Vishank A Shah, Mariyam Humayun, Batya Radzik, Ryan Healy, Caitlin Palmisano, Mirinda Anderson-White, Eusebia Calvillo, Romergryko Geocadin, Charles Brown, Charles Hogue, Wendy Ziai, Sung-Min Cho, Jose I Suarez, Lucia Rivera-Lara
{"title":"动脉瘤性蛛网膜下腔出血的早期相对低血压低于无创脑氧饱和度得出的最佳血压阈值：一项初步研究。","authors":"Vishank A Shah, Mariyam Humayun, Batya Radzik, Ryan Healy, Caitlin Palmisano, Mirinda Anderson-White, Eusebia Calvillo, Romergryko Geocadin, Charles Brown, Charles Hogue, Wendy Ziai, Sung-Min Cho, Jose I Suarez, Lucia Rivera-Lara","doi":"10.1097/CCM.0000000000006826","DOIUrl":null,"url":null,"abstract":"<p><strong>Objectives: </strong>Impairment in cerebral autoregulation (CA) after aneurysmal subarachnoid hemorrhage (aSAH) is associated with delayed cerebral ischemia (DCI) and poor outcomes. We assessed: 1) feasibility of defining CA-based optimal mean arterial pressure (MAPOpt) thresholds using noninvasive cerebral oximetry and 2) associations of relative hypotension below MAPOpt in the early brain injury (EBI) and pre-DCI phase with DCI and long-term outcomes after aSAH.</p><p><strong>Design: </strong>Pilot observational study on a prospective cohort.</p><p><strong>Setting: </strong>Single-center Neuro-ICU.</p><p><strong>Patients: </strong>aSAH patients with altered consciousness.</p><p><strong>Interventions: </strong>Continuous noninvasive cerebral oximetry neuromonitoring.</p><p><strong>Measurements and main results: </strong>Daily MAPOpt was defined as observed MAP (MAPObs) corresponding to lowest cerebral oximetry-derived autoregulation index. Outcomes included DCI and 1-year modified Rankin Scale (mRS). Mixed-effects linear regression assessed MAPOpt trajectories. Multivariable generalized estimating equation models assessed associations between daily %time below MAPOpt ± 5 mm Hg (MAPOpt range) and DCI and poor 1-year mRS (mRS 4-6). We included 118 daily MAPOpt measurements (118/128 epochs = 92.2% feasibility) estimated from 35 aSAH patients receiving cerebral oximetry monitoring for median duration of 4 days (interquartile range [IQR], 3-4 d), beginning on median of hospital day 2 (1-3). Median (IQR) age was 64 years (52-69 yr), World Federation of Neurological Surgeons grade 4 (2-5), and modified Fisher Scale 4 (3-4). DCI and poor 1-year outcome occurred in 15 (42.9%) and 20 (57.1%) patients, respectively. Patients that developed DCI had higher median MAPOpt (102.5 vs. 85 mm Hg; p = 0.03), upward trajectory of MAPOpt (β-coefficient = +19 mm Hg; p = 0.04 vs. +4 mm Hg; p = 0.56), and greater %time with MAPObs below MAPOpt range (39.7% vs. 12.7%; p = 0.01) in the early phase. In covariate-adjusted models, %time below MAPOpt range was independently associated with DCI and poor 1-year mRS (adjusted odds ratio, 1.02; 95% CI, 1.002-1.03; p = 0.03).</p><p><strong>Conclusions: </strong>Defining individualized MAPOpt thresholds using noninvasive cerebral oximetry was feasible. Relative hypotension below oximetry-based MAPOpt in the EBI and pre-DCI phase (days~2-6) was associated with DCI and poor long-term functional outcome, supporting further exploration of individualized hemodynamic optimization in the early phase of aSAH.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":6.0000,"publicationDate":"2025-08-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Early Relative Hypotension Below Noninvasive Cerebral Oximetry-Derived Optimal Blood Pressure Thresholds in Aneurysmal Subarachnoid Hemorrhage: A Pilot Study.