(Stroke. 1997;28:2465-2472.)
© 1997 American Heart Association, Inc.
Articles |
Noninvasive Prediction of Intracranial Pressure Curves Using Transcranial Doppler Ultrasonography and Blood Pressure Curves
From the Department of Neurology, Technical University of Munich (Germany).
 |
Abstract |
|---|
 Top Abstract IntroductionTheoretical ConsiderationsSubjects and MethodsResultsDiscussionAppendix 1References |
|---|
Background and Purpose Until now the assessment of intracranial pressure (ICP) required invasive methods. The objective of this study was to introduce an approach to a noninvasive assessment of continuous ICP curves.
Methods The intracranial compartment was considered a "black box" system with an input signal, the arterial blood pressure (ABP), and an output signal, the ICP. A so-called weight function described the relationship between ABP and ICP curves. Certain parameters, called transcranial Doppler (TCD) characteristics, were calculated from the cerebral blood flow velocity (FV) and the ABP curves and were used to estimate this weight function. From simultaneously sampled FV, ABP, and (invasively measured) ICP curves of a defined group of patients with severe head injuries, the TCD characteristics and the weight function were computed. Multiple regression analysis revealed a mathematical formula for calculating the weight function from TCD characteristics. This formula was used to generate the ICP simulation. FV, ABP, and ICP recordings from 11 patients (mean age, 46±14 years) with severe head injury were studied. In each patient, ICP was computed by a simulation procedure, generated from the data of the remaining 10 patients. The simulation period was 100 seconds.
Results Corresponding pressure trends with a mean absolute difference of 4.0±1.8 mm Hg between computed and measured ICP were observed. Shapes of pulse and respiratory ICP modulations were clearly predicted.
Conclusions These results demonstrate that this method constitutes a promising step toward a noninvasive ICP prediction that may be clinically applicable under well-defined conditions.
Key Words: blood flow velocity • blood pressure • head injury • intracranial pressure • ultrasonics
|
Introduction |
|---|
|
TopAbstractIntroductionTheoretical ConsiderationsSubjects and MethodsResultsDiscussionAppendix 1References |
|---|
Acute cerebral diseases frequently lead to a rise in ICP. Monitoring of this parameter could be of vital importance in ensuring the efficacy of therapeutic measures in the case of foudroyant ICP changes, for example. Quantitative data, in particular continuous ICP waves, have only been recorded thus far through invasive methods (eg, an epidural ICP monitoring device). On the other hand, various studies have shown that an increased ICP leads to changes of FV waveforms in intracranial arteries, which are accessible by means of TCD. Using Fourier analysis of FV and ABP curves, Aaslid et al1 developed an estimation formula for ICP. Klingelhöfer et al2 3 4 showed that the MFV decreases with increasing ICP, while the Pourcelot Index (R) increases. A strong correlation (r=.873, P>.001) between the product, mean systemic ABPxR/MFV, and the ICP was observed. This facilitates, under certain conditions that were laid out in the study, a simple quantitative estimation of the ICP. Similar findings concerning the relationships between flow velocity parameters, ABP, and ICP were published by other authors.5 6 7 8 Chan et al5 showed that a reduction of CPP resulted in a greater fall in diastolic flow velocity than other flow parameters. As CPP decreased below a critical value of 70 mm Hg, they observed a strongly correlated progressive increase in FV pulsatility index. Furthermore, a couple of mathematical models, derived from electrical or mechanical analogues of intracranial dynamics, have been developed in recent years9 10 11 12 13 14 15 to explain the pathogenetic basis of ICP waves under certain physiological and pathological conditions. For example, Ursino's model was used to simulate aspects of the ICP waveforms, such as the response to various clinical tests,16 17 the dependence of ICP pulse amplitude on the mean value,17 the pattern of cerebral autoregulation,18 19 and the genesis of Lundberg A and B waves.19 20 21 In contrast to these investigations, our study is not concerned with the inner structure of the intracranial compartment. The intracranial compartment is considered a "black box" system, which is described indirectly by its transformation of the input signal, the ABP curve, into the output signal, the ICP curve. The black box approach and some of the mathematical techniques in our study were formerly used by Kasuga et al,22 who described in an animal study with six dogs the dependence of ICP waves on ABP waveforms for each dog individually. The aim of the current study, however, is to introduce a mathematical model that leads, using the ABP curve and certain characteristics derived from the simultaneously recorded FV and ABP curves, to a noninvasive prediction of the ICP curve in a defined group of patients with severe acute brain damage.
