPubMedGoogle Scholar
  23. 23.
    •• Czosnyka M, et al. Monitoring of cerebrovascular autoregulation: facts, myths, and missing links. Neurocrit Care. 2009;10(3):373–86. This review discusses the basic concepts of cerebral autoregulation monitoring.CrossRefPubMedGoogle Scholar
  24. 24.
    Czosnyka M, et al. Monitoring of cerebral autoregulation in head-injured patients. Stroke. 1996;27(10):1829–34.CrossRefPubMedGoogle Scholar
  25. 25.
    Budohoski KP, et al. Monitoring cerebral autoregulation after head injury. Which component of transcranial Doppler flow velocity is optimal? Neurocrit Care. 2012;17(2):211–8.CrossRefPubMedGoogle Scholar
  26. 26.
    •• Claassen JA, et al. Transfer function analysis of dynamic cerebral autoregulation: a white paper from the International Cerebral Autoregulation Research Network. J Cereb Blood Flow Metab. 2016;36(4):665–80. Guidelines from Cerebral Autoregulation Research Network to improve standardization of parameters and settings for application of transfer function analysis in studies of dynamic cerebral autoregulation.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Tan CO. Defining the characteristic relationship between arterial pressure and cerebral flow. J Appl Physiol. 1985), 2012;113(8):1194–200.CrossRefGoogle Scholar
  28. 28.
    Czosnyka M, et al. Continuous assessment of the cerebral vasomotor reactivity in head injury. Neurosurgery. 1997;41(1):11–7. discussion 17-9CrossRefPubMedGoogle Scholar
  29. 29.
    Liu X, et al. Comparison of frequency and time domain methods of assessment of cerebral autoregulation in traumatic brain injury. J Cereb Blood Flow Metab. 2015;35(2):248–56.CrossRefPubMedGoogle Scholar
  30. 30.
    Jaeger M, et al. Clinical significance of impaired cerebrovascular autoregulation after severe aneurysmal subarachnoid hemorrhage. Stroke. 2012;43(8):2097–101.CrossRefPubMedGoogle Scholar
  31. 31.
    Reinhard M, et al. Dynamic cerebral autoregulation associates with infarct size and outcome after ischemic stroke. Acta Neurol Scand. 2012;125(3):156–62.CrossRefPubMedGoogle Scholar
  32. 32.
    •• Steiner LA, et al. Continuous monitoring of cerebrovascular pressure reactivity allows determination of optimal cerebral perfusion pressure in patients with traumatic brain injury. Crit Care Med. 2002;30(4):733–8. This study first desribes the concept of optimal cerebral perfusion pressure using continuous autoregulation monitoring.CrossRefPubMedGoogle Scholar
  33. 33.
    Aries MJ, et al. Enhanced visualization of optimal cerebral perfusion pressure over time to support clinical decision making. Crit Care Med. 2016;44(10):e996–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Depreitere B, et al. Pressure autoregulation monitoring and cerebral perfusion pressure target recommendation in patients with severe traumatic brain injury based on minute-by-minute monitoring data. J Neurosurg. 2014;120(6):1451–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Donnelly J, Aries MJ, Czosnyka M. Further understanding of cerebral autoregulation at the bedside: possible implications for future therapy. Expert Rev Neurother. 2015;15(2):169–85.CrossRefPubMedGoogle Scholar
  36. 36.
    Donnelly J, et al. Regulation of the cerebral circulation: bedside assessment and clinical implications. Crit Care. 2016;20(1):129.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Czosnyka M, et al. Cerebral autoregulation following head injury. J Neurosurg. 2001;95(5):756–63.CrossRefPubMedGoogle Scholar
  38. 38.
    Aries MJ, et al. Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury. Crit Care Med. 2012;40(8):2456–63.CrossRefPubMedGoogle Scholar
  39. 39.
    Panerai RB, et al. Association between dynamic cerebral autoregulation and mortality in severe head injury. Br J Neurosurg. 2004;18(5):471–9.CrossRefPubMedGoogle Scholar
  40. 40.
