Multimodality monitoring for cerebral perfusion pressure optimization in comatose patients with intracerebral hemorrhage

Sang-Bae Ko, H. Alex Choi, Gunjan Parikh, Raimund Helbok, J. Michael Schmidt, Kiwon Lee, Neeraj Badjatia, Jan Claassen, E. Sander Connolly, Stephan A. Mayer

Research output: Contribution to journalArticle

41 Citations (Scopus)

Abstract

BACKGROUND AND PURPOSE-: Limited data exist to recommend specific cerebral perfusion pressure (CPP) targets in patients with intracerebral hemorrhage. We sought to determine the feasibility of brain multimodality monitoring for optimizing CPP and potentially reducing secondary brain injury after intracerebral hemorrhage. METHODS-: We retrospectively analyzed brain multimodality monitoring data targeted at perihematomal brain tissue in 18 comatose intracerebral hemorrhage patients (median monitoring, 164 hours). Physiological measures were averaged over 1-hour intervals corresponding to each microdialysis sample. Metabolic crisis was defined as a lactate/pyruvate ratio >40 with a brain glucose concentration <0.7 mmol/L. Brain tissue hypoxia (BTH) was defined as PbtO2 <15 mm Hg. Pressure reactivity index and oxygen reactivity index were calculated. RESULTS-: Median age was 59 years, median Glasgow Coma Scale score was 6, and median intracerebral hemorrhage volume was 37.5 mL. The risk of BTH, and to a lesser extent metabolic crisis, increased with lower CPP values. Multivariable analyses showed that CPP <80 mm Hg was associated with a greater risk of BTH (odds ratio, 1.5; 95% confidence interval, 1.1-2.1; P=0.01) compared to CPP >100 mm Hg as a reference range. Six patients died (33%). Survivors had significantly higher CPP and PbtO2 and lower ICP values starting on postbleed day 4, whereas lactate/pyruvate ratio and pressure reactivity index values were persistently lower, indicating preservation of aerobic metabolism and pressure autoregulation. CONCLUSIONS-: PbtO2 monitoring can be used to identify CPP targets for optimal brain tissue oxygenation. In patients who do not undergo multimodality monitoring, maintaining CPP >80 mm Hg may reduce the risk of BTH.

Original languageEnglish
Pages (from-to)3087-3092
Number of pages6
JournalStroke
Volume42
Issue number11
DOIs
StatePublished - 1 Nov 2011

Fingerprint

Cerebrovascular Circulation
Cerebral Hemorrhage
Coma
Brain
Pyruvic Acid
Lactic Acid
Pressure
Microdialysis
Physiologic Monitoring
Brain Injuries
Survivors
Reference Values
Homeostasis
Glucose

Keywords

  • brain tissue oxygen
  • cerebral perfusion pressure
  • intracerebral hemorrhage
  • intracranial pressure
  • lactate/pyruvate ratio
  • metabolic crisis
  • pressure reactivity index

Cite this

Ko, Sang-Bae ; Choi, H. Alex ; Parikh, Gunjan ; Helbok, Raimund ; Schmidt, J. Michael ; Lee, Kiwon ; Badjatia, Neeraj ; Claassen, Jan ; Connolly, E. Sander ; Mayer, Stephan A. / Multimodality monitoring for cerebral perfusion pressure optimization in comatose patients with intracerebral hemorrhage. In: Stroke. 2011 ; Vol. 42, No. 11. pp. 3087-3092.
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abstract = "BACKGROUND AND PURPOSE-: Limited data exist to recommend specific cerebral perfusion pressure (CPP) targets in patients with intracerebral hemorrhage. We sought to determine the feasibility of brain multimodality monitoring for optimizing CPP and potentially reducing secondary brain injury after intracerebral hemorrhage. METHODS-: We retrospectively analyzed brain multimodality monitoring data targeted at perihematomal brain tissue in 18 comatose intracerebral hemorrhage patients (median monitoring, 164 hours). Physiological measures were averaged over 1-hour intervals corresponding to each microdialysis sample. Metabolic crisis was defined as a lactate/pyruvate ratio >40 with a brain glucose concentration <0.7 mmol/L. Brain tissue hypoxia (BTH) was defined as PbtO2 <15 mm Hg. Pressure reactivity index and oxygen reactivity index were calculated. RESULTS-: Median age was 59 years, median Glasgow Coma Scale score was 6, and median intracerebral hemorrhage volume was 37.5 mL. The risk of BTH, and to a lesser extent metabolic crisis, increased with lower CPP values. Multivariable analyses showed that CPP <80 mm Hg was associated with a greater risk of BTH (odds ratio, 1.5; 95{\%} confidence interval, 1.1-2.1; P=0.01) compared to CPP >100 mm Hg as a reference range. Six patients died (33{\%}). Survivors had significantly higher CPP and PbtO2 and lower ICP values starting on postbleed day 4, whereas lactate/pyruvate ratio and pressure reactivity index values were persistently lower, indicating preservation of aerobic metabolism and pressure autoregulation. CONCLUSIONS-: PbtO2 monitoring can be used to identify CPP targets for optimal brain tissue oxygenation. In patients who do not undergo multimodality monitoring, maintaining CPP >80 mm Hg may reduce the risk of BTH.",
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author = "Sang-Bae Ko and Choi, {H. Alex} and Gunjan Parikh and Raimund Helbok and Schmidt, {J. Michael} and Kiwon Lee and Neeraj Badjatia and Jan Claassen and Connolly, {E. Sander} and Mayer, {Stephan A.}",
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Ko, S-B, Choi, HA, Parikh, G, Helbok, R, Schmidt, JM, Lee, K, Badjatia, N, Claassen, J, Connolly, ES & Mayer, SA 2011, 'Multimodality monitoring for cerebral perfusion pressure optimization in comatose patients with intracerebral hemorrhage', Stroke, vol. 42, no. 11, pp. 3087-3092. https://doi.org/10.1161/STROKEAHA.111.623165

