What is the recommended cerebral perfusion pressure (CPP) goal in managing diffuse axonal injury (DAI)?

From the Guidelines

The recommended cerebral perfusion pressure (CPP) goal in managing diffuse axonal injury (DAI) should be maintained at ≥ 60 mmHg, as suggested by the most recent and highest quality study 1. This target aims to maintain adequate blood flow to the injured brain while avoiding both hypoperfusion and hyperperfusion. CPP is calculated as the difference between mean arterial pressure (MAP) and intracranial pressure (ICP), with the formula CPP = MAP - ICP.

To achieve this target, clinicians should monitor both blood pressure and ICP closely, using vasopressors like norepinephrine or phenylephrine if needed to increase MAP, while simultaneously managing ICP through measures such as head elevation to 30 degrees, adequate sedation, osmotic therapy with mannitol or hypertonic saline, and CSF drainage if necessary. Maintaining this CPP range helps prevent secondary brain injury by ensuring adequate oxygen and nutrient delivery to brain tissue while minimizing cerebral edema.

It's also important to note that this value should be adjusted (individualized) based on neuromonitoring data and the cerebral auto-regulation status of the individual patient, as emphasized in the guidelines 1. The stepwise approach in case of intracranial hypertension (IH) should also be considered, as outlined in the consensus algorithm 1.

Key considerations in managing CPP in DAI patients include:

• Monitoring and managing blood pressure and ICP closely
• Using vasopressors and other measures to maintain adequate CPP
• Individualizing treatment based on continuous multimodal monitoring
• Adjusting CPP targets based on neuromonitoring data and cerebral auto-regulation status
• Considering the stepwise approach in case of IH, as outlined in the consensus algorithm 1

From the Research

Cerebral Perfusion Pressure Goal in Diffuse Axonal Injury

• The recommended cerebral perfusion pressure (CPP) goal in managing diffuse axonal injury (DAI) is a topic of ongoing debate and research 2, 3, 4, 5, 6.
• The Brain Trauma Foundation has updated their guidelines to recommend a lower CPP goal of 60 mmHg 2.
• However, some studies suggest that a CPP range of 50-70 mmHg may be more appropriate, with individualized targets based on cerebral autoregulation and pressure reactivity index (PRx) 3, 5, 6.
• The use of advanced neuromonitoring techniques, such as continuous multimodal brain monitoring, may help to optimize individual CPP-guided treatment 3, 5, 6.
• Deviations from individualized CPPopt (optimal cerebral perfusion pressure) have been associated with poor outcomes, including mortality and severe disability 5, 6.
• Further research is needed to determine the optimal CPP goal in DAI and to develop effective strategies for individualized CPP management 2, 3, 4, 5, 6.

Key Findings

• A CPP threshold of 70 mmHg is commonly recommended, but may not be necessary for all patients 2.
• Individualized CPP management based on cerebral autoregulation and PRx may be more effective than a one-size-fits-all approach 3, 5, 6.
• Advanced neuromonitoring techniques can help to optimize CPP-guided treatment and improve patient outcomes 3, 5, 6.
• Further research is needed to confirm the optimal CPP goal in DAI and to develop effective strategies for individualized CPP management 2, 3, 4, 5, 6.

Implications for Practice

• Clinicians should consider individualized CPP management based on cerebral autoregulation and PRx when treating patients with DAI 3, 5, 6.
• Advanced neuromonitoring techniques, such as continuous multimodal brain monitoring, may be useful in optimizing CPP-guided treatment 3, 5, 6.
• Further research is needed to develop effective strategies for individualized CPP management and to confirm the optimal CPP goal in DAI 2, 3, 4, 5, 6.