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Review
. 2025 Oct 1;53(10):e2062-e2075.
doi: 10.1097/CCM.0000000000006790. Epub 2025 Aug 19.

Determination of Cerebral Autoregulation at the Bedside: A Narrative Review

Jeffrey R Vitt  1 , Spyridoula Tsetsou  2 , Laura Galarza  3   4 , Aarti Sarwal  5 , Swarna Rajagopalan  6
Affiliations
Review

Determination of Cerebral Autoregulation at the Bedside: A Narrative Review

Jeffrey R Vitt et al. Crit Care Med. .

Abstract

Objectives: To summarize the current evidence on cerebral autoregulation (CAR) monitoring techniques in critical care settings, highlighting their advantages, limitations, and practical applications at the bedside to inform understanding and clinical decision-making for various acute brain injuries and systemic illnesses.

Data sources: Articles were retrieved using Ovid MEDLINE, PubMed, and Cochrane library using a comprehensive combination of subject headings and key words including "cerebral autoregulation," "transcranial Doppler," "near-infrared spectroscopy," and "intracranial pressure." See Supplemental Appendix A ( https://links.lww.com/CCM/H763 ) for complete list of search terms. Relevant articles as well as those discovered through the review process (e.g., references in selected articles) were incorporated into the article.

Study selection: Original research, review articles, commentaries, and guidelines focusing on bedside CAR monitoring methodologies, their validation, and applications in critically ill patients were included. The review encompassed both acute brain injury and systemic critical illness conditions.

Data extraction: Data from included publications were evaluated and synthesized into a comprehensive narrative review examining CAR monitoring methods and clinical applications.

Data synthesis: Three commonly used bedside approaches for assessing CAR were identified. Transcranial Doppler ultrasound measures vessel flow velocity response to blood pressure changes, either through vasopressor administration or monitoring spontaneous fluctuations. Near-infrared spectroscopy evaluates regional cerebral oxygenation changes in response to hemodynamic alterations through continuous, noninvasive forehead sensors. Intracranial pressure monitoring enables assessment of pressure reactivity index through analyzing the correlation between intracranial and arterial blood pressure. CAR impairment is common across critical illness, from acute brain injury to systemic conditions like sepsis, cardiac surgery, and hepatic failure, where dysregulation can lead to secondary brain injury and worse outcomes. While each technique offers unique insights into CAR status, they vary in invasiveness, continuous monitoring capability, and technical requirements. Evidence suggests these methods can help to detect impaired CAR, identify optimal perfusion targets, and may guide individualized management strategies.

Conclusions: Bedside CAR monitoring represents a promising approach for personalizing hemodynamic management in critically ill patients. While current evidence supports its role in prognostication and management decisions, further research is needed to standardize assessment methods and validate CAR-guided therapy across different critical care conditions. Multimodal monitoring approaches may provide complementary information to optimize patient care.

Keywords: bedside; cerebral autoregulation; intracranial pressure; near-infrared spectroscopy; neuromonitoring; transcranial Doppler ultrasound.

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Conflict of interest statement

Dr. Tsetsou is partially supported through Biomedical Advanced Research and Development Authority of the U.S. Department of Health and Human Services and U.S. Army Medical Research Acquisition Activity. Dr. Sarwal’s institution has received compensation for research support for conducting multicenter clinical trial from Bard, Biogen, Novartis, and CVR Global; she received personal compensation for serving as a speaker/faculty and Continuous Medical Education courses with Society of Critical Care Medicine (SCCM); she is a consultant (member, Clinical Events Committee) for clinical trial Reinvigorate ( ClinicalTrials.gov identifier: NCT05998018) sponsored by Stimdia Medical Inc (January 1, 2023 – ongoing) and a consultant (member, Data Safety Monitoring Board) for Phase 2 MR-301 clinical trial ( ClinicalTrials.gov identifier: NCT06253923) sponsored by SHINKEI Therapeutics, Inc (January 30, 2024 – ongoing). She received funding from the SCCM, the European Society of Critical Care Medicine, the Emirates Critical Care Conference, the International Symposium On Intensive Care & Emergency Medicine, CCM Manchester, Image Monitoring, and Butterfly; she has a compensated relationship as a Social Media Editor with Critical Care Medicine; she serves as social media editor of neurocritical care and treasurer of American Society of Neuroimaging in an uncompensated role, a member of the Board of Directors of the Neurocritical Care Society, and Chair Elect of the Neuroscience Section of the SCCM; she received a loan of devices for investigator-initiated trial from Butterfly and Image Monitoring (Viasonix); and she received compensation as a consultant for clinical trials sponsored by Stimdia and Shinkei Therapeutics. Dr. Rajagopalan serves in uncompensated roles as ultrasound section co-chair and visual abstract editor with Neurocritical Care Society; she has received compensation as a consultant for Ceribell in the past; and she is currently a principal investigator using wearable technology from Kandu. The remaining authors have disclosed that they do not have any potential conflicts of interest.

References

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