    • Donnelly J, et al. Individualizing thresholds of cerebral perfusion pressure using estimated limits of autoregulation. Crit Care Med. 2017;45(9):1464–71. This paper describes an approach to calculating and monitoring limits of autoregulation in individual patients.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Lantigua H, et al. Subarachnoid hemorrhage: who dies, and why? Crit Care. 2015;19(1):309.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Hop JW, et al. Case-fatality rates and functional outcome after subarachnoid hemorrhage: a systematic review. Stroke. 1997;28(3):660–4.CrossRefPubMedGoogle Scholar
  43. 43.
    Springer MV, et al. Predictors of global cognitive impairment 1 year after subarachnoid hemorrhage. Neurosurgery. 2009;65(6):1043–51.CrossRefPubMedGoogle Scholar
  44. 44.
    Brown RJ, et al. The relationship between delayed infarcts and angiographic vasospasm after aneurysmal subarachnoid hemorrhage. Neurosurgery. 2013;72(5):702–8.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Macdonald RL, et al. Clazosentan to overcome neurological ischemia and infarction occurring after subarachnoid hemorrhage (CONSCIOUS-1): randomized, double-blind, placebo-controlled phase 2 dose-finding trial. Stroke. 2008;39(11):3015–21.CrossRefPubMedGoogle Scholar
  46. 46.
    Macdonald RL, et al. Clazosentan, an endothelin receptor antagonist, in patients with aneurysmal subarachnoid haemorrhage undergoing surgical clipping: a randomised, double-blind, placebo-controlled phase 3 trial (CONSCIOUS-2). Lancet Neurol. 2011;10(7):618–25.CrossRefPubMedGoogle Scholar
  47. 47.
    Budohoski KP, et al. Clinical relevance of cerebral autoregulation following subarachnoid haemorrhage. Nat Rev Neurol. 2013;9(3):152–63.CrossRefPubMedGoogle Scholar
  48. 48.
    Rasmussen G, et al. Cerebral blood flow autoregulation in experimental subarachnoid haemorrhage in rat. Acta Neurochir. 1992;119(1):128–33.CrossRefPubMedGoogle Scholar
  49. 49.
    Pickard, J.D., et al., Aspects of cerebrovascular autoregulation following subarachnoid haemorrhage, in stimulated cerebral blood flow: experimental findings and clinical significance, P. Schmiedek, K. Einhäupl, and C.-M. Kirsch, Editors. 1992, Springer Berlin Heidelberg: Berlin p 220-225.Google Scholar
  50. 50.
    Voldby B, Enevoldsen EM, Jensen FT. Cerebrovascular reactivity in patients with ruptured intracranial aneurysms. J Neurosurg. 1985;62(1):59–67.CrossRefPubMedGoogle Scholar
  51. 51.
    Lang EW, Diehl RR, Mehdorn HM. Cerebral autoregulation testing after aneurysmal subarachnoid hemorrhage: the phase relationship between arterial blood pressure and cerebral blood flow velocity. Crit Care Med. 2001;29(1):158–63.CrossRefPubMedGoogle Scholar
  52. 52.
    Jaeger M, et al. Continuous monitoring of cerebrovascular autoregulation after subarachnoid hemorrhage by brain tissue oxygen pressure reactivity and its relation to delayed cerebral infarction. Stroke. 2007;38(3):981–6.CrossRefPubMedGoogle Scholar
  53. 53.
    Budohoski KP, et al. Impairment of cerebral autoregulation predicts delayed cerebral ischemia after subarachnoid hemorrhage: a prospective observational study. Stroke. 2012;43(12):3230–7.CrossRefPubMedGoogle Scholar
  54. 54.
    Soehle M, et al. Continuous assessment of cerebral autoregulation in subarachnoid hemorrhage. Anesth Analg. 2004;98(4):1133–9.  table of contentsCrossRefPubMedGoogle Scholar
  55. 55.
    Lam JM, et al. Predicting delayed ischemic deficits after aneurysmal subarachnoid hemorrhage using a transient hyperemic response test of cerebral autoregulation. Neurosurgery. 2000;47(4):819–25. discussions 825–6CrossRefPubMedGoogle Scholar
  56. 56.