\",\"authors\":\"Vishank A Shah, Mariyam Humayun, Batya Radzik, Ryan Healy, Caitlin Palmisano, Mirinda Anderson-White, Eusebia Calvillo, Romergryko Geocadin, Charles Brown, Charles Hogue, Wendy Ziai, Sung-Min Cho, Jose I Suarez, Lucia Rivera-Lara\",\"doi\":\"10.1097/CCM.0000000000006826\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Objectives: </strong>Impairment in cerebral autoregulation (CA) after aneurysmal subarachnoid hemorrhage (aSAH) is associated with delayed cerebral ischemia (DCI) and poor outcomes. We assessed: 1) feasibility of defining CA-based optimal mean arterial pressure (MAPOpt) thresholds using noninvasive cerebral oximetry and 2) associations of relative hypotension below MAPOpt in the early brain injury (EBI) and pre-DCI phase with DCI and long-term outcomes after aSAH.</p><p><strong>Design: </strong>Pilot observational study on a prospective cohort.</p><p><strong>Setting: </strong>Single-center Neuro-ICU.</p><p><strong>Patients: </strong>aSAH patients with altered consciousness.</p><p><strong>Interventions: </strong>Continuous noninvasive cerebral oximetry neuromonitoring.</p><p><strong>Measurements and main results: </strong>Daily MAPOpt was defined as observed MAP (MAPObs) corresponding to lowest cerebral oximetry-derived autoregulation index. Outcomes included DCI and 1-year modified Rankin Scale (mRS). Mixed-effects linear regression assessed MAPOpt trajectories. Multivariable generalized estimating equation models assessed associations between daily %time below MAPOpt ± 5 mm Hg (MAPOpt range) and DCI and poor 1-year mRS (mRS 4-6). We included 118 daily MAPOpt measurements (118/128 epochs = 92.2% feasibility) estimated from 35 aSAH patients receiving cerebral oximetry monitoring for median duration of 4 days (interquartile range [IQR], 3-4 d), beginning on median of hospital day 2 (1-3). Median (IQR) age was 64 years (52-69 yr), World Federation of Neurological Surgeons grade 4 (2-5), and modified Fisher Scale 4 (3-4). DCI and poor 1-year outcome occurred in 15 (42.9%) and 20 (57.1%) patients, respectively. Patients that developed DCI had higher median MAPOpt (102.5 vs. 85 mm Hg; p = 0.03), upward trajectory of MAPOpt (β-coefficient = +19 mm Hg; p = 0.04 vs. +4 mm Hg; p = 0.56), and greater %time with MAPObs below MAPOpt range (39.7% vs. 12.7%; p = 0.01) in the early phase. In covariate-adjusted models, %time below MAPOpt range was independently associated with DCI and poor 1-year mRS (adjusted odds ratio, 1.02; 95% CI, 1.002-1.03; p = 0.03).</p><p><strong>Conclusions: </strong>Defining individualized MAPOpt thresholds using noninvasive cerebral oximetry was feasible. Relative hypotension below oximetry-based MAPOpt in the EBI and pre-DCI phase (days~2-6) was associated with DCI and poor long-term functional outcome, supporting further exploration of individualized hemodynamic optimization in the early phase of aSAH.</p>\",\"PeriodicalId\":10765,\"journal\":{\"name\":\"Critical Care Medicine\",\"volume\":\" \",\"pages\":\"\"},\"PeriodicalIF\":6.0000,\"publicationDate\":\"2025-08-19\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Critical Care Medicine\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://doi.org/10.1097/CCM.0000000000006826\",\"RegionNum\":1,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q1\",\"JCRName\":\"CRITICAL CARE MEDICINE\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Critical Care Medicine","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1097/CCM.0000000000006826","RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"CRITICAL CARE MEDICINE","Score":null,"Total":0}
引用次数: 0
摘要
