Abstract
Background and Objective: Cerebral microdialysis (CMD) enables monitoring brain tissue metabolism and risk factors for secondary brain injury such as an imbalance of consumption, altered utilization, and delivery of oxygen and glucose, frequently present following spontaneous intracerebral hemorrhage (SICH). The aim of this study was to evaluate the relationship between lactate/pyruvate ratio (LPR) with hemodynamic variables [mean arterial blood pressure (MABP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), and cerebrovascular pressure reactivity (PRx)] and metabolic variables (glutamate, glucose, and glycerol), within the cerebral peri-hemorrhagic region, with the hypothesis that there may be an association between these variables, leading to a worsening of outcome in comatose SICH patients.Methods: This is an international multicenter cohort study regarding a retrospective dataset analysis of non-consecutive comatose patients with supratentorial SICH undergoing invasive multimodality neuromonitoring admitted to neurocritical care units pertaining to three different centers. Patients with SICH were included if they had an indication for invasive ICP and CMD monitoring, were >18 years of age, and had a Glasgow Coma Scale (GCS) score of ≤8.Results: Twenty-two patients were included in the analysis. A total monitoring time of 1,558 h was analyzed, with a mean (SD) monitoring time of 70.72 h (66.25) per patient. Moreover, 21 out of the 22 patients (95%) had disturbed cerebrovascular autoregulation during the observation period. When considering a dichotomized LPR for a threshold level of 25 or 40, there was a statistically significant difference in all the measured variables (PRx, glucose, glutamate), but not glycerol. When dichotomized PRx was considered as the dependent variable, only LPR was related to autoregulation. A lower PRx was associated with a higher survival [27.9% (23.1%) vs. 56.0% (31.3%), p = 0.03].Conclusions: According to our results, disturbed autoregulation in comatose SICH patients is common. It is correlated to deranged metabolites within the peri-hemorrhagic region of the clot and is also associated with poor outcome.
Highlights
Spontaneous intracerebral hemorrhage (SICH) accounts for almost 15% of all strokes worldwide, with the incidence rates of primary SICH in low- and middle-income countries being twice the rates compared to high-income countries (22 vs. 10 per 100,000 persons/year) in 2000–2008, and with case fatality rates of 30–48% in low- to middleincome countries and 25–30% in high-income countries [1, 2]
When dichotomizing cerebrovascular pressure reactivity (PRx) as the dependent variable, the unadjusted logistic mixed model shows lactate/pyruvate ratio (LPR) as the only cerebral microdialysis (CMD) variable related to cerebrovascular autoregulation (CA)
In the adjusted analysis using linear mixedeffects analysis, considering LPR as the dependent variable, the best model resulting from the ANOVA comparison was the one which included PRx, glucose, and glutamate (BIC = 3,585) as fixed effects and a random intercept for patients but not for centers (Table 3)
Summary
Spontaneous intracerebral hemorrhage (SICH) accounts for almost 15% of all strokes worldwide, with the incidence rates of primary SICH in low- and middle-income countries being twice the rates compared to high-income countries (22 vs. 10 per 100,000 persons/year) in 2000–2008, and with case fatality rates of 30–48% in low- to middleincome countries and 25–30% in high-income countries [1, 2]. Following SICH-induced acute brain injury, an imbalance of consumption, utilization, and delivery of oxygen and glucose, along with intracranial hypertension and a reduced cerebral perfusion pressure (CPP) which accompanies hematoma expansion, are responsible for secondary injuries [3,4,5,6]. Monitoring these parameters in order to properly direct treatment is possible with cerebral microdialysis (CMD). The aim of this study was to evaluate the relationship between lactate/pyruvate ratio (LPR) with hemodynamic variables [mean arterial blood pressure (MABP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), and cerebrovascular pressure reactivity (PRx)] and metabolic variables (glutamate, glucose, and glycerol), within the cerebral peri-hemorrhagic region, with the hypothesis that there may be an association between these variables, leading to a worsening of outcome in comatose SICH patients
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