Brian Appavu1,2, Stephen Foldes3,4, Brian T Burrows3, Austin Jacobson3, Todd Abruzzo3,4, Varina Boerwinkle3,4, Anthony Willyerd3,4, Tara Mangum3,4, Vishal Gunnala3,4, Iris Marku3,4, P D Adelson3,4. 1. Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA. bappavu@phoenixchildrens.com. 2. Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA. bappavu@phoenixchildrens.com. 3. Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA. 4. Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA.
Abstract
BACKGROUND: Management after cerebral arteriovenous malformation (AVM) rupture aims toward preventing hemorrhagic expansion while maintaining cerebral perfusion to avoid secondary injury. We investigated associations of model-based indices of cerebral autoregulation (CA) and autonomic function (AF) with outcomes after pediatric cerebral AVM rupture. METHODS: Multimodal neurologic monitoring data from the initial 3 days after cerebral AVM rupture were retrospectively analyzed in children (< 18 years). AF indices included standard deviation of heart rate (HRsd), root-mean-square of successive differences in heart rate (HRrmssd), low-high frequency ratio (LHF), and baroreflex sensitivity (BRS). CA indices include pressure reactivity index (PRx), wavelet pressure reactivity indices (wPRx and wPRx-thr), pulse amplitude index (PAx), and correlation coefficient between intracranial pressure pulse amplitude and cerebral perfusion pressure (RAC). Percent time of cerebral perfusion pressure (CPP) below lower limits of autoregulation (LLA) was also computed for each CA index. Primary outcomes were determined using Pediatric Glasgow Outcome Score Extended-Pediatrics (GOSE-PEDs) at 12 months and acquired epilepsy. Association of biomarkers with outcomes was investigated using linear regression, Wilcoxon signed-rank, or Chi-square. RESULTS: Fourteen children were analyzed. Lower AF indices were associated with poor outcomes (BRS [p = 0.04], HRsd [p = 0.04], and HRrmssd [p = 0.00]; and acquired epilepsy (LHF [p = 0.027]). Higher CA indices were associated with poor outcomes (PRx [p = 0.00], wPRx [p = 0.00], and wPRx-thr [p = 0.01]), and acquired epilepsy (PRx [p = 0.02] and wPRx [p = 0.00]). Increased time below LLA was associated with poor outcome (percent time below LLA based on PRx [p = 0.00], PAx [p = 0.04], wPRx-thr [p = 0.03], and RAC [p = 0.01]; and acquired epilepsy (PRx [p = 0.00], PAx [p = 0.00], wPRx-thr [p = 0.03], and RAC [p = 0.01]). CONCLUSIONS: After pediatric cerebral AVM rupture, poor outcomes are associated with AF and CA when applying various neurophysiologic model-based indices. Prospective work is needed to assess these indices of CA and AF in clinical decision support.
BACKGROUND: Management after cerebral arteriovenous malformation (AVM) rupture aims toward preventing hemorrhagic expansion while maintaining cerebral perfusion to avoid secondary injury. We investigated associations of model-based indices of cerebral autoregulation (CA) and autonomic function (AF) with outcomes after pediatric cerebral AVM rupture. METHODS: Multimodal neurologic monitoring data from the initial 3 days after cerebral AVM rupture were retrospectively analyzed in children (< 18 years). AF indices included standard deviation of heart rate (HRsd), root-mean-square of successive differences in heart rate (HRrmssd), low-high frequency ratio (LHF), and baroreflex sensitivity (BRS). CA indices include pressure reactivity index (PRx), wavelet pressure reactivity indices (wPRx and wPRx-thr), pulse amplitude index (PAx), and correlation coefficient between intracranial pressure pulse amplitude and cerebral perfusion pressure (RAC). Percent time of cerebral perfusion pressure (CPP) below lower limits of autoregulation (LLA) was also computed for each CA index. Primary outcomes were determined using Pediatric Glasgow Outcome Score Extended-Pediatrics (GOSE-PEDs) at 12 months and acquired epilepsy. Association of biomarkers with outcomes was investigated using linear regression, Wilcoxon signed-rank, or Chi-square. RESULTS: Fourteen children were analyzed. Lower AF indices were associated with poor outcomes (BRS [p = 0.04], HRsd [p = 0.04], and HRrmssd [p = 0.00]; and acquired epilepsy (LHF [p = 0.027]). Higher CA indices were associated with poor outcomes (PRx [p = 0.00], wPRx [p = 0.00], and wPRx-thr [p = 0.01]), and acquired epilepsy (PRx [p = 0.02] and wPRx [p = 0.00]). Increased time below LLA was associated with poor outcome (percent time below LLA based on PRx [p = 0.00], PAx [p = 0.04], wPRx-thr [p = 0.03], and RAC [p = 0.01]; and acquired epilepsy (PRx [p = 0.00], PAx [p = 0.00], wPRx-thr [p = 0.03], and RAC [p = 0.01]). CONCLUSIONS: After pediatric cerebral AVM rupture, poor outcomes are associated with AF and CA when applying various neurophysiologic model-based indices. Prospective work is needed to assess these indices of CA and AF in clinical decision support.
Authors: Marek Sykora; Marek Czosnyka; Xiuyun Liu; Joseph Donnelly; Nathalie Nasr; Jennifer Diedler; Francois Okoroafor; Peter Hutchinson; David Menon; Peter Smielewski Journal: Crit Care Med Date: 2016-06 Impact factor: 7.598
Authors: Sue R Beers; Stephen R Wisniewski; Pamela Garcia-Filion; Ye Tian; Thomas Hahner; Rachel P Berger; Michael J Bell; P David Adelson Journal: J Neurotrauma Date: 2012-04-10 Impact factor: 5.269
Authors: Marcel J H Aries; Marek Czosnyka; Karol P Budohoski; Luzius A Steiner; Andrea Lavinio; Angelos G Kolias; Peter J Hutchinson; Ken M Brady; David K Menon; John D Pickard; Peter Smielewski Journal: Crit Care Med Date: 2012-08 Impact factor: 7.598
Authors: Luzius A Steiner; Marek Czosnyka; Stefan K Piechnik; Piotr Smielewski; Doris Chatfield; David K Menon; John D Pickard Journal: Crit Care Med Date: 2002-04 Impact factor: 7.598
Authors: Jennifer C Laws; Lori C Jordan; Lindsay M Pagano; John C Wellons; Michael S Wolf Journal: Pediatr Neurol Date: 2022-02-02 Impact factor: 3.372
Authors: Matthew P Kirschen; Kerri LaRovere; Binod Balakrishnan; Jennifer Erklauer; Conall Francoeur; Saptharishi Lalgudi Ganesan; Anuj Jayakar; Marlina Lovett; Matthew Luchette; Craig A Press; Michael Wolf; Peter Ferrazzano; Mark S Wainwright; Brian Appavu Journal: Pediatr Neurol Date: 2021-11-12 Impact factor: 4.210