Download PDF
Semin Respir Crit Care Med 2001; 22(1): 003-012
DOI: 10.1055/s-2001-13835
Copyright © 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Management of Cerebral Perfusion Pressure

Roman Hlatky, Yu Furuya, Alex B. Valadka, Claudia S. Robertson
  • Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
Further Information

Publication History

Publication Date:
31 December 2001 (online)

    Permissions and Reprints

ABSTRACT

The management of cerebral perfusion pressure is among the most controversial treatment issues. Cerebral perfusion pressure (CPP) is normally expressed as the difference between mean arterial blood pressure and intracranial pressure and has two important physiological roles in the patient with severe head injury. First, CPP represents the pressure gradient acting across the cerebrovascular bed and hence is an important factor in the regulation of cerebral blood flow. Second, CPP contributes to the hydrostatic pressure within the intracerebral vessels, and therefore is one of the factors that determines edema formation in the injured brain. The border between adequate and inadequate CPP should be assessed individually and continuously, as it may fluctuate in time. The treatment plan that includes rapid identification of intracranial hemorrhage, rapid evacuation of extraaxial blood, treatment of intracranial hypertension, and promotion of cerebral and systemic perfusion is likely to provide the best outcome for all patients.

KEYWORD

Brain injury - cerebral perfusion pressure - cerebral blood flow

REFERENCES

  • 1 Brain Trauma Foundation. Management and Prognosis of Severe Traumatic Brain Injury. Part 1: Guidelines for the Management of Severe Traumatic Brain Injury.  J Neurotrauma . 2000;  6/7 449-554
    PubMedGoogle Scholar
  • 2 Aaslid R. Cerebral hemodynamics. In: Newell DW, Aaslid R, eds. Transcranial Doppler New York: Raven 1992: 49-55
    Google Scholar
  • 3 Lassen N A. Cerebral blood flow and oxygen consumption in man.  Physiol Rev . 1959;  39 183-238
    PubMedGoogle Scholar
  • 4 Ghajar J. Intracranial pressure monitoring techniques.  New Horizons . 1995;  3 395-399
    PubMedGoogle Scholar
  • 5 Rosner M J, Rosner S D, Johnson A H. Cerebral perfusion pressure: management protocol and clinical results.  J Neurosurg . 1995;  83 949-962
    CrossrefPubMedGoogle Scholar
  • 6 Bouma G J, Muizelaar J P, Choi S C. Cerebral circulation and metabolism after severe traumatic brain injury: the elusive role of ischaemia.  J Neurosurg . 1991;  75 685-693
    CrossrefPubMedGoogle Scholar
  • 7 Jaggi J L, Obrist W D, Gennarelli T A. Relationship of early cerebral blood flow and metabolism to outcome in acute head injury.  J Neurosurg . 1990;  72 176-182
    CrossrefPubMedGoogle Scholar
  • 8 Martin N A, Patwardhan R V, Alexander M J. Characterization of cerebral hemodynamic phases following severe head trauma: hypoperfusion, hyperemia, and vasospasm.  J Neurosurg . 1997;  87 9-19
    CrossrefPubMedGoogle Scholar
  • 9 Pfenninger E G, Reith A, Breitig D. Early changes of intracranial pressure, perfusion pressure, and blood flow after acute head injury. Part 1: An experimental study of the underlying pathophysiology.  J Neurosurg . 1989;  70 774-779
    PubMedGoogle Scholar
  • 10 Hovda D A, Lee S M, Smith M L. The neurochemical and metabolic cascade following brain injury: moving from animal models to man.  J Neurotrauma . 1995;  12 903-907
    PubMedGoogle Scholar