|
Theoretical Considerations |
|---|
|
TopAbstractIntroductionTheoretical ConsiderationsSubjects and MethodsResultsDiscussionAppendix 1References |
|---|
The mathematical model for the noninvasive ICP simulation is based on results from systems analysis.23 Systems analysis provides a method to describe systems, in particular physiological systems, with input and output signals. The outgoing signals are considered the system's responses to its stimulation by incoming signals. Systems analysis does not analyze the inner structure or the realization of a system but characterizes the system by means of its responses to incoming signals. The basic mathematical tools to describe the system's response to the incoming signal are the weight function and the transfer function. The weight function transforms the input signal into the output signal and, on the other hand, can be computed from the input and the output signals. A detailed description of the concepts of systems analysis and the systems' properties is given by Marmarelis and Marmarelis.23 In this study the system under investigation is the intracranial compartment, with the ABP as the input signal and the ICP as the system's response. The applicability of this model was shown by Kasuga et al22 in an animal study, in which the weight function was computed from a short time interval of the ABP and the (invasively measured) ICP curves. It was shown that even beyond this time interval, the weight function transformed the ABP curve into the ICP curve quite accurately. The basic idea of our procedure is to use certain hemodynamic parameters, the so-called TCD characteristics, to approximate the weight function. This allows the transformation of the ABP curve into the simulated ICP curve without the need of invasive measurements. To differentiate between the weight function and its approximation, the approximation will be called the simulation function.
|
Subjects and Methods |
|---|
|
TopAbstractIntroductionTheoretical ConsiderationsSubjects and MethodsResultsDiscussionAppendix 1References |
|---|
Patients
We studied 11 intensive care patients (age, 20 to 59 years; mean age, 46±14 years; 8 men, 3 women). At the time of recording all the patients were mechanically ventilated. Their PaCO2 ranged from 30 to 35 mm Hg. One patient had an infarct in the right territory of the MCA, 2 had a gunshot head injury, and the others suffered from severe head injury (Glasgow Coma Scale
7). No patient showed a vasospasm or a
stenosis of the intracranial or extracranial brain-supplying
arteries. A Doppler CO2 test24 was
performed in each patient to estimate the state of cerebral
vasoreactivity. All patients showed a relative CO2
reactivity less than 2.5% 
MFV/mm Hg PaCO2;
in 3 patients (patients 6, 8, 11) it was less than 2%. In addition,
the relationship between CPP and FV in the recorded data was
analyzed by a method introduced by Czosnyka et al25
for an assessment of cerebral autoregulation. When we adapted his
categorization of autoregulation into "intact," "gray zone,"
and "impaired," 7 patients belonged to the gray zone and 4 patients
(patients 2, 6, 8, 11) belonged to the impaired category. Considering
these two tests, we concluded that none of the patients had an intact
autoregulation. The disturbance ranged from medium to
severe impairment.
Transcranial Doppler Ultrasonography
TCD measurements were taken by a 2-MHz pulsed Doppler
device26 (TC 2–64B, EME). Flow patterns of the MCA were
continuously recorded on the same side that the epidural device was
implanted. A sampling frequency of 25 Hz was used. The probe was fixed
mechanically with a specially developed probe holder with elastic bands
and fixation strips.
Blood Pressure Recording
Blood pressure was measured with a blood pressure monitoring
device (Gould Statham 23 ID), which was implanted into the radial or
femoral artery. Together with the FV and ICP curves, it was
continuously and simultaneously transmitted to a computer
system.
