20. Cerebral Compartmental Compliances
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1 20. Cerebral Compartmental Compliances
2 CBF a (t) Cerebral arterial inflow Cerebral arterial blood volume (C a BV) mean CBF a 0 CBF v (t) Cerebral venous outflow CBV(t) mean CBV + - t t ΔCBV (CBF (t) CBF (t))dt 0 a v t 1 t 2 Cerebral blood volume t Thanks to Dr.M.Kasprowicz R-R interval of ECG Avezaat CJ, van Eijndhoven JH. (1986) The role of the pulsatile pressure variations in intracranial pressure monitoring. Neurosurg Rev 9:
3 Cerebral arterial blood volume Assumptions: Diameter of the MCA artery unchanged during the cardiac cycle Venous outflow constant during the cardiac cycle Thanks to Dr. E.Carrera
4 CBV Thanks to Dr. M.Kasprowicz
5 CaBV pulsation and shape of pulse waveorm of ICP? Thanks to Dr. E.Carrera
6 Thanks to Dr. E.Carrera
7 Thanks to Dr. E.Carrera
8 Thanks to Dr. E.Carrera
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10 Compartmental compliances of brain Cerebral arterial compliance (C a ) Amp CaBV C a = Amp ABP Cerebrospinal + venous compliance (C i ) Amp CaBV C= i Amp ICP Thanks to Dr. E.Carrera
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12 Change of Cerebral Compliance (Ci) during infusion study Thanks to Dr.DJ Kim
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14 Compartmental compliances (C a, C i ) Thanks to Dr.DJ Kim
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16 Thanks to Dr.E.Carrera
17 Thanks to Dr.E.Carrera
18 Thanks to Dr.E.Carrera
19 Thanks to Dr.E.Carrera
20 Stenotic disease- reaction to Diamox (Toulouse study) Thanks to Dr.N.Nasr
21 Thanks to Dr.N.Nasr
22 Thanks to Dr.E.Carrera Hypocapnia in TBI Baseline characteristics Example :18 yo woman GCS =7 Age (years) 39.5 ± 3.4 Gender (women) 6 (22%) GCS 5 (3-8) Physiological variables ABP (mmhg) 97 ± 9 ICP (mmhg) 18 ± 7 CPP (mmhg) 79 ± 8 PaCO 2 (mmhg) 38 ± 0.5
23 Thanks to Dr.E.Carrera ABP ICP CBFV Ci Ca Results Early hyperventilation CSF compartment Reduction in ICP: (17.5 to 13.9 mmhg; p<0.001) Significant increase in Ci Decrease in ICP correlated with the increase in Ci (r 2 =0.2; p=0.02) Arterial compartment Reduction in CBFV (75 to 63 cm/s; p<0.001) Significant decrease in Ca Reduction in CBFV correlated with the reduction in Ca (r 2 =0.2; p=0.02).
24 Ca Ci CBFV ICP ABP Thanks to Dr.E.Carrera Results Sustained hyperventilation CSF compartment Re-increase in ICP (13.9 to 15.3 mmhg; p<0.001) No significant change in Ci Arterial compartment No changes in CBFV (63 vs 62 cm/s; p=0.3) No significant change in Ca
25 Thanks to Dr. DJ Kim Definition Monro-Kellie doctrine When the volume of one compartment increases, there must be a corresponding and compensatory decrease in the volume of the other compartment Brain volume [V brain ] arterial blood Volume [V a-blood ] C a. Venous blood Volume [V v-blood ] Skull rigid body C b C i Brain volume [V brain ] CSF volume [V csf ]
26 Algorithm to estimate ICC Thanks to Dr. DJ Kim Negative ICC - Inverse relationship between C a% and C i% - Monro-Kellie doctrine is obeyed Positive ICC - Direct proportional relationship between C a% and C i% - Monro-Kellie doctrine is not followed
![Observation II Plateau waves (transient changes in cerebral blood volume) ABP [mmhg] 105 100 95 90 Thanks to Dr. DJ Kim ICP [mmhg] CBFva [cm/s] ICC Ca% [%] 60 50 40 30 20 80 60 40 20 1 0.5 0-0.](/docs-images/40/21771434/images/27-0.png "5-1 400 250 100 Strong haemodynamic exitation (Sudden decrease cerebral blood volume) Ci% [%] 400 300 200 100 0 0 4 8 12 16 20 Time [min] Findings: C a% and C i% change in opposite directions, which")
27 Observation II Plateau waves (transient changes in cerebral blood volume) ABP [mmhg] Thanks to Dr. DJ Kim ICP [mmhg] CBFva [cm/s] ICC Ca% [%] Strong haemodynamic exitation (Sudden decrease cerebral blood volume) Ci% [%] Time [min] Findings: C a% and C i% change in opposite directions, which makes ICC solidly negative
28 Thanks to Dr. DJ Kim Observation I Arterial hypertension (transient changes in arterial blood pressure) ABP [mmhg] Strong haemodynamic exitation (Sudden increase arterial blood pressure) ICP [mmhg] CBFva [cm/s] Conpensating mechanism (i.e. autoregulation) ICC Ca% [%] Ci% [%] Time [min] Findings: C a% and C i% change in opposite directions, which makes ICC solidly negative
29 ABP [mmhg] ICP [mmhg] CBFva [cm/s] ICC Ca% [%] Ci% [%] Thanks to Dr. DJ Kim Observation III Intracranial hypertension (traumatic brain injury) Time [min] Findings: C a% and C i% change in same directions, which makes ICC positive
30 Outcome I Distribution of ICC with different outcome cohorts P (Kruskall-Wallis test ) < Survived Fatal
31 Outcome II Change in ICC over time Thanks to Dr. DJ Kim Weight Fatal Survived ICC is significantly greater in patients who died, particularly over the first few days after head injury
32 Thanks to Dr. DJ Kim Correlation I Relationship between ICC and ICP Corr. R=0.65; p<0.001
33 Outcome III Regression of ICC vs mortality rate Intracranial hypertension (IH) -Average ICP > 20 mmhg for entrie NCCU stay Thanks to Dr. DJ Kim IH (30% ) ICC=0.7 IH (65% )
34 Messages to take home Relative changes in compartmental compliances may be assessed with TCD and ABP/ICP waveforms Absolute values unknown- we do not know cross-sectional area of MCA During plateau wave Ca increases and Ci decreases During hyperventilation in TBI Ci increases and Ca decreases Reactivity of Ca to change in PaCO2 is useful in carotid artery stenosis Relative changes in Ca and Ci : monitoring of Monro-Kelly Doctrine?
Monitoring of Cerebral Blood Flow. Transcranial Doppler Laser Doppler Flowmetry Thermal dilution method (Hemedex)
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