  • 11 Marion D W, Darby J, Yonas H. Acute regional cerebral blood flow changes caused by severe head injuries.  J Neurosurg . 1991;  74 407-414
    PubMedGoogle Scholar
  • 12 Bouma G J, Muizelaar J P, Stringer W A. Ultra-early evaluation of regional cerebral blood flow in severely head-injured patients using xenon-enhanced computerized tomography.  J Neurosurg . 1992;  77 360-368
    CrossrefPubMedGoogle Scholar
  • 13 Muizelaar J P, Ward J D, Marmarou A. Cerebral blood flow and metabolism in severely head-injured children. Part 2: Autoregulation.  J Neurosurg . 1989;  71 72-76
    PubMedGoogle Scholar
  • 14 Diringer M N, Yundt K, Videen T. No reduction in cerebral metabolism as a result of early moderate hyperventilation following severe traumatic brain injury.  J Neurosurg . 2000;  92 7-13
    PubMedGoogle Scholar
  • 15 Martin N A, Doberstein C, Alexander M. Posttraumatic cerebral arterial spasm.  J Neurotrauma . 1995;  12 897-901
    PubMedGoogle Scholar
  • 16 Bouma G J, Muizelaar J P. Cerebral blood flow, cerebral blood volume, and cerebrovascular reactivity after severe head injury.  J Neurotrauma . 1992;  S333-S348 (S333-S348)
    PubMedGoogle Scholar
  • 17 Hekmatpanah J, Hekmatpanah C R. Microvascular alterations following cerebral contusion in rats. Light, scanning, and electron microscope study.  J Neurosurg . 1985;  62 888-897
    PubMedGoogle Scholar
  • 18 Schroder M L, Muizelaar J P, Bullock M R. Focal ischemia due to traumatic contusions documented by stable xenon-CT and ultrastructural studies.  J Neurosurg . 1995;  82 966-971
    PubMedGoogle Scholar
  • 19 Cherian L, Goodman J C, Robertson C S. Nitric oxide concentrations in the brain after controlled cortical impact injury in rats.  J Neurophysiol . 2000;  83 2171-2178
    PubMedGoogle Scholar
  • 20 Robertson C S, Grossman R G, Goodman J C. The predictive values of cerebral anaerobic metabolism with cerebral infarction after head injury.  J Neurosurg . 1989;  67 361-368
    PubMedGoogle Scholar
  • 21 Obrist W D, Marion D W, Aggarwal S. Time course of cerebral blood flow and metabolism in comatose patients with acute head injury.  J Cereb Blood Flow Metab . 1993;  13 S571
    PubMedGoogle Scholar
  • 22 Obrist W D, Langfitt T W, Jaggi J L. Cerebral blood flow and metabolism in comatose patients with acute head-injury: relationship to intracranial hypertension.  J Neurosurg . 1984;  61 241-245
    PubMedGoogle Scholar
  • 23 Bruce D A, Langfitt T W, Miller J D. Regional cerebral blood flow, intracranial pressure, and brain metabolism in comatose patients.  J Neurosurg . 1973;  38 131-144
    PubMedGoogle Scholar
  • 24 Kelly D F, Kordestani R K, Martin N A. Hyperemia following traumatic brain injury: relationship to intracranial hypertension and outcome.  J Neurosurg . 1996;  85 762-771
    PubMedGoogle Scholar
  • 25 Robertson C S, Contant C F, Gokaslan Z L. Cerebral blood flow, arteriovenous oxygen difference, and outcome in head injured patients.  J Neurol Neurosurg Psychiatry . 1992;  55 594-603
    PubMedGoogle Scholar
  • 26 Muizelaar J P, Marmarou A, DeSalles A AF. Cerebral blood flow and metabolism in severe head-injured children. Part 1: Relationship with GCS score, outcome, ICP, and PVI.  J Neurosurg . 1989;  71 63-71
    CrossrefPubMedGoogle Scholar
  • 27 Robertson C S, Narayan R K, Gokaslan Z L. Cerebral arteriovenous oxygen difference as an estimate of cerebral blood flow in comatose patients.  J Neurosurg . 1989;  70 222-230
    PubMedGoogle Scholar
