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Assessing Cerebral Autoregulation via Oscillatory Lower Body Negative Pressure and Projection Pursuit Regression
Published on: December 10, 2014
Cerebral Autoregulation, Brain Injury, and the Transitioning Premature Infant
Zachary A Vesoulis1, Amit M Mathur1
1Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA.
Insights
Clinical advancements have reduced preterm infant brain injuries, but cerebral palsy remains a risk. Impaired cerebrovascular autoregulation, crucial for brain blood flow, is a key factor. New monitoring technologies offer improved assessment and potential neuroprotection strategies.
Area of Science:
- Neonatal Neurology and Neuroprotection
- Cerebrovascular Physiology
- Biomedical Engineering
Background:
- Preterm infant brain injuries like intraventricular hemorrhage and white matter injury contribute to cerebral palsy and adverse neurodevelopmental outcomes.
- Ischemia-reperfusion injury, linked to dysregulation of cerebral blood flow, is a common pathway for these injuries.
- Current hemodynamic monitoring methods (e.g., mean arterial blood pressure, echocardiography) have limitations in assessing injury risk and guiding neuroprotection.
Purpose of the Study:
- To review technological advancements in assessing cerebrovascular autoregulation in preterm infants.
- To explore how clinical factors influence hemodynamic status and cerebral blood flow regulation in preterm neonates.
- To examine the contribution of cerebral autoregulation dysfunction to preterm brain injury and discuss future bedside monitoring.
Main Methods:
- Review of technological advancements, focusing on near-infrared spectroscopy (NIRS) for bedside monitoring of cerebrovascular autoregulation.
- Exploration of clinical factors (hypotension, vasoactive medications, hypoxia, ventilation) affecting hemodynamic state and cerebral blood flow.
- Analysis of the link between impaired cerebral autoregulation and the development of brain injury in preterm infants.
Main Results:
- Technological evolution, particularly NIRS, has provided new insights into cerebrovascular autoregulation mechanisms in preterm infants.
- Various clinical factors significantly alter the hemodynamic state and cerebral blood flow regulation in this vulnerable population.
- Impaired cerebral autoregulation is increasingly recognized as a critical factor contributing to preterm brain injury.
Conclusions:
- Advancements in monitoring cerebrovascular autoregulation offer promising avenues for neuroprotection in preterm infants.
- Understanding the impact of clinical factors on cerebral blood flow regulation is essential for preventing brain injury.
- Future research focusing on bedside measurement of autoregulation holds potential for improved clinical management and neurodevelopmental outcomes.
Abstract:
Improvements in clinical management of the preterm infant have reduced the rates of the two most common forms of brain injury, such as severe intraventricular hemorrhage and white matter injury, both of which are contributory factors in the development of cerebral palsy. Nonetheless, they remain a persistent challenge and are associated with a significant increase in the risk of adverse neurodevelopment outcomes. Repeated episodes of ischemia-reperfusion represent a common pathway for both forms of injury, arising from discordance between systemic blood flow and the innate regulation of cerebral blood flow in the germinal matrix and periventricular white matter. Nevertheless, establishing firm hemodynamic boundaries, as a part of neuroprotective strategy, has challenged researchers. Existing measures either demonstrate inconsistent relationships with injury, as in the case of mean arterial blood pressure, or are not feasible for long-term monitoring, such as cardiac output estimated by echocardiography. These challenges have led some researchers to focus on the mechanisms that control blood flow to the brain, known as cerebrovascular autoregulation. Historically, the function of the cerebrovascular autoregulatory system has been difficult to quantify; however, the evolution of bedside monitoring devices, particularly near-infrared spectroscopy, has enabled new insights into these mechanisms and how impairment of blood flow regulation may contribute to catastrophic injury. In this review, we first seek to examine how technological advancement has changed the assessment of cerebrovascular autoregulation in premature infants. Next, we explore how clinical factors, including hypotension, vasoactive medications, acute and chronic hypoxia, and ventilation, alter the hemodynamic state of the preterm infant. Additionally, we examine how developmentally linked or acquired dysfunction in cerebral autoregulation contributes to preterm brain injury. In conclusion, we address exciting new approaches to the measurement of autoregulation and discuss the feasibility of translation to the bedside.
