• Frederick A Zeiler, Ari Ercole, Marek Czosnyka, Peter Smielewski, Gregory Hawryluk, HutchinsonPeter J APJADivision of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK., David K Menon, and Marcel Aries.
• Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, Winnipeg, Canada; Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK; Biomedical Engineering, Faculty of Engineering, Winnipeg, Canada; Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada. Electronic address: Frederick.Zeiler@umanitoba.ca.
• Br J Anaesth. 2020 Apr 1; 124 (4): 440453440-453.

AbstractImpaired cerebrovascular reactivity in adult moderate and severe traumatic brain injury (TBI) is known to be associated with worse global outcome at 6-12 months. As technology has improved over the past decades, monitoring of cerebrovascular reactivity has shifted from intermittent measures, to experimentally validated continuously updating indices at the bedside. Such advances have led to the exploration of individualised physiologic targets in adult TBI management, such as optimal cerebral perfusion pressure (CPP) values, or CPP limits in which vascular reactivity is relatively intact. These targets have been shown to have a stronger association with outcome compared with existing consensus-based guideline thresholds in severe TBI care. This has sparked ongoing prospective trials of such personalised medicine approaches in adult TBI. In this narrative review paper, we focus on the concept of cerebral autoregulation, proposed mechanisms of control and methods of continuous monitoring used in TBI. We highlight multimodal cranial monitoring approaches for continuous cerebrovascular reactivity assessment, physiologic and neuroimaging correlates, and associations with outcome. Finally, we explore the recent 'state-of-the-art' advances in personalised physiologic targets based on continuous cerebrovascular reactivity monitoring, their benefits, and implications for future avenues of research in TBI.Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

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