Multimodality monitoring for cerebral perfusion pressure optimization in comatose patients with intracerebral hemorrhage. / Ko, Sang-Bae; Choi, H. Alex; Parikh, Gunjan; Helbok, Raimund; Schmidt, J. Michael; Lee, Kiwon; Badjatia, Neeraj; Claassen, Jan; Connolly, E. Sander; Mayer, Stephan A.

In: Stroke, Vol. 42, No. 11, 01.11.2011, p. 3087-3092.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Multimodality monitoring for cerebral perfusion pressure optimization in comatose patients with intracerebral hemorrhage

AU - Ko, Sang-Bae

AU - Choi, H. Alex

AU - Parikh, Gunjan

AU - Helbok, Raimund

AU - Schmidt, J. Michael

AU - Lee, Kiwon

AU - Badjatia, Neeraj

AU - Claassen, Jan

AU - Connolly, E. Sander

AU - Mayer, Stephan A.

PY - 2011/11/1

Y1 - 2011/11/1

N2 - BACKGROUND AND PURPOSE-: Limited data exist to recommend specific cerebral perfusion pressure (CPP) targets in patients with intracerebral hemorrhage. We sought to determine the feasibility of brain multimodality monitoring for optimizing CPP and potentially reducing secondary brain injury after intracerebral hemorrhage. METHODS-: We retrospectively analyzed brain multimodality monitoring data targeted at perihematomal brain tissue in 18 comatose intracerebral hemorrhage patients (median monitoring, 164 hours). Physiological measures were averaged over 1-hour intervals corresponding to each microdialysis sample. Metabolic crisis was defined as a lactate/pyruvate ratio >40 with a brain glucose concentration <0.7 mmol/L. Brain tissue hypoxia (BTH) was defined as PbtO2 <15 mm Hg. Pressure reactivity index and oxygen reactivity index were calculated. RESULTS-: Median age was 59 years, median Glasgow Coma Scale score was 6, and median intracerebral hemorrhage volume was 37.5 mL. The risk of BTH, and to a lesser extent metabolic crisis, increased with lower CPP values. Multivariable analyses showed that CPP <80 mm Hg was associated with a greater risk of BTH (odds ratio, 1.5; 95% confidence interval, 1.1-2.1; P=0.01) compared to CPP >100 mm Hg as a reference range. Six patients died (33%). Survivors had significantly higher CPP and PbtO2 and lower ICP values starting on postbleed day 4, whereas lactate/pyruvate ratio and pressure reactivity index values were persistently lower, indicating preservation of aerobic metabolism and pressure autoregulation. CONCLUSIONS-: PbtO2 monitoring can be used to identify CPP targets for optimal brain tissue oxygenation. In patients who do not undergo multimodality monitoring, maintaining CPP >80 mm Hg may reduce the risk of BTH.

AB - BACKGROUND AND PURPOSE-: Limited data exist to recommend specific cerebral perfusion pressure (CPP) targets in patients with intracerebral hemorrhage. We sought to determine the feasibility of brain multimodality monitoring for optimizing CPP and potentially reducing secondary brain injury after intracerebral hemorrhage. METHODS-: We retrospectively analyzed brain multimodality monitoring data targeted at perihematomal brain tissue in 18 comatose intracerebral hemorrhage patients (median monitoring, 164 hours). Physiological measures were averaged over 1-hour intervals corresponding to each microdialysis sample. Metabolic crisis was defined as a lactate/pyruvate ratio >40 with a brain glucose concentration <0.7 mmol/L. Brain tissue hypoxia (BTH) was defined as PbtO2 <15 mm Hg. Pressure reactivity index and oxygen reactivity index were calculated. RESULTS-: Median age was 59 years, median Glasgow Coma Scale score was 6, and median intracerebral hemorrhage volume was 37.5 mL. The risk of BTH, and to a lesser extent metabolic crisis, increased with lower CPP values. Multivariable analyses showed that CPP <80 mm Hg was associated with a greater risk of BTH (odds ratio, 1.5; 95% confidence interval, 1.1-2.1; P=0.01) compared to CPP >100 mm Hg as a reference range. Six patients died (33%). Survivors had significantly higher CPP and PbtO2 and lower ICP values starting on postbleed day 4, whereas lactate/pyruvate ratio and pressure reactivity index values were persistently lower, indicating preservation of aerobic metabolism and pressure autoregulation. CONCLUSIONS-: PbtO2 monitoring can be used to identify CPP targets for optimal brain tissue oxygenation. In patients who do not undergo multimodality monitoring, maintaining CPP >80 mm Hg may reduce the risk of BTH.

KW - brain tissue oxygen

KW - cerebral perfusion pressure

KW - intracerebral hemorrhage

KW - intracranial pressure

KW - lactate/pyruvate ratio

KW - metabolic crisis

KW - pressure reactivity index

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U2 - 10.1161/STROKEAHA.111.623165

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