Amerikkalaisessa systemoidussa katsauksessa «The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Guidelines for cerebral perfusion pressure. J Neurotrauma 2000;17:50»1 todetaan, että maintenance of a CPP above 70 mmHg is a therapeutic option that may be associated with a substantial reduction in mortality and improvement in quality of survival and is likely to enhance perfusion to ischemic regions of the brain following severe TBI. No study has demonstrated that the incidence of intracranial hypertension, morbidity, or mortality is increased by the active maintenance of CPP above 70 mmHg, even if this means normalizing the intravascular volume or inducing systemic hypertension.

Juul ym. tutkivat satunnaistetussa prospektiivisessa monikeskustutkimuksessa aivojen perfuusiopaineen ja kallonsisäisen paineen merkitystä vaikean aivovamman ennusteelle «Juul N, Morris GF, Marshall SB ym. Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury. The Executive Committee of the »2.

Methods: The authors examined the relative contribution of these two parameters to outcome in a series of 427 patients prospectively studied in an international, multicenter, randomized, double-blind trial of the N-methyl-D-aspartate antagonist Selfotel. Mortality rates rose from 9.6 % in 292 patients who had no clinically defined episodes of neurological deterioration to 56.4 % in 117 patients who suffered one or more of these episodes; 18 patients were lost to follow up. Correspondingly, favorable outcome, defined as good or moderate on the Glasgow Outcome Scale at 6 months, fell from 67.8 % in patients without neurological deterioration to 29.1 % in those with neurological deterioration. In patients who had clinical evidence of neurological deterioration, the relative influence of ICP and CPP on outcome was assessed. The most powerful predictor of neurological worsening was the presence of intracranial hypertension (ICP > or = 20 mmHg) either initially or during neurological deterioration. There was no correlation with the CPP as long as the CPP was greater than 60 mmHg.

Conclusions: Treatment protocols for the management of severe head injury should emphasize the immediate reduction of raised ICP to less than 20 mmHg if possible. A CPP greater than 60 mmHg appears to have little influence on the outcome of patients with severe head injury.

• Tutkimuksen laatu: tasokas
• Sovellettavuus suomalaiseen väestöön: hyvä

Yhdysvalloissa tehdyssä monikeskustutkimuksessa «Clifton GL, Miller ER, Choi SC ym. Fluid thresholds and outcome from severe brain injury. Crit Care Med 2002;30:739-45 »3 verrattiin hypotermian ja normotermian vaikutuksia aivovammapoitlaiden selviytymiseen. Samalla tutkittiin kallosisäisen paineen, keskiverenpaineen, aivojen perfuusiopaineen ja nesteytyksen vaikutuksia. Potilaiden yleishoidossa noudatettiin Eur J Emerg Med 1996;3:109–127 annettuja suosituksia. Tutkimusryhmien välillä ei ollut eroja mainittujen muuttujien vaikutuksissa selviytymiseen. Huonon selvitymisen riski kasvoi, kun aivojen perfuusiopaine oli alle 60 mmHg (CPP alle 50 mmHg OR 1.21, 95 % luottamusväli 0.63–2.35; CPP alle 60 mmHg OR 0.86, 95 % luottamusväli 0.53–1.41; CPP alle 70 mmHg OR 0.89, 95 % luottamusväli 0.59–1.36.)

Kirjoittajien johtopäätös oli, että perfuusiopainetavoitteen tulisi olla 70 mmHg, jotta voitaisiin luotettavasti välttää alle 60 mmHg perfuusiopaine.

• Tutkimuksen laatu: kelvollinen
• Sovellettavuus suomalaiseen väestöön: kohtalainen