. 2021 Jun;34(3):731-738.

doi: 10.1007/s12028-020-01185-x. Epub 2021 Jan 25.

Cerebrovascular Autoregulation Monitoring in the Management of Adult Severe Traumatic Brain Injury: A Delphi Consensus of Clinicians

B Depreitere¹, G Citerio², M Smith³, P David Adelson^{4

5}, M J Aries⁶, T P Bleck⁷, P Bouzat⁸, R Chesnut⁹, V De Sloovere¹⁰, M Diringer¹¹, J Dureanteau¹², A Ercole¹³, G Hawryluk¹⁴, C Hawthorne¹⁵, R Helbok¹⁶, S P Klein¹⁷, J O Neumann¹⁸, C Robba¹⁹, L Steiner^{20

21}, N Stocchetti²², F S Taccone²³, A Valadka²⁴, S Wolf²⁵, F A Zeiler^{13

26

27

28

29}, G Meyfroidt³⁰

Affiliations

¹ Neurosurgery, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium. bart.depreitere@uzleuven.be.
² Intensive Care Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.
³ Neurocritical Care Unit, National Hospital for Neurology and Neurosurgery, University College London, London, UK.
⁴ Barrow Neurological Institute At Phoenix Childrens Hospital, Department of Child Health/Neurosurgery, University of Arizona College of Medicine, Tucson, AZ, USA.
⁵ Department of Neurosurgery, Mayo Clinic School of Medicine, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA.
⁶ Department of Intensive Care, Maastricht University Medical Center, University of Maastricht, Maastricht, The Netherlands.
⁷ Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
⁸ Grenoble Alps Trauma Center, Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, Grenoble, France.
⁹ Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA.
¹⁰ Anesthesiology, University Hospitals Leuven, Leuven, Belgium.
¹¹ Department of Neurology, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, USA.
¹² Université Paris Sud - Hôpitaux Universitaires Paris-Sud, Paris, France.
¹³ Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
¹⁴ Section of Neurosurgery, University of Manitoba, Winnipeg, MB, Canada.
¹⁵ Head and Neck Anaesthesia and Neurocritical Care, Institute of Neurological Sciences, Glasgow, UK.
¹⁶ Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
¹⁷ Neurosurgery, University Hospital Brussels, Brussels, Belgium.
¹⁸ Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany.
¹⁹ Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genova, Italy.
²⁰ Anesthesiology, University Hospital Basel, Basel, Switzerland.
²¹ Department of Clinical Research, University of Basel, Basel, Switzerland.
²² Department of Physiopathology and Transplant, Milan University and Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
²³ Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium.
²⁴ Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA.
²⁵ Department of Neurosurgery, University Hospital Berlin Charité, Berlin, Germany.
²⁶ Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
²⁷ Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
²⁸ Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
²⁹ Centre on Aging, University of Manitoba, Winnipeg, Canada.
³⁰ Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.

PMID: 33495910
PMCID: PMC8179892
DOI: 10.1007/s12028-020-01185-x

Cerebrovascular Autoregulation Monitoring in the Management of Adult Severe Traumatic Brain Injury: A Delphi Consensus of Clinicians

B Depreitere et al. Neurocrit Care. 2021 Jun.

. 2021 Jun;34(3):731-738.

doi: 10.1007/s12028-020-01185-x. Epub 2021 Jan 25.