ICP Measurement
The ICP was measured with an implanted epidural ICP monitoring
device with an air pouch probe and an hourly automatic
recalibration27 28 29 (Spiegelberg Plc/Ltd/Co). The following
plausibility criterion had to be met when measuring: the measured ICP
should fit the overall clinical presentation of the
patient, lifting the head should lead to a decrease in ICP, and a
short-lived increase in ICP should occur when the airway is
suctioned.
Recording and Evaluation of the Curves
Two PC/i 486 computers were used for recording and
analyzing the FV, APB, and ICP curves. One of the computers was
portable, and each was fitted with a data acquisition system (DAP
2400/Microstar Laboratories). The used sampling frequency was 25 Hz.
The mathematical and statistical calculations were supported by a
software tool (Real Time Graphics and Measurement Tools/Quinn
Curtis).
Noninvasive ICP Simulation
With the use of patients' data, consisting of
simultaneously recorded FV, ABP, and (invasively
measured) ICP curves, the procedure was generated in three steps. A
more precise description of the calculations performed can be found in
the "Appendix."
Step 1: Computing the Weight Function From the Given ABP and
ICP Curves
The weight function between ABP and ICP curves was computed at
different times of recording. To transform the ABP into the ICP
curve with maximum precision during a defined time interval (in this
study an interval of 14 heart cycles was chosen), a system of linear
equations had to be calculated. The solution of this system of
equations resulted in a vector containing the coefficients of the
weight function. In a representation of ABP and ICP curves by a
sequence of distinct sample values, the weight function is a vector of
numbers. The weight function generally allowed any number of
coefficients to be selected. However, for technical reasons (regarding
precision and calculation time), 25 coefficients were chosen. For a
given weight function (f0, f1, ...,
f24), the ICP value at point k in the time sequence could
be computed by the values of the ABP recorded at times k-24,
k-23, ..., k-1, k according to the formula
ICPk=f0*ABPk+f1*ABPk-1+f23*ABPk-23+f24*ABPk-24.
Step 2: Calculation of TCD Characteristics
In this study the coefficients of a weight function
between FV and ABP curves were used as TCD characteristics. The
computation was similar to the one described in Step 1 and performed at
the same times. For technical reasons six coefficients were used here
to define the weight function instead of 25.
Step 3: Statistical Processing to Calculate the Relationship
Between Weight Functions and TCD Characteristics
The relationship between the TCD characteristics of step 2 and
the 25 coefficients of the weight function in step 1 was described by
an approximating linear function (ie, a matrix A and a
vector B), which was calculated through a sequence of 25
multiple regression analyses (one for each of the 25
coefficients of the weight function) of the patients' data. This
process was similar to a standard linear regression between one
dependent and one independent variable. In contrast to the standard
situation, we had 25 dependent variables, and each of them was
related to six independent variables (the TCD characteristics).
This process established a nonindividual relationship between TCD
characteristics and the simulation function by means of a linear
function.
After steps 1 to 3 were performed, the noninvasive ICP simulation
procedure worked as follows (Fig 1
):
While the FV and ABP curves were recorded, the TCD characteristics
were computed every 10 seconds and transferred to the simulation
function. Finally, the simulation function transformed the ABP curve
into the simulated ICP curve.
|
Application of Noninvasive ICP Simulation
To test the predictive capability of the ICP simulation, a group
of 11 patients was studied. In each patient, measured and predicted ICP
were compared during a time interval of 100 seconds. For each patient
tested, the remaining 10 patients were taken as a reference group to
generate the ICP simulation (by performing steps 1 to 3). This ICP
simulation was then used to predict the ICP of the patient to be
tested. In addition to this short-term study, in 6 patients the ICP
simulation was repeated after 1 hour. In 3 of these 6 patients, two
additional ICP simulations were obtained on the following day 1 hour
apart from each other. As a measure of the simulation's precision, the
mean of the absolute values of the differences between measured and
predicted ICP values (MAD-ICP) was taken. The mean was calculated over
the sample points during the 100-second time period. Since data were
sampled at a frequency of 25 Hz, the average was taken from 2500 ICP
values. As a measure of the simulation's capability of predicting the
mean ICP averaged over one cardiac cycle (ICPCC), we
calculated the mean of the absolute differences between measured and
predicted ICPCC (MAD-ICPCC). Both
parameters MAD-ICP and MAD-ICPCC are
presented in the results together with their corresponding 95th
percentiles, 95%-ICP and 95%-ICPCC, which are the upper
limits of 95% of the absolute differences between measured and
predicted ICP and between measured and predicted ICPCC,
respectively.