  • 28 Andersen B J, Marmarou A. Post-traumatic selective stimulation of glycolysis.  Brain Res . 1992;  585 184-189
    CrossrefPubMedGoogle Scholar
  • 29 Yoshino A, Hovda D A, Kawamata T. Dynamic changes in local cerebral glucose utilization following cerebral concussion in rats: evidence of a hyper- and subsequent hypometabolic state.  Brain Res . 1991;  561 106-111
    CrossrefPubMedGoogle Scholar
  • 30 Bergsneider M, Hovda D A, Shalmon E. Cerebral hyperglycolysis following severe traumatic brain injury in humans: a positron emission tomography study.  J Neurosurg . 1997;  86 241-251
    CrossrefPubMedGoogle Scholar
  • 31 Suwanwela C, Suwanwela N. Intracranial arterial narrowing and spasm in acute head injury.  J Neurosurg . 1972;  36 314-323
    PubMedGoogle Scholar
  • 32 Weber M, Grolimund P, Seiler R W. Evaluation of posttraumatic cerebral blood flow velocities by transcranial Doppler ultrasonography.  Neurosurgery . 1990;  27 106-112
    PubMedGoogle Scholar
  • 33 Kita H, Marmarou A. The cause of acute brain swelling after the closed head injury in rats.  Acta Neurochir Suppl (Wien) . 1994;  60 452-455
    PubMedGoogle Scholar
  • 34 Marmarou A, Barzo P, Fatouros P. Traumatic brain swelling in head injured patients: brain edema or vascular engorgement?.  Acta Neurochir Suppl (Wien) . 1997;  70 68-70
    PubMedGoogle Scholar
  • 35 Barzo P, Marmarou A, Fatouros P. Contribution of vasogenic and cellular edema to traumatic brain swelling measured by diffusion-weighted imaging.  J Neurosurg . 1997;  87 900-907
    PubMedGoogle Scholar
  • 36 Barzo P, Marmarou A, Fatouros P. Biphasic pathophysiological response of vasogenic and cellular edema in traumatic brain swelling.  Acta Neurochir Suppl (Wien) . 1997;  70 119-122
    PubMedGoogle Scholar
  • 37 Marshall L F, Smith R W, Shapiro H M. The outcome with aggressive treatment in severe head injuries. Part I: Significance of intracranial pressure monitoring.  J Neurosurg . 1979;  50 20-25
    PubMedGoogle Scholar
  • 38 Miller J D, Butterworth J, Gudeman S K. Further experience in the management of severe head injury.  J Neurosurg . 1981;  54 289-299
    CrossrefPubMedGoogle Scholar
  • 39 Saul T G, Ducker T B. Effect of intracranial pressure monitoring and aggressive treatment on mortality in severe head injury.  J Neurosurg . 1982;  56 498-503
    CrossrefPubMedGoogle Scholar
  • 40 Becker D P, Miller J D, Ward J D. The outcome from severe head injury with early diagnosis and intensive management.  J Neurosurg . 1977;  47 491-502
    CrossrefPubMedGoogle Scholar
  • 41 Kroppenstedt S N, Kern M, Thomale U W. Effect of cerebral perfusion pressure on contusion volume following impact injury.  J Neurosurg . 1999;  90 520-526
    PubMedGoogle Scholar
  • 42 Chestnut R M, Marshall L F, Klauber M R. The role of secondary brain injury in determining the outcome from severe head-injury.  J Trauma . 1993;  34 216-222
    CrossrefPubMedGoogle Scholar
  • 43 Marmarou A, Anderson R L, Ward J D. Impact of ICP instability and hypotension on outcome in patients with severe head injury.  J Neurosurg . 1991;  75 S59-S64
    PubMedGoogle Scholar
  • 44 Pietropaoli J A, Rogers F B, Shackford S R. The deleterious effects of intraoperative hypotension on outcome in patients with severe head injuries.  J Trauma . 1992;  33 403-407
    PubMedGoogle Scholar
  • 45 Miller J D, Sweet R C, Narayan R. Early insults to the injured brain.  JAMA . 1978;  240 439-442
    CrossrefPubMedGoogle Scholar
