Summary
Introduction: Monitoring of cerebral autoregulation (CA) in patients with a traumatic brain injury (TBI) can provide an individual ‘optimal’ cerebral perfusion pressure (CPP) target (CPPopt) at which CA is best preserved. This potentially offers an individualized precision medicine approach. Retrospective data suggest that deviation of CPP from CPPopt is associated with poor outcomes. We are prospectively assessing the feasibility and safety of this approach in the COGiTATE [CPPopt Guided Therapy: Assessment of Target Effectiveness] study. Its primary objective is to demonstrate the feasibility of individualizing CPP at CPPopt in TBI patients. The secondary objectives are to investigate the safety and physiological effects of this strategy.
Methods: The COGiTATE study has included patients in four European hospitals in Cambridge, Leuven, Nijmegen, and Maastricht (coordinating centre). Patients with severe TBI requiring intracranial pressure (ICP)–directed therapy are allocated into one of two groups. In the intervention group, CPPopt is calculated using a published (modified) algorithm. In the control group, the CPP target recommended in the Brain Trauma Foundation guidelines (CPP 60–70 mmHg) is used.
Results: Patient recruitment started in February 2018 and will continue until 60 patients have been studied. Fifty-one patients (85% of the intended total) have been recruited in October 2019. The first results are expected early 2021.
Conclusion: This prospective evaluation of the feasibility, safety and physiological implications of autoregulation-guided CPP management is providing evidence that will be useful in the design of a future phase III study in severe TBI patients.
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References
Balestreri M, Czosnyka M, Hutchinson P, Steiner LA, Hiler M, Smielewski P, Pickard JD (2006) Impact of intracranial pressure and cerebral perfusion pressure on severe disability and mortality after head injury. Neurocrit Care 4(1):8–13. https://doi.org/10.1385/NCC:4:1:008
Carney N, Totten AM, O’Reilly C et al (2017) Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery 80(1):6–15
Hawryluk GWJ, Aguilera S, Buki A et al (2019) A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive Care Med 45:1783–1794. https://doi.org/10.1007/s00134-019-05805-9
Smith M, Maas AIR (2019) An algorithm for patients with intracranial pressure monitoring: filling the gap between evidence and practice. Intensive Care Med 45(12):1819–1821. https://doi.org/10.1007/s00134-019-05818-4
Donnelly J, Aries MJ, Czosnyka M (2014) Further understanding of cerebral autoregulation at the bedside: possible implications for future therapy. Expert Rev Neurother 15(2):169–185
Aries MJH, Czosnyka M, Budohoski KP et al (2012) Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury. Crit Care Med 40(8):2456–2463
Steiner LA, Czosnyka M, Piechnik SK (2002) Continuous monitoring of cerebrovascular pressure reactivity allows determination of optimal cerebral perfusion pressure in patients with traumatic brain injury. Crit Care 30(4):733–738
Beqiri E, Smielewski P, Robba C, Czosnyka M, Cabeleira MT, Tas J, Donnelly J, Outtrim JG, Hutchinson P, Menon D, Meyfroidt G, Depreitere B, Aries MJ, Ercole A (2019) Feasibility of individualised severe traumatic brain injury management using an automated assessment of optimal cerebral perfusion pressure: the COGiTATE phase II study protocol. BMJ Open 9(9):e030727. https://doi.org/10.1136/bmjopen-2019-030727
Aries MJH, Wesselink R, Elting JWJ, Donnelly J, Czosnyka M, Ercole A, Maurits NM, Smielewski P (2016) Enhanced visualization of optimal cerebral perfusion pressure over time to support clinical decision making. Crit Care Med 44(10):e996–e999
Depreitere B, Güiza F, van den Berghe G, Schuhmann MU, Maier G, Piper I, Meyfroidt G (2014) Pressure autoregulation monitoring and cerebral perfusion pressure target recommendation in patients with severe traumatic brain injury based on minute-by-minute monitoring data. J Neurosurg 120(6):1451–1457
Liu X, Maurits NM, Aries MJH et al (2017) Monitoring of optimal cerebral perfusion pressure in traumatic brain injured patients using a multi-window weighting algorithm. J Neurotrauma 34(22):3081–3088
Zuercher P, Groen JL, Aries MJH, Steyerberg EW, Maas AIR, Ercole A, Menon DK (2016) Reliability and validity of the therapy intensity level scale: analysis of clinimetric properties of a novel approach to assess management of intracranial pressure in traumatic brain injury. J Neurotrauma 33(19):1768–1774
Lassen NA (1964) Autoregulation of cerebral blood flow. Circ Res 15(Suppl):201–204
Brady KM, Hudson A, Hood R, DeCaria B, Lewis C, Hogue CW (2020) Personalizing the definition of hypotension to protect the brain. Anesthesiology 132(1):170–179. https://doi.org/10.1097/ALN.0000000000003005
Brown CH, Neufeld KJ, Tian J et al (2019) Effect of targeting mean arterial pressure during cardiopulmonary bypass by monitoring cerebral autoregulation on postsurgical delirium among older patients: a nested randomized clinical trial. JAMA Surg 154(9):819–826. https://doi.org/10.1001/jamasurg.2019.1163
Petersen NH, Silverman A, Wang A, Strander S, Kodali S, Matouk C, Sheth KN (2019) Association of personalized blood pressure targets with hemorrhagic transformation and functional outcome after endovascular stroke therapy. JAMA Neurol 76(10):1256–1258. https://doi.org/10.1001/jamaneurol.2019.2120
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M.J. Aries has received a clinical grant from the European Society of Intensive Care Medicine to support the COGiTATE study.
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M. Czosnyka and P. Smielewski have a financial interest in ICM+ software.
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Tas, J. et al. (2021). An Update on the COGiTATE Phase II Study: Feasibility and Safety of Targeting an Optimal Cerebral Perfusion Pressure as a Patient-Tailored Therapy in Severe Traumatic Brain Injury. In: Depreitere, B., Meyfroidt, G., Güiza, F. (eds) Intracranial Pressure and Neuromonitoring XVII. Acta Neurochirurgica Supplement, vol 131. Springer, Cham. https://doi.org/10.1007/978-3-030-59436-7_29
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