Related Experiment Video
Updated: Jun 22, 2026
A Detailed Protocol for Physiological Parameters Acquisition and Analysis in Neurosurgical Critical Patients
Published on: October 17, 2017
Exploring the Upper Limits of Cerebral Perfusion Pressure in Pediatric Traumatic Brain Injury: A STARSHIP Analysis
Stefan Yu Bögli1,2, Ihsane Olakorede3, Claudia Ann Smith3
1Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK. stefanyu.boegli@usz.ch.
Insights
High cerebral perfusion pressure (CPP) may not worsen outcomes in pediatric traumatic brain injury (TBI). This study suggests current guidelines might be too strict, but more research is needed to confirm safety and efficacy in TBI patients.
Area of Science:
- Pediatric neurocritical care
- Traumatic brain injury research
- Cerebrovascular physiology
Background:
- Low cerebral perfusion pressure (CPP) is a known poor prognostic marker in pediatric traumatic brain injury (TBI).
- Cerebrovascular autoregulation normally maintains stable cerebral blood flow, but high CPP can disrupt this, increasing risks.
- The pediatric response to high CPP is less understood, prompting investigation into its upper autoregulation limit and impact on outcomes.
Purpose of the Study:
- To characterize the upper limit of autoregulation in children with TBI.
- To investigate the association between high CPP levels and patient outcomes.
Main Methods:
- Analysis of data from the prospective, multicenter STARSHIP study (135 children with TBI).
- Exploration of the relationship between CPP levels and the pressure reactivity index (PRx) using visual and statistical methods.
- Assessment of CPP's prognostic value through overall averages, dose metrics, and time spent above thresholds.
Main Results:
- No definitive upper limit of autoregulation was identified; PRx increased significantly only above 100 mm Hg.
- Hourly CPP dose and time spent above 90 mm Hg showed a trend toward worse outcomes.
- Heatmap analysis identified CPP regions with varying risk stratifications.
- No significant CPP differences were observed between patients with or without ARDS or secondary hemorrhages.
Conclusions:
- Contrary to expectations, high CPP levels (above current guidelines) may not be associated with worse outcomes in this pediatric TBI cohort.
- The observational nature and potential confounders necessitate caution in interpreting these findings.
- Prospective trials are required to definitively assess the safety and efficacy of targeting higher CPP in pediatric TBI management.
Background:
Low cerebral perfusion pressure (CPP) has previously been identified as a key prognostic marker after pediatric traumatic brain injury (TBI). Cerebrovascular autoregulation supports stabilization of cerebral blood flow within the autoregulation range. Beyond the upper limit of this range, cerebral blood flow increases with increasing CPP, leading to increased risk of intracranial hypertension and blood-brain barrier disruptions. Based on the hypothesis that children are less sensitive to high CPP, we aimed to characterize the pediatric upper limit of autoregulation and the association between high CPP and outcome.
Methods:
Data acquired as part of the "Studying Trends of Autoregulation in Severe Head Injury in Paediatrics" (STARSHIP) study (a prospective, multicenter, observational study that enrolled 135 children with TBI from July 2018 to March 2023) were explored. The association between different levels of CPP and the autoregulation proxy measure, the pressure reactivity index (PRx), were explored visually. The prognostic value of CPP was assessed by exploring overall averages, overall dose, hourly dose, and percentage time spent above specific thresholds. We employed univariable/multivariable (χ2 tests, logistic regression, sliding dichotomy) and visual (heatmap) methods.
Results:
No clear upper limit of autoregulation could be identified with PRx increasing beyond 0.2 only with CPP values beyond 100 mm Hg. Using iterative χ2 testing and logistic regression analyses, similarly, only hourly dose and percentage time beyond CPP of 90 mm Hg displayed a trend toward worse outcome. Using heatmap analyses, regions of CPP with differing risk stratifications could be identified. No difference in CPP could be identified between patients with and without acute respiratory distress syndrome or secondary hemorrhages.
Conclusions:
In contrast to the well-established association between low CPP and poor outcome, our findings suggest that exposure to CPP values above those recommended by the Brain Trauma Foundation guidelines may not be associated with worse outcomes in this cohort. However, given the observational nature of the study and potential confounding factors, these results highlight the need for prospective trials to assess the safety and efficacy of targeting higher CPP in pediatric TBI.
Related Concept Videos
01:14Increased Intracranial Pressure l: Introduction
01:29Increased Intracranial Pressure ll: Pathophysiology