Cerebrovascular pressure reactivity monitoring using wavelet analysis in traumatic brain injury patients: A retrospective study,PLOS Medicine

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Cerebrovascular pressure reactivity monitoring using wavelet analysis in traumatic brain injury patients: A retrospective study
PLOS Medicine ( IF 10.5 ) Pub Date : 2017-07-25 , DOI: 10.1371/journal.pmed.1002348
Xiuyun Liu ₁ , Joseph Donnelly ₁ , Marek Czosnyka _{1,

2} , Marcel J H Aries _{1,

3} , Ken Brady ₄ , Danilo Cardim ₁ , Chiara Robba _{1,

5} , Manuel Cabeleira ₁ , Dong-Joo Kim ₆ , Christina Haubrich ₇ , Peter J Hutchinson ₁ , Peter Smielewski ₁

Affiliation

Background

After traumatic brain injury (TBI), the ability of cerebral vessels to appropriately react to changes in arterial blood pressure (pressure reactivity) is impaired, leaving patients vulnerable to cerebral hypo- or hyperperfusion. Although, the traditional pressure reactivity index (PRx) has demonstrated that impaired pressure reactivity is associated with poor patient outcome, PRx is sometimes erratic and may not be reliable in various clinical circumstances. Here, we introduce a more robust transform-based wavelet pressure reactivity index (wPRx) and compare its performance with the widely used traditional PRx across 3 areas: its stability and reliability in time, its ability to give an optimal cerebral perfusion pressure (CPPopt) recommendation, and its relationship with patient outcome.

Methods and findings

Five hundred and fifteen patients with TBI admitted in Addenbrooke’s Hospital, United Kingdom (March 23rd, 2003 through December 9th, 2014), with continuous monitoring of arterial blood pressure (ABP) and intracranial pressure (ICP), were retrospectively analyzed to calculate the traditional PRx and a novel wavelet transform-based wPRx. wPRx was calculated by taking the cosine of the wavelet transform phase-shift between ABP and ICP. A time trend of CPPopt was calculated using an automated curve-fitting method that determined the cerebral perfusion pressure (CPP) at which the pressure reactivity (PRx or wPRx) was most efficient (CPPopt_PRx and CPPopt_wPRx, respectively).

There was a significantly positive relationship between PRx and wPRx (r = 0.73), and wavelet wPRx was more reliable in time (ratio of between-hour variance to total variance, wPRx 0.957 ± 0.0032 versus PRx and 0.949 ± 0.047 for PRx, p = 0.002). The 2-hour interval standard deviation of wPRx (0.19 ± 0.07) was smaller than that of PRx (0.30 ± 0.13, p < 0.001). wPRx performed better in distinguishing between mortality and survival (the area under the receiver operating characteristic [ROC] curve [AUROC] for wPRx was 0.73 versus 0.66 for PRx, p = 0.003). The mean difference between the patients’ CPP and their CPPopt was related to outcome for both calculation methods. There was a good relationship between the 2 CPPopts (r = 0.814, p < 0.001). CPPopt_wPRx was more stable than CPPopt_PRx (within patient standard deviation 7.05 ± 3.78 versus 8.45 ± 2.90; p < 0.001).

Key limitations include that this study is a retrospective analysis and only compared wPRx with PRx in the cohort of patients with TBI. Prior prospective validation is required to better assess clinical utility of this approach.

Conclusions

wPRx offers several advantages to the traditional PRx: it is more stable in time, it yields a more consistent CPPopt recommendation, and, importantly, it has a stronger relationship with patient outcome. The clinical utility of wPRx should be explored in prospective studies of critically injured neurological patients.

中文翻译：

创伤性脑损伤患者使用小波分析监测脑血管压力反应性：一项回顾性研究

背景

创伤性脑损伤 (TBI) 后，脑血管对动脉血压变化（压力反应性）的适当反应能力受损，使患者容易出现脑灌注不足或过度灌注。尽管传统的压力反应指数 (PRx) 已证明压力反应受损与患者预后不良有关，但 PRx 有时不稳定，在各种临床情况下可能并不可靠。在这里，我们介绍了一种更稳健的基于变换的小波压力反应指数 (wPRx)，并将其与广泛使用的传统 PRx 在 3 个方面的性能进行了比较：它的稳定性和时间可靠性，它提供最佳脑灌注压 (CPPopt) 的能力推荐及其与患者预后的关系。

方法和发现

回顾性分析在英国阿登布鲁克医院（2003 年 3 月 23 日至 2014 年 12 月 9 日）收治的 515 名 TBI 患者，连续监测动脉血压（ABP）和颅内压（ICP），计算传统PRx 和一种新颖的基于小波变换的 wPRx。wPRx 是通过取 ABP 和 ICP 之间的小波变换相移的余弦来计算的。使用自动曲线拟合方法计算 CPPopt 的时间趋势，该方法确定压力反应性（PRx 或 wPRx）最有效的脑灌注压（CPP）（分别为 CPPopt_PRx 和 CPPopt_wPRx）。

PRx 和 wPRx 之间存在显着正相关（r = 0.73），小波 wPRx 在时间上更可靠（小时间方差与总方差之比，wPRx 0.957 ± 0.0032 与 PRx 相比，PRx 为 0.949 ± 0.047，p = 0.002)。wPRx 的 2 小时间隔标准差 (0.19 ± 0.07) 小于 PRx (0.30 ± 0.13, p < 0.001)。wPRx 在区分死亡率和生存率方面表现更好（wPRx 的受试者工作特征 [ROC] 曲线 [AUROC] 下面积为 0.73，而 PRx 为 0.66，p = 0.003）。患者的 CPP 和他们的 CPPopt 之间的平均差异与两种计算方法的结果有关。2 个 CPPopts 之间存在良好的关系 (r = 0.814, p< 0.001)。CPPopt_wPRx 比 CPPopt_PRx 更稳定（在患者标准偏差 7.05 ± 3.78 对 8.45 ± 2.90 范围内；p < 0.001）。

主要限制包括该研究是一项回顾性分析，并且仅在 TBI 患者队列中比较了 wPRx 与 PRx。需要事先进行前瞻性验证，以更好地评估这种方法的临床效用。