Stefan Yu Bögli, Ihsane Olakorede, Claudia Ann Smith, Peter Hutchinson, Marek Czosnyka, Peter Smielewski, Shruti Agrawal
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Based on the hypothesis that children are less sensitive to high CPP, we aimed to characterize the pediatric upper limit of autoregulation and the association between high CPP and outcome.</p><p><strong>Methods: </strong>Data acquired as part of the \"Studying Trends of Autoregulation in Severe Head Injury in Paediatrics\" (STARSHIP) study (a prospective, multicenter, observational study that enrolled 135 children with TBI from July 2018 to March 2023) were explored. The association between different levels of CPP and the autoregulation proxy measure, the pressure reactivity index (PRx), were explored visually. The prognostic value of CPP was assessed by exploring overall averages, overall dose, hourly dose, and percentage time spent above specific thresholds. We employed univariable/multivariable (χ<sup>2</sup> tests, logistic regression, sliding dichotomy) and visual (heatmap) methods.</p><p><strong>Results: </strong>No clear upper limit of autoregulation could be identified with PRx increasing beyond 0.2 only with CPP values beyond 100 mm Hg. Using iterative χ<sup>2</sup> testing and logistic regression analyses, similarly, only hourly dose and percentage time beyond CPP of 90 mm Hg displayed a trend toward worse outcome. Using heatmap analyses, regions of CPP with differing risk stratifications could be identified. No difference in CPP could be identified between patients with and without acute respiratory distress syndrome or secondary hemorrhages.</p><p><strong>Conclusions: </strong>In contrast to the well-established association between low CPP and poor outcome, our findings suggest that exposure to CPP values above those recommended by the Brain Trauma Foundation guidelines may not be associated with worse outcomes in this cohort. However, given the observational nature of the study and potential confounding factors, these results highlight the need for prospective trials to assess the safety and efficacy of targeting higher CPP in pediatric TBI.</p>","PeriodicalId":19118,"journal":{"name":"Neurocritical Care","volume":" ","pages":""},"PeriodicalIF":3.6000,"publicationDate":"2025-09-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Exploring the Upper Limits of Cerebral Perfusion Pressure in Pediatric Traumatic Brain Injury: A STARSHIP Analysis.\",\"authors\":\"Stefan Yu Bögli, Ihsane Olakorede, Claudia Ann Smith, Peter Hutchinson, Marek Czosnyka, Peter Smielewski, Shruti Agrawal\",\"doi\":\"10.1007/s12028-025-02358-2\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Background: </strong>Low cerebral perfusion pressure (CPP) has previously been identified as a key prognostic marker after pediatric traumatic brain injury (TBI). 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引用次数: 0
摘要
背景:低脑灌注压(CPP)已被确定为儿童创伤性脑损伤(TBI)后的关键预后指标。脑血管自动调节支持脑血流在自动调节范围内的稳定。超过这个范围的上限,脑血流量随着CPP的增加而增加,导致颅内高压和血脑屏障破坏的风险增加。基于儿童对高CPP不敏感的假设,我们旨在描述儿童自我调节上限以及高CPP与预后之间的关系。方法:研究“儿童严重头部损伤的自我调节研究趋势”(STARSHIP)研究(一项前瞻性、多中心、观察性研究,从2018年7月至2023年3月招募了135名TBI儿童)获得的数据。不同水平的CPP与自动调节代理指标压力反应性指数(PRx)之间的关系进行了可视化探讨。通过总体平均、总剂量、小时剂量和超过特定阈值的时间百分比来评估CPP的预后价值。我们采用单变量/多变量(χ2检验、逻辑回归、滑动二分法)和视觉(热图)方法。结果:只有当CPP值超过100 mm Hg时,PRx值才会超过0.2,并没有明确的自调节上限。通过迭代χ2检验和logistic回归分析,同样,只有小时剂量和超过90 mm Hg的百分比时间才有恶化的趋势。利用热图分析,可以确定不同风险分层的CPP区域。在有和没有急性呼吸窘迫综合征或继发性出血的患者中,CPP没有差异。结论:与低CPP与不良预后之间的既定关联相反,我们的研究结果表明,在该队列中,暴露于高于脑外伤基金会指南推荐值的CPP值可能与较差的预后无关。然而,鉴于该研究的观察性和潜在的混杂因素,这些结果强调需要前瞻性试验来评估以更高CPP为目标治疗儿童TBI的安全性和有效性。
Exploring the Upper Limits of Cerebral Perfusion Pressure in Pediatric Traumatic Brain Injury: A STARSHIP Analysis.
Background: Low cerebral perfusion pressure (CPP) has previously been identified as a key prognostic marker after pediatric traumatic brain injury (TBI). Cerebrovascular autoregulation supports stabilization of cerebral blood flow within the autoregulation range. Beyond the upper limit of this range, cerebral blood flow increases with increasing CPP, leading to increased risk of intracranial hypertension and blood-brain barrier disruptions. Based on the hypothesis that children are less sensitive to high CPP, we aimed to characterize the pediatric upper limit of autoregulation and the association between high CPP and outcome.
Methods: Data acquired as part of the "Studying Trends of Autoregulation in Severe Head Injury in Paediatrics" (STARSHIP) study (a prospective, multicenter, observational study that enrolled 135 children with TBI from July 2018 to March 2023) were explored. The association between different levels of CPP and the autoregulation proxy measure, the pressure reactivity index (PRx), were explored visually. The prognostic value of CPP was assessed by exploring overall averages, overall dose, hourly dose, and percentage time spent above specific thresholds. We employed univariable/multivariable (χ2 tests, logistic regression, sliding dichotomy) and visual (heatmap) methods.
Results: No clear upper limit of autoregulation could be identified with PRx increasing beyond 0.2 only with CPP values beyond 100 mm Hg. Using iterative χ2 testing and logistic regression analyses, similarly, only hourly dose and percentage time beyond CPP of 90 mm Hg displayed a trend toward worse outcome. Using heatmap analyses, regions of CPP with differing risk stratifications could be identified. No difference in CPP could be identified between patients with and without acute respiratory distress syndrome or secondary hemorrhages.
Conclusions: In contrast to the well-established association between low CPP and poor outcome, our findings suggest that exposure to CPP values above those recommended by the Brain Trauma Foundation guidelines may not be associated with worse outcomes in this cohort. However, given the observational nature of the study and potential confounding factors, these results highlight the need for prospective trials to assess the safety and efficacy of targeting higher CPP in pediatric TBI.
期刊介绍:
Neurocritical Care is a peer reviewed scientific publication whose major goal is to disseminate new knowledge on all aspects of acute neurological care. It is directed towards neurosurgeons, neuro-intensivists, neurologists, anesthesiologists, emergency physicians, and critical care nurses treating patients with urgent neurologic disorders. These are conditions that may potentially evolve rapidly and could need immediate medical or surgical intervention. Neurocritical Care provides a comprehensive overview of current developments in intensive care neurology, neurosurgery and neuroanesthesia and includes information about new therapeutic avenues and technological innovations. Neurocritical Care is the official journal of the Neurocritical Care Society.