1. Multimodal Monitoring in Head Injured Patients - Management of CPP: Detection and Treatment of optimal CPP Jürgen Meixensberger Department of Neurosurgery

2. 1. Why? 2. Critical Border ? 3. Time Course ? 4. Individual optimized CPP ? 5. Therapy Effect of reduced CBF Ischemia Edema, Lactate Penumbra Infarction Loss of electric activity Cell death Loss of Na/K Pump, ATP ml/100g/min CPP = index of input pressure determining CBF and perfusion

3. Risk to secondary ischemic brain damage  Traumatic brain injury diffuse focal, multiple  Subarachnoid Hemorrhage Vasospasm  Ischemic Stroke Penumbra

4. CPP „Adequate cerebral perfusion pressure is necessary to provide a sufficient cerebral blood flow. The question, whether to treat increased ICP or maintainance of CPP as first treatment goal, is still controversial in the literature.“ Guideline German Society of Neurosurgery Traumatic Brain Injury in Adults AWMF – Leitlinien – Register Nr. 008/001

5. Cerebral Perfusion Pressure CPP Definition Cerebral Perfusion Pressure* is a surrogate of cerebral blood flow CBF. CBF = CPP (MAP – ICP*)/CVR * Referenced to the Foramen of Monroi

6. Jaeger M, Acta Neurochir 2005 Valadka A, Acta Neurochir 2002 Menzel M, J Neurosurg Anesthesiol 1999 Doppenberg E, Surg Neurol 1998 Induced Hypertension Meixensberger J, JNNP 2003 CPP and Cerebral Oxygenation Individual increasing of CPP guided by P ti O 2 >10 mmHg decreased significantly amount of hypoxic episodes after TBI.

7. 1. Why? 2. Critical Border ? 3. Time Course ? 4. Individual optimized CPP ? 5. Causes 6. Therapy CPP=70 mmHg CPP=90 mmHg Coles JP, Brain 2004

8.  The optimal CPP in patients suffering from TBI is unclear.  Recommendations: From CPP>50, > 60 mmHg to CPP>90 mmHg  Reduced as well as high CPP influenced Outcome in a negative manner. Robertson et al. Crit Care Med 1999, Contant et al. J Neurosurg 2001 (n=189) Balestreri et al. Neurocrit Care 2006 (n=429)

9. Balestreri et al Neurocritical Care 2006 N = 429 Outcome - Function of ICP and CPP

10. Optimal CPP Brain Trauma Foundation, J Neurotrauma 2003,2007 CPP < 70 mmHg EBIC, Acta Neurochir 1997 CPP 60–70 mmHg CPP > 60 mmHg Avoid CPP < 50 mmHg Intact Autoregulation: CPP > 70 mmHg Robertson C, Crit Care Med 1999Robertson et al., Contant et al. J Neurosurg 2001 (n=189) Balestreri et al. Neurocrit Care 2006 (n=429) Meixensberger J, Acta Neurochir 1993

11. Optimized CPP - Therapy TBI N = 30 * Episode > 10 min *

12. 1. Why? 2. Critical Border ? 3. Time Course ? 4. Individual optimized CPP ? 5. Causes 6. Therapy % p ti O 2 < 10 mmHg Day 1-2Day 3-5Day 6-8 CPP mmHg FREQUENCYFREQUENCY % p ti O 2 < 10 mmHg

13. 1. Why? 2. Critical Border ? 3. Time Course ? 4. Individual optimized CPP ? 5. Causes 6. Therapy Effect of reduced CBF Ischemia Edema, Lactate Penumbra Infarction Loss of electric activity Cell death Loss of Na/K Pump, ATP ml/100g/min

14.  Concept individual optimized CPP (CPP opt ) Steiner et al. Crit Care Med 2002 (n=114)  Based on continous monitoring of cerebrovascular pressure reactivity index PRX  PRx = moving correlation coefficient MAP / ICP Czosnyka et al. Neurosurgery 1997

15. CPP PRx Individual optimized CPP Steiner et al. Crit Care Med 2002 CPP opt

16. CPP PRx Individual optimized CPP Steiner et al. Crit Care Med 2002 CPP opt + P ti O 2

17.  TBIn=33  Continous Monitoring (ICM-plus Software) MAP ICP[Codman] CPP P ti O 2 [Licox]  PRx = moving correlationcoefficient MAP / ICP  Czosnyka et al. Neurosurgey 1997  Data analysis CPP vs. PRx CPP vs. P ti O 2 CPP-class of 5 mmHg

18. Results:  CPP opt n=28/33(85 %)  CPP opt n=760-65 mmHg n=165-70 mmHg n=870-75 mmHg n=175-80 mmHg n=680-85 mmHg n=385-90 mmHg n=290-95 mmHg CPP PRx

19. CPP opt CPP

20. CPP opt PRxP ti O 2 CPP

21. CPP opt PRx CPP

22. PRxP ti O 2 CPP opt CPP

23. CPP opt PRxP ti O 2 n=28 CPP Jaeger et al Crit Care Med 2010

24. Therapeutic Options: CPP > 60, < 70 mmHg *  Induced hypervolemia with cristalloids Cave: heart insufficience  No body/head – elevation 0°  Inotropica – infusion Cave: acute coronary syndrome, arrhythmia  Diuretics – Reduction of centralvenous pressure  Ventilation - „best PEEP“ - concept * Option; Prognostic value only given by case reports;

25. Management of CPP after TBI Recommendations: Avoid CPP < 50 mmHg – to minimize edema formation CPP > 70 – 80 mmHg – can improve perfusion if autoregulation is intact Class II evidence CPP of 60 mmHg – sufficient CBF and cerebral perfusion in most cases Ancillary monitoring is helpful to target CPP

26. CPP – Management - Protocols White H, Venkatesh B Neurosurg Anesth 2008

27. Management of CPP after TBI Recommendations: Need for more data  Individualized optimal CPP based on hemodynamic monitoring/ pressure autoregulation indices  Randomized outcome studies

28. Thank You for Your Attention !