|
Results |
|---|
|
TopAbstractIntroductionTheoretical ConsiderationsSubjects and MethodsResultsDiscussionAppendix 1References |
|---|
A comparison between typical examples of predicted and measured curves in the short-term study (Figs 2 through 5
)
shows that waveform modulations caused by pulse and respiration were
clearly predicted by the simulated curves. However, the size of the
amplitudes could not be preserved. The amplitudes varied between half
and double their original size. An example of the simulation's
capability of predicting changes in the mean ICP is seen in Fig 3
(patient 11), in which the sudden ICP decrease after 40 seconds, as
well as its gradual increase afterward, was repeated in the ICP
simulation. As mentioned above, the amplitudes of the pulse and
respiratory waveform modulations were larger in the simulation curve
than in the original ICP recording. When we used the MAD-ICP to
measure the simulation's precision, patient 11 had the most incorrect
prediction, having an MAD-ICP of 7.5±2.6 mm Hg. In summary of
the 11 patients in the short-term study, the MAD-ICP was less than
3 mm Hg in 4 patients and less than 5 mm Hg in 8 patients,
and the maximum MAD-ICP was 7.5 mm Hg. The MAD-ICPCC
was slightly lower than the MAD-ICP; it was less than 3 mm Hg in
4 patients and less than 5 mm Hg in 9 patients, and again the
maximum was 7.5 mm Hg. On average the patients' MAD-ICP was
4.0±1.8 mm Hg, and the MAD-ICPCC was 3.8±1.9
mm Hg (Table ). The 95th percentiles
specify the maximum distances to the measured ICP in 95% of the
predicted values. The 95%-ICP was less than 5 mm Hg in 3
patients and less than 10 mm Hg in 8 patients, and the maximum
was 12.8 mm Hg. The 95%-ICPCC was less than 5
mm Hg in 4 patients and less than 10 mm Hg in 11 patients, and
the maximum was 11.7 mm Hg. Repeated ICP simulations after 1 hour
in 6 patients and additionally in 3 patients after 24 hours showed
prediction errors (MAD-ICP, MAD-ICPCC) similar to the first
ICP simulation (Table). Furthermore, in each of these patients mean ICP
was either always underestimated or always overestimated, with similar
error margins. Therefore, trends in ICP changes were reflected in the
ICP simulation.
