KidsBrainIT: Visualization of the Impact of Cerebral Perfusion Pressure Insult Intensity and Duration on Childhood Brain Trauma Outcome.

Abstract

Background: Cerebral perfusion pressure (CPP) dose-response on post-traumatic brain injury (TBI) outcome in children remains unknown. This project aimed to produce the first pediatric post-TBI CPP dose-response visualization plot from the international multicenter KidsBrainIT data set.

Methods: Fully anonymized prospectively collected routine minute-by-minute intracranial pressure (ICP), mean arterial blood pressure, and CPP time series data from 104 pediatric patients with TBI were categorized into CPP intensity duration episodes, albeit CPP above or below a range of thresholds. These episodes were then correlated with the 6-month modified Glasgow Outcome Score (GOS) and depicted in 3D color-coded CPP dose-response plots. Additionally, the effects of cerebrovascular reactivity patterns and ICP were examined.

Results: Our pediatric CPP dose-response plots resembled the previously published adult CPP dose-response plots: on the CPP pressure time plots, an exponential "black" transition curve separated CPP episodes associated with poor ("red," GOS < 4) and good ("blue") outcome. Lower and higher ends of CPP intensity were only tolerated for shorter durations. A "safe" CPP zone (56-89 mm Hg) was identified for childhood TBI with active cerebrovascular reactivity pattern and ICP < 20 mm Hg. Passive cerebrovascular reactivity pattern reduced the area of safe CPP doses. ICP levels > 20 mm Hg were associated with worse outcome, irrespective of CPP dose.

Conclusions: The pediatric CPP dose-response on poor outcome was visualized successfully for the first time. Because the "critical" lower CPP limit exceeds the current recommended minimum CPP target for pediatric TBI treatments, there is an urgent need to validate childhood CPP dose-response to provide evidence-based CPP clinical targets in the future.