Research Reports - Time spent with impaired autoregulation is linked with outcome in severe infant/paediatric traumatic brain injury

Acta Neurochir (Wien). 2017 Sep 4. doi: 10.1007/s00701-017-3308-8. [Epub ahead of
print]

Hockel K(1), Diedler J(2), Neunhoeffer F(3), Heimberg E(3), Nagel C(4), Schuhmann
MU(2).

BACKGROUND: It could be shown in traumatic brain injury (TBI) in adults that the
functional status of cerebrovascular autoregulation (AR), determined by the
pressure reactivity index (PRx), correlates to and even predicts outcome. We
investigated PRx, cerebral perfusion pressure (CPP) and intracranial pressure
(ICP) and their correlation to outcome in severe infant and paediatric TBI.
METHODS: Seventeen patients (range, 1 day to 14 years) with severe TBI (median
GCS at presentation, 4) underwent long-term computerised ICP and mean arterial
pressure (MAP) monitoring using dedicated software to determine CPP and PRx and
optimal CPP (CPP level where PRx shows best autoregulation) continuously. Outcome
was determined at discharge and at follow-up using the Glasgow Outcome Scale.
RESULTS: Favourable outcome was reached in eight patients, unfavourable outcome
in seven patients. Two patients died. Nine patients underwent decompressive
craniectomy to control ICP during Intensive Care Unit treatment. When
dichotomised to outcome, no significant difference was found for overall ICP, CPP
and PRx. The time with severely impaired AR (PRx >0.2) was significantly longer
for patients with unfavourable outcome (64 h vs 6 h, p = 0.001). Continuously
impaired AR of ≥24 h and age <1 year was associated to unfavourable outcome.
Children with favourable outcome spent the entire monitoring time at or above the
optimal CPP.
CONCLUSIONS: Integrity of AR has a similar role for outcome after TBI in the
paediatric population as in adults. The amount of time spent with deranged AR
seems to be associated with outcome; a factor especially critical for infant
patients. The results of this preliminary study need to be validated in the
future. 

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