  • 46 Gobiet W, Grote W, Bock W J. The relation between intracranial pressure, mean arterial pressure and cerebral blood flow in patients with severe head injury.  Acta Neurochir . 1975;  32 13-24
    CrossrefPubMedGoogle Scholar
  • 47 Marmarou A, Ward J D, Young H F. Impact of ICP instability and hypotension on outcome in patients with sever head trauma.  J Neurosurg . 1991;  S59-S66 (S59-S66)
    PubMedGoogle Scholar
  • 48 Miller J D, Dearden N M, Piper I R. Control of intracranial pressure in patients with severe head injury.  J Neurotrauma . 1992;  S317-S326 (S317-S326)
    PubMedGoogle Scholar
  • 49 Marmarou A, Anderson R L, Ward J D. Impact of ICP instability and hypotension on outcome in patients with severe head injury.  J Neurosurg . 1991;  75 S59-S64
    PubMedGoogle Scholar
  • 50 Robertson C S, Valadka A B, Hannay H J. Prevention of secondary insults after severe head injury.  Crit Care Med . 1999;  27 2086-2095
    CrossrefPubMedGoogle Scholar
  • 51 Rosner M J, Becker D P. Origin and evolution of plateau waves: experimental observations and a theoretical model.  J Neurosurg . 1984;  60 312-324
    PubMedGoogle Scholar
  • 52 Rosner M J, Coley I B. Cerebral perfusion pressure, intracranial pressure, and head elevation.  J Neurosurg . 1986;  65 636-641
    CrossrefPubMedGoogle Scholar
  • 53 Rosner M J, Daughton S. Cerebral perfusion pressure management in head injury.  J Trauma . 1990;  30 933-940
    PubMedGoogle Scholar
  • 54 Gopinath S P, Robertson C S, Contant C F. Jugular venous desaturation and outcome after head injury.  J Neurol Neurosurg Psychiatry . 1994;  57 717-723
    CrossrefPubMedGoogle Scholar
  • 55 Chan K H, Dearden M, Miller J D. Transcranial Doppler waveform differences in hyperemic and nonhyperemic patients after severe head injury.  Surg Neurol . 1992;  32 433-436
    PubMedGoogle Scholar
  • 56 Markwalder T, Grolimund P, Seiler R, Roth F, Aaslid R. Dependency of blood flow velocity in the middle cerebral artery on end-tidal carbon dioxide partial pressure.  J Cereb Blood Flow Metab . 1984;  4 368-372
    PubMedGoogle Scholar
  • 57 Newell D W, Weber J P, Watson R. Effect of transient moderate hyperventilation on dynamic cerebral autoregulation after severe head injury.  Neurosurgery . 1996;  39 35-44
    CrossrefPubMedGoogle Scholar
  • 58 Chan K H, Miller J D, Piper I R. Cerebral blood flow at constant cerebral perfusion pressure but changing arterial and intracranial pressure: relationship to autoregulation.  J Neurosurg Anesth . 1992;  4 188-193
    PubMedGoogle Scholar
  • 59 Barzo P, Doczi T, Csete K. Measurements of regional cerebral blood flow and blood flow velocity in experimental intracranial hypertension: infusion via the cisterna magna in rabbits.  Neurosurgery . 1991;  28 821-825
    PubMedGoogle Scholar
  • 60 Paulson O B, Olesen J, Christensen M S. Cerebral autoregulation.  Cerebrovasc Brain Metab Rev . 1990;  2 161-192
    PubMedGoogle Scholar
  • 61 Baumbach G L, Faraci F M, Heistad D D. Effects of local reduction in pressure on endothelium-dependent responses of cerebral arterioles.  Stroke . 1994;  25 1456-1462
    PubMedGoogle Scholar
  • 62 Bouma G J, Muizelaar J P, Bandoh K, Marmarou A. Blood pressure and intracranial pressure-volume dynamics in severe head injury: relationship with cerebral blood flow.  J Neurosurg . 1992;  77 15-19
    CrossrefPubMedGoogle Scholar
  • 63 Unterberg A W, Kiening K L, Hartl R. Multimodal monitoring in patients with head injury: evaluation of the effects of treatment on cerebral oxygenation.  J Trauma . 1997;  42 S32-S37