Authors

Affiliations

¹ Neurosurgery, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium. bart.depreitere@uzleuven.be.
² Intensive Care Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.
³ Neurocritical Care Unit, National Hospital for Neurology and Neurosurgery, University College London, London, UK.
⁴ Barrow Neurological Institute At Phoenix Childrens Hospital, Department of Child Health/Neurosurgery, University of Arizona College of Medicine, Tucson, AZ, USA.
⁵ Department of Neurosurgery, Mayo Clinic School of Medicine, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA.
⁶ Department of Intensive Care, Maastricht University Medical Center, University of Maastricht, Maastricht, The Netherlands.
⁷ Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
⁸ Grenoble Alps Trauma Center, Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, Grenoble, France.
⁹ Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA.
¹⁰ Anesthesiology, University Hospitals Leuven, Leuven, Belgium.
¹¹ Department of Neurology, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, USA.
¹² Université Paris Sud - Hôpitaux Universitaires Paris-Sud, Paris, France.
¹³ Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
¹⁴ Section of Neurosurgery, University of Manitoba, Winnipeg, MB, Canada.
¹⁵ Head and Neck Anaesthesia and Neurocritical Care, Institute of Neurological Sciences, Glasgow, UK.
¹⁶ Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
¹⁷ Neurosurgery, University Hospital Brussels, Brussels, Belgium.
¹⁸ Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany.
¹⁹ Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genova, Italy.
²⁰ Anesthesiology, University Hospital Basel, Basel, Switzerland.
²¹ Department of Clinical Research, University of Basel, Basel, Switzerland.
²² Department of Physiopathology and Transplant, Milan University and Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
²³ Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium.
²⁴ Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA.
²⁵ Department of Neurosurgery, University Hospital Berlin Charité, Berlin, Germany.
²⁶ Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
²⁷ Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
²⁸ Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
²⁹ Centre on Aging, University of Manitoba, Winnipeg, Canada.
³⁰ Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.

PMID: 33495910
PMCID: PMC8179892
DOI: 10.1007/s12028-020-01185-x

Abstract

Background: Several methods have been proposed to measure cerebrovascular autoregulation (CA) in traumatic brain injury (TBI), but the lack of a gold standard and the absence of prospective clinical data on risks, impact on care and outcomes of implementation of CA-guided management lead to uncertainty.

Aim: To formulate statements using a Delphi consensus approach employing a group of expert clinicians, that reflect current knowledge of CA, aspects that can be implemented in TBI management and CA research priorities.

Methods: A group of 25 international academic experts with clinical expertise in the management of adult severe TBI patients participated in this consensus process. Seventy-seven statements and multiple-choice questions were submitted to the group in two online surveys, followed by a face-to-face meeting and a third online survey. Participants received feedback on average scores and the rationale for resubmission or rephrasing of statements. Consensus on a statement was defined as agreement of more than 75% of participants.

Results: Consensus amongst participants was achieved on the importance of CA status in adult severe TBI pathophysiology, the dynamic non-binary nature of CA impairment, its association with outcome and the inadvisability of employing universal and absolute cerebral perfusion pressure targets. Consensus could not be reached on the accuracy, reliability and validation of any current CA assessment method. There was also no consensus on how to implement CA information in clinical management protocols, reflecting insufficient clinical evidence.

Conclusion: The Delphi process resulted in 25 consensus statements addressing the pathophysiology of impaired CA, and its impact on cerebral perfusion pressure targets and outcome. A research agenda was proposed emphasizing the need for better validated CA assessment methods as well as the focused investigation of the application of CA-guided management in clinical care using prospective safety, feasibility and efficacy studies.

Keywords: Adult; Cerebral blood flow; Cerebral perfusion pressure; Consensus development; Homeostasis; Traumatic brain injury.

PubMed Disclaimer

Conflict of interest statement

All of the authors declare that they have nothing to disclose.

Comment in

Cerebral Autoregulation: The Concept the Legend the Promise.
Lazaridis C. Lazaridis C. Neurocrit Care. 2021 Jun;34(3):717-719. doi: 10.1007/s12028-020-01186-w. Epub 2021 Jan 25. Neurocrit Care. 2021. PMID: 33495911 No abstract available.

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Cerebrovascular Autoregulation Monitoring in the Management of Adult Severe Traumatic Brain Injury: A Delphi Consensus of Clinicians

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Cerebrovascular Autoregulation Monitoring in the Management of Adult Severe Traumatic Brain Injury: A Delphi Consensus of Clinicians

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