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Multicenter Study
. 2025 Aug 4;29(1):344.
doi: 10.1186/s13054-025-05568-4.

Visualizations of autoregulatory insults in moderate-to-severe paediatric traumatic brain injury: a secondary analysis from the multicentre STARSHIP trial

Teodor Svedung Wettervik  1   2 , Claudia Ann Smith  3 , Anders Hånell  4 , Stefan Yu Bögli  3 , Peter Hutchinson  3 , Shruti Agrawal #  5   6 , Peter Smielewski #  3 ; STARSHIP study team
Collaborators, Affiliations
Multicenter Study

Visualizations of autoregulatory insults in moderate-to-severe paediatric traumatic brain injury: a secondary analysis from the multicentre STARSHIP trial

Teodor Svedung Wettervik et al. Crit Care. .

Abstract

Background: Paediatric traumatic brain injury (TBI) is a heterogeneous condition with age-dependent differences in systemic and cerebral physiology, making cerebral perfusion pressure (CPP) challenging to target. Monitoring cerebral autoregulation using the pressure reactivity index (PRx) and deriving an autoregulatory optimal CPP (CPPopt) may personalize treatment, but evidence in children remains limited. In this multicentre paediatric TBI study, we aimed to explore and visualize PRx and CPPopt in relation to outcome.

Methods: In this secondary analysis of the prospective, multicentre study (STARSHIP), 98 paediatric TBI patients (1-16 years) from 10 paediatric intensive care units, in the UK, between 2018 and 2023, with high-frequency physiological data and 12-month GOS-E Peds outcomes, not treated with decompressive craniectomy, were included. Intracranial pressure (ICP), PRx, CPP, and ΔCPPopt were correlated with outcome using insult intensity/duration heatmaps across the full monitoring period. Two-variable heatmaps incorporating PRx were also used to assess how autoregulation modified the relationship between ICP, CPP, and ΔCPPopt with outcome.

Results: There was a transition from favourable to unfavourable outcome when PRx exceeded + 0.00 for longer episodes. Furthermore, there was a transition towards worse outcome when CPP went below 40 mmHg and above 100 mmHg for sustained durations. For ΔCPPopt, the transition towards poor prognosis occurred for values below - 20 mmHg, but positive ΔCPPopt was tolerated. In the two-variable heatmaps, PRx above + 0.50 together with ICP above 20 mmHg, CPP below 60 mmHg, or negative ΔCPPopt were particularly associated with unfavourable outcome.

Conclusions: This novel study visualized the safe and dangerous intervals for PRx and CPPopt as well as the interaction effect between the autoregulatory status and ICP, CPP, and ΔCPPopt in relation to outcome in paediatric TBI. Future prospective trials are needed to evaluate the safety, feasibility, and efficacy of PRx/CPPopt guided management.

Keywords: Cerebral autoregulation; Optimal cerebral perfusion pressure; Outcome; Paediatric; Pressure reactivity index; Traumatic brain injury.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The study was approved by the Health Research Authority, South West-Central Bristol Research Ethics Committee (Ref: 18/SW/0053, 23/SW/011). Informed consent was obtained by the patients’ caregivers. Consent for publication: Not applicable. Competing interests: ICM+ is a software licensed by Cambridge Enterprise Ltd. PS has a financial interest in a part of licensing fee; the licensing fee was waivered for this study.

Figures

Fig. 1
Fig. 1
Visualizations of ICP and PRx intensity/duration insults and their relation to outcome– in paediatric TBI patients aged > 12 months and without DC. Outcome heatmap– The outcome heatmaps indicate the colour-coded correlation coefficient between the number of GMT-weighted insults of specific intensities for specific durations and GOS-E Peds for ICP (A) and PRx (C). Red colour indicates an association between more insults of a certain intensity and duration and higher GOS-E Peds (worse outcome), whereas blue colour indicates the opposite association. Density heatmap– The density heatmaps indicate the logarithmic data frequency of ICP (B) and PRx (D). Blue colour indicates highly frequent values, while red colour indicates that they were rare DC = Decompressive craniectomy. GMT = Good Monitoring Time. GOS-E Peds = Glasgow Outcome Scale-Extended Paediatric revision. ICP = Intracranial pressure. PRx = Pressure reactivity index. TBI = Traumatic brain injury
Fig. 2
Fig. 2
Visualizations of CPP and ΔCPPopt intensity/duration insults and their relation to outcome– in paediatric TBI patients aged > 12 months and without DCOutcome heatmap– The outcome heatmaps indicate the colour-coded correlation coefficient between the number of GMT-weighted insults of specific intensities (e.g., CPP below 50 mmHg) for specific durations (e.g., 15 min) and GOS-E Peds for CPP below (A) and above (B) threshold as well as ΔCPPopt below (C) and above (D) threshold. Red colour indicates an association between more insults of a certain intensity and duration and higher GOS-E Peds (worse outcome), whereas blue colour indicates the opposite association Density heatmap– The density heatmaps indicate the logarithmic data frequency of CPP below (E) and above (F) threshold as well as ΔCPPopt below (G) and above (H) threshold. Blue colour indicates highly frequent values, while red colour indicates that they were rare CPP = Cerebral perfusion pressure. CPPopt = Optimal CPP. DC = Decompressive craniectomy. GMT = Good Monitoring Time. GOS-E Peds = Glasgow Outcome Scale-Extended Paediatric revision. TBI = Traumatic brain injury
Fig. 3
Fig. 3
Optimized outcome dichotomy and data density of PRx in combination with ICP, CPP, and ∆CPPopt– in paediatric TBI patients aged > 12 months and without DC. Outcome heatmap - The outcome heatmaps indicate the colour-coded correlation coefficient between percentage of good monitoring time of PRx in combination with ICP (A), CPP (C), and ∆CPPopt (E) for specific intervals in relation to GOS-E Peds. Red colour indicates an association between a higher %GMT and higher GOS-E (worse outcome), whereas blue colour indicates the opposite association. Density heatmap - The density heatmaps indicate the data frequency of PRx in combination with ICP (B), CPP (D), and ∆CPPopt (F) values. Blue colour indicates highly frequent PRx values, while red colour indicates that they were rare CPP = Cerebral perfusion pressure. CPPopt = Optimal CPP. DC = Decompressive craniectomy. GMT = Good monitoring time. GOS-E Peds = Glasgow Outcome Scale-Extended Paediatric revision. ICP = Intracranial pressure. PRx = Pressure reactivity index. TBI = Traumatic brain injury
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