目的：动脉瘤性蛛网膜下腔出血（aSAH）后脑自动调节（CA）的损害与延迟性脑缺血（DCI）和不良预后相关。我们评估了：1)使用无创脑血氧仪确定基于ca的最佳平均动脉压（MAPOpt）阈值的可行性；2)早期脑损伤（EBI）和DCI前阶段相对低血压低于MAPOpt与DCI和aSAH后长期预后的相关性。设计：前瞻性队列的先导观察性研究。设置：单中心神经- icu。患者：意识改变的aSAH患者。干预措施：连续无创脑血氧测定和神经监测。测量和主要结果：每日MAPOpt被定义为观察到的最低脑氧饱和度自动调节指数对应的MAP （MAPObs）。结果包括DCI和1年修正Rankin量表（mRS）。混合效应线性回归评估MAPOpt轨迹。多变量广义估计方程模型评估了每日低于MAPOpt±5毫米汞柱（MAPOpt范围）的%时间与DCI和1年不良mRS （mRS 4-6）之间的关系。我们纳入了从住院第2天（1-3）开始，接受脑血氧仪监测的35例aSAH患者中位持续时间为4天（四分位数间距[IQR]， 3-4天）的118次每日MAPOpt测量（118/128次= 92.2%可行性）。中位（IQR）年龄为64岁（52-69岁），世界神经外科联合会评分4级（2-5），修正Fisher评分4级（3-4）。DCI和1年预后不良的患者分别为15例（42.9%）和20例（57.1%）。发生DCI的患者在早期有较高的中位MAPOpt (102.5 vs. 85 mm Hg, p = 0.03)， MAPOpt上升轨迹（β-系数= +19 mm Hg, p = 0.04 vs. +4 mm Hg, p = 0.56）， mapob低于MAPOpt范围的时间更长（39.7% vs. 12.7%, p = 0.01）。在协变量校正模型中，低于MAPOpt范围的%时间与DCI和1年mRS差独立相关（校正优势比1.02;95% CI, 1.002-1.03; p = 0.03）。结论：使用无创脑血氧仪确定个体化MAPOpt阈值是可行的。EBI和DCI前阶段（2-6天）基于血氧计的MAPOpt相对低血压与DCI和较差的长期功能预后相关，支持进一步探索aSAH早期个体化血流动力学优化。
Early Relative Hypotension Below Noninvasive Cerebral Oximetry-Derived Optimal Blood Pressure Thresholds in Aneurysmal Subarachnoid Hemorrhage: A Pilot Study.
Objectives: Impairment in cerebral autoregulation (CA) after aneurysmal subarachnoid hemorrhage (aSAH) is associated with delayed cerebral ischemia (DCI) and poor outcomes. We assessed: 1) feasibility of defining CA-based optimal mean arterial pressure (MAPOpt) thresholds using noninvasive cerebral oximetry and 2) associations of relative hypotension below MAPOpt in the early brain injury (EBI) and pre-DCI phase with DCI and long-term outcomes after aSAH.
Design: Pilot observational study on a prospective cohort.
Setting: Single-center Neuro-ICU.
Patients: aSAH patients with altered consciousness.
Measurements and main results: Daily MAPOpt was defined as observed MAP (MAPObs) corresponding to lowest cerebral oximetry-derived autoregulation index. Outcomes included DCI and 1-year modified Rankin Scale (mRS). Mixed-effects linear regression assessed MAPOpt trajectories. Multivariable generalized estimating equation models assessed associations between daily %time below MAPOpt ± 5 mm Hg (MAPOpt range) and DCI and poor 1-year mRS (mRS 4-6). We included 118 daily MAPOpt measurements (118/128 epochs = 92.2% feasibility) estimated from 35 aSAH patients receiving cerebral oximetry monitoring for median duration of 4 days (interquartile range [IQR], 3-4 d), beginning on median of hospital day 2 (1-3). Median (IQR) age was 64 years (52-69 yr), World Federation of Neurological Surgeons grade 4 (2-5), and modified Fisher Scale 4 (3-4). DCI and poor 1-year outcome occurred in 15 (42.9%) and 20 (57.1%) patients, respectively. Patients that developed DCI had higher median MAPOpt (102.5 vs. 85 mm Hg; p = 0.03), upward trajectory of MAPOpt (β-coefficient = +19 mm Hg; p = 0.04 vs. +4 mm Hg; p = 0.56), and greater %time with MAPObs below MAPOpt range (39.7% vs. 12.7%; p = 0.01) in the early phase. In covariate-adjusted models, %time below MAPOpt range was independently associated with DCI and poor 1-year mRS (adjusted odds ratio, 1.02; 95% CI, 1.002-1.03; p = 0.03).
Conclusions: Defining individualized MAPOpt thresholds using noninvasive cerebral oximetry was feasible. Relative hypotension below oximetry-based MAPOpt in the EBI and pre-DCI phase (days~2-6) was associated with DCI and poor long-term functional outcome, supporting further exploration of individualized hemodynamic optimization in the early phase of aSAH.
期刊介绍：
Critical Care Medicine is the premier peer-reviewed, scientific publication in critical care medicine. Directed to those specialists who treat patients in the ICU and CCU, including chest physicians, surgeons, pediatricians, pharmacists/pharmacologists, anesthesiologists, critical care nurses, and other healthcare professionals, Critical Care Medicine covers all aspects of acute and emergency care for the critically ill or injured patient.
Each issue presents critical care practitioners with clinical breakthroughs that lead to better patient care, the latest news on promising research, and advances in equipment and techniques.
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