    Harper AM, Glass HI. Effect of alterations in the arterial carbon dioxide tension on the blood flow through the cerebral cortex at normal and low arterial blood pressures. J Neurol Neurosurg Psychiatry. 1965;28(5):449–52.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Harper AM, et al. The effect of experimental spasm on the CO2 response of cerebral bloodflow in primates. Neuroradiology. 1972;3(3):134–6.CrossRefPubMedGoogle Scholar
  58. 58.
    Otite F, et al. Impaired cerebral autoregulation is associated with vasospasm and delayed cerebral ischemia in subarachnoid hemorrhage. Stroke. 2014;45(3):677–82.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    •• Santos GA, et al. Pathophysiologic differences in cerebral autoregulation after subarachnoid hemorrhage. Neurology. 2016;86(21):1950–6. This study showed a new approach to characterizing autoregulatory function and its use to accurately predict neurologic complications after subarachnoid hemorrhage on an individual patient level.CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Dabus G, Nogueira RG. Current options for the management of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm: a comprehensive review of the literature. Interventional Neurology. 2013;2(1):30–51.CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Grise EM, Adeoye O. Blood pressure control for acute ischemic and hemorrhagic stroke. Curr Opin Crit Care. 2012;18(2):132–8.CrossRefPubMedGoogle Scholar
  62. 62.
    Diringer MN, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocrit Care. 2011;15(2):211.CrossRefPubMedGoogle Scholar
  63. 63.
    Soehle M, Jaeger M, Meixensberger J. Online assessment of brain tissue oxygen autoregulation in traumatic brain injury and subarachnoid hemorrhage. Neurol Res. 2003;25(4):411–7.CrossRefPubMedGoogle Scholar
  64. 64.
    Bijlenga P, et al. “Optimal cerebral perfusion pressure” in poor grade patients after subarachnoid hemorrhage. Neurocrit Care. 2010;13(1):17–23.CrossRefPubMedGoogle Scholar
  65. 65.
    Zweifel C, et al. Continuous assessment of cerebral autoregulation with near-infrared spectroscopy in adults after subarachnoid hemorrhage. Stroke. 2010;41(9):1963–8.CrossRefPubMedGoogle Scholar
  66. 66.
    Astrup J, Siesjo BK, Symon L. Thresholds in cerebral ischemia—the ischemic penumbra. Stroke. 1981;12(6):723–5.CrossRefPubMedGoogle Scholar
  67. 67.
    Dohmen C, et al. Identification and clinical impact of impaired cerebrovascular autoregulation in patients with malignant middle cerebral artery infarction. Stroke. 2007;38(1):56–61.CrossRefPubMedGoogle Scholar
  68. 68.
    Aries MJ, et al. Cerebral autoregulation in stroke: a review of transcranial Doppler studies. Stroke. 2010;41(11):2697–704.CrossRefPubMedGoogle Scholar
  69. 69.
    Qureshi AI, et al. Prevalence of elevated blood pressure in 563,704 adult patients with stroke presenting to the ED in the United States. Am J Emerg Med. 2007;25(1):32–8.CrossRefPubMedPubMedCentralGoogle Scholar
  70. 70.
    Vemmos KN, et al. U-shaped relationship between mortality and admission blood pressure in patients with acute stroke. J Intern Med. 2004;255(2):257–65.CrossRefPubMedGoogle Scholar
  71. 71.
    Jauch, E.C., et al., Guidelines for the early management of patients with acute ischemic stroke. A guideline for healthcare professionals from the American Heart Association/American Stroke Association; 2013.Google Scholar
  72. 72.
    Brady K, et al. Real-time continuous monitoring of cerebral blood flow autoregulation using near-infrared spectroscopy in patients undergoing cardiopulmonary bypass. Stroke. 2010;41(9):1951–6.CrossRefPubMedPubMedCentralGoogle Scholar
  73. 73.
    Steiner LA, et al. Near-infrared spectroscopy can monitor dynamic cerebral autoregulation in adults. Neurocrit Care. 2009;10(1):122–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Anson Wang
    • 1
  • Santiago Ortega-Gutierrez
    • 2
  • Nils H. Petersen
    • 1
  1. 1.Department of NeurologyYale School of MedicineNew HavenUSA
  2. 2.Department of Neurology, Neurosurgery and RadiologyUniversity of IowaIowa CityUSA

Personalised recommendations