    PubMedGoogle Scholar
  • 64 Durward Q J, Del Maestro F R, Amacher A L. The influence of systemic arterial pressure and intracranial pressure on the development of cerebral vasogenic edema.  J Neurosurg . 1983;  59 803-809
    PubMedGoogle Scholar
  • 65 Grande P O, Asgeirsson B, Nordstrom C H. Physiologic principles for volume regulation of a tissue enclosed in a rigid shell with application to the injured brain.  J Trauma . 1997;  42 S23-S31
    PubMedGoogle Scholar
  • 66 Asgeirsson B, Grande P O, Nordstrom C H. A new therapy of post-trauma brain edema based on haemodynamic principles for brain volume regulation.  Intensive Care Med . 1994;  20 260-267
    CrossrefPubMedGoogle Scholar
  • 67 Grande P O, Nordstrom C H. Treatment of increased ICP in severe head-injured patients: guidelines for the Lund therapy. In: von Wild KRH, ed. Pathophysiological Principles and Controversies in Neurointensive Care Munich: W Zuckschwerdt 1998: 123-128
    Google Scholar
  • 68 Juul N, Morris G F, Marshall S B. Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury.  J Neurosurg . 2000;  92 1-6
    CrossrefPubMedGoogle Scholar
  • 69 Narayan R K, Greenberg R P, Miller J D. Improved confidence of outcome prediction in severe head injury: a comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning, and intracranial pressure.  J Neurosurg . 1981;  54 751-762
    CrossrefPubMedGoogle Scholar
  • 70 Mathew P, Graham D I, Bullock R. Focal brain injury: histological evidence of delayed inflammatory response in a new rodent model of focal cortical injury.  Acta Neurochir Suppl . 1994;  60 428-430
    PubMedGoogle Scholar
  • 71 Chan K H, Dearden N M, Miller J D. Multimodality monitoring as a guide to treatment of intracranial hypertension after severe brain injury.  Neurosurgery . 1993;  32 547-553
    PubMedGoogle Scholar
  • 72 Fortune J B, Feustel P J, Weigle C GM. Continuous measurement of jugular venous oxygen saturation in response to transient elevations of blood pressure in head-injured patients.  J Neurosurg . 1994;  80 461-468
    PubMedGoogle Scholar
  • 73 McGraw C P. A cerebral perfusion pressure greater than 80 mm Hg is more beneficial. In: Hoff J, Betz A, eds. Intracranial Pressure VII Berlin: Springer-Verlag 1989: 839-841
    Google Scholar
  • 74 Mendelow A D, Allcutt D A, Chambers I R. Intracranial and perfusion pressure monitoring in the head injured patient: which index?. In: Avezaat C, van Eijndhoven J, Maas A, eds. Intracranial Pressure VIII Berlin: Springer-Verlag 1993: 544-548
    Google Scholar
  • 75 Changaris D G, McGraw C P, Richardson J D. Correlation of cerebral perfusion pressure and Glasgow Coma Scale to outcome.  J Trauma . 1987;  27 1007-1013
    PubMedGoogle Scholar
  • 76 Rosner M J, Daughton S. Cerebral perfusion pressure management in head injury.  J Trauma . 1990;  30 933-941
    PubMedGoogle Scholar
  • 77 Marion D W, Carlier P M, Obrist W D. Treatment of cerebral ischemia improves outcome following severe traumatic brain injury.  Abstr J Neurotrauma . 1993;  S102 (S102)
    PubMedGoogle Scholar
  • 78 Lee J H, Martin N A, Alsina G. Hemodynamically significant cerebral vasospasm and outcome after head injury: a prospective study.  J Neurosurg . 1997;  87 221-233
    PubMedGoogle Scholar
  • 79 Chan K H, Dearden N M, Miller J. The significance of post-traumatic increase in cerebral blood flow velocity: a transcranial Doppler ultrasound study.  Neurosurgery . 1992;  30 699-700
    PubMedGoogle Scholar
      >