Simultaneous Bedside Assessment of Global Cerebral Blood Flow and Effective Cerebral Perfusion Pressure in Patients with Intracranial Hypertension

Background: We examined a bedside technique transcerebral double-indicator dilution (TCID) for global cerebral blood flow (CBF) as well as the concept of effective cerebral perfusion pressure (CPPeff) during different treatment options for intracranial hypertension, and compared global CBF and CPPeff with simultaneously obtained conventional parameters. Methods: Twenty-six patients developing intracranial hypertension in the course of traumatic brain injury or subarachnoid hemorrhage were prospectively analyzed using a combined assessment during elevated ventilation (n=15) or osmotherapy (hypertonic saline or mannitol). For calculation of global CBF, injections of ice-cold indocyanine green boluses were performed and temperature and dye concentration changes were monitored in the thoracic aorta and the jugular bulb. CBF was then calculated according to the mean transit time principle. Estimation of CCP, the arterial pressure at which cerebral blood flow becomes zero, was performed by synchronized registration of corresponding values of blood flow velocity in the middle cerebral artery and arterial pressure and extrapolation to zero-flow velocity. CPPeff was calculated as mean arterial pressure minus critical closing pressure (CPPeff=MAPc−CCP). Results: Elevated ventilation causes a decrease in both ICP (P<0.001) and CBF (P<0.001). While CPPconv increased (P<0.001), CPPeff decreased during this observation (P=0.002). Administration of osmotherapeutic agents resulted in a decrease of ICP (P<0.001) and a temporary increase of CBF (P=0.052). CPPconv and CPPeff showed no striking difference under osmotherapy. Conclusion: TCID allows repeated measurements of global CBF at the bedside. Elevated ventilation lowered and osmotherapy temporarily raised global CBF. In situations of increased vasotonus, CPPeff is a better indicator of blood flow changes than conventional CP

Cerebral blood flow reactivity in patients undergoing selective amygdalohippocampectomy for epilepsy of mesial temporal origin. A prospective randomized comparison of the trans-Sylvian and the transcortical approach

Objective: The aim of this study was to assess (1) whether vasoreactivity is altered in patients with epilepsy and (2) whether the two most commonly used approaches, the trans-Sylvian (TS) and the trans-cortical (TC) route, differ in their impact on cortical blood flow. Methods: Patients were randomized to undergo selective amygdalohippocampectomy (selAH) through a TC or TS route. Before and after selAH, we recorded microcirculation parameters on the superficial cortex surrounding the surgical corridor. Blood flow and velocity were measured using laser Doppler flowmetry and micro-Doppler, respectively. Cortical oxygen saturation (SO2) was measured using remission spectrophotometry under hypocapnic and normocapnic conditions. Results: Ten patients were operated using the TS approach, and eight were operated via the TC approach. Vasomotor reactivity patterns measured with micro-Doppler were physiologically prior to selAH in both groups. After completion of surgery, a significant increase in SO2-values occurred in the TS group (before: 56.7 2.2, after: 65.5 +/- 3.0%SO2), but not in the TC group (before: 52.9 +/- 5.2, after: 53.0 +/- 3.7%SO2). The rate of critical SO2 values below 25% was significantly higher after the TC approach (12.3%) compared to the TS approach (5.2%; p < 0.05). Discussion: Our findings provide the first invasively measured evidence that patients with mesial temporal lobe epilepsy have preserved cerebral blood flow responses to alterations in CO2. In addition, local cortical SO2 was higher in the TS group than in the TC group after selAH. This may be a sign of reactive cortical vessel dilation after proximal vessel manipulation associated with the TS approach. In contrast, the lower values of SO2 after the TC approach indicate tissue ischaemia surrounding the surgical corridor surrounding the corticotomy