|
|
|
|
|
|
Discussion |
|---|
|
TopAbstractIntroductionTheoretical ConsiderationsSubjects and MethodsResultsDiscussionAppendix 1References |
|---|
The ICP simulation was performed in patients with severe head injuries, impaired autoregulation, nondetectable vasospasm or stenosis, and a PaCO2 between 30 and 35 mm Hg. Our results suggest that for this defined category of patients, a noninvasive ICP simulation based on FV and ABP recordings may have value for clinical applications. In 4 of 11 patients in the short-term test, the MAD-ICP was less than 3 mm Hg, in another 4 patients the MAD-ICP was between 3 and 5 mm Hg, and only in 3 patients was the MAD-ICP greater than 5 mm Hg, with a maximum of 7.5 mm Hg. The MAD-ICPCC, which measured the simulation of cardiac cycle mean ICPCC, was slightly lower. Considering 5 mm Hg as a critical threshold for the MAD-ICP as well as the MAD-ICPCC, we therefore conclude that in 8 of the 11 patients the simulation is sufficiently precise to measure ICP changes and to facilitate therapeutic decisions. The 95%-ICPCC in these patients varied from 1.9 to 7.9 mm Hg, which means that even in the most inaccurate simulation regarding this parameter (patient 7: 95%-ICPCC=7.9 mm Hg), 95% of the predicted cardiac cycle means differed less than 7.9 mm Hg from the measured values. The evaluations of the medium-term (1 hour) and long-term (24 hours) follow-up tests confirmed these results. In view of the potential clinical application it was important to verify that even less precise simulations of the absolute values still accurately predicted ICPCC changes and trends. In our study this held true for single recording intervals of 100 seconds as well as repeated measurements within 24 hours (eg, patient 11). In the repeatedly measured patients the behavior of the ICP simulation was consistent within one patient, ie, in the same patient the predicted means of ICP (Table
) were either always lower or always
higher than the measured ones, with similar error margins. Therefore,
trends of ICP were reproduced. In particular, this observation may be
important because ICP simulations on the basis of TCD are
problematic for extensive continuous measurements (eg, 
24
hours) because of potential adverse effects of ultrasound exposure and
the impairment of the patient by long-term probe fixations. Prediction
should be done by long-term follow-up simulations over short or medium
time periods. However, since the number of repeated measurements was
small, investigations are continuing to confirm this observation. In this study the accuracy of ICP prediction was lowest in patients 10 and 11. At the same time the measured ICP was lowest in patient 10 and highest in patient 11. To search for possible explanations of this fact, sources of potential errors in the used method should be regarded. According to the American national standard of the Association for Advancement of Medical Instrumentation, errors of 10% in the assessment of mean ICP are tolerated even in accurately working ICP monitoring devices.30 In our study patients with obviously erroneous ICP measurements, contradicting the patient's clinical presentation, had been excluded. Despite these plausibility checks, minor errors in the assessment of ICP by the epidural device might have occurred. Since the accuracy of measurement decreases with increasing ICP,28 this might affect the results in patients with high ICP. Although it is impossible to decide in which patients these potential errors have influenced the accuracy of ICP prediction, these effects might explain the differing results in patient 11. Errors in ICP measurements additionally have a more subtle effect. Since each patient is also a member of the reference group, which is used to generate the ICP simulation procedure, errors influence the behavior of the simulation procedure itself. If these errors are not systemic and only happen occasionally, this influence should be small because of the statistical process in the generation of the ICP simulation. Another problem arises from the variability of normal values of MFV in the MCA; standard deviations of ±12 cm/s were stated by several authors.31 32 33 This variation in MCA must be considered, particularly in patients with low ICP, such as patient 10, and might lead to individually differing results of ICP prediction.
As mentioned before, our main criteria for the precision of simulation were the MAD-ICP and the MAD-ICPCC. A simple comparison between measured and predicted mean ICP (means over the whole simulation period) could result in an overestimation of the precision of simulation. This happens, for instance, if the predicted curve oscillates around the measured curve with similar deviations above and below the invasive recording, thereby canceling each other out and pretending a false precision. In the present study this occurred in patient 9, in whom similar means of ICP (measured: 30.8 mm Hg; predicted: 32.0 mm Hg) but a high MAD-ICP (5.8 mm Hg) and MAD-ICPCC (4.9 mm Hg) could be observed. Such behavior can be discovered through high standard deviations of MAD-ICP (±5.3 mm Hg) and MAD-ICPCC (±4.3 mm Hg). On the other hand, a simulation curve that only differs from measured ICP by, eg, the sizes of pulse waveform amplitudes, having identical ICPCC, leads to a nonzero MAD-ICP. This is the reason why the MAD-ICPCC and 95%-ICPCC values were lower than the corresponding MAD-ICP and 95%-ICP values. By definition the chosen TCD characteristics provide a precise description of the dependencies between ABP and intracranial FV curves, detecting the relationship between the waveform modulations as well as the mean values. Since the "driving force" for blood flow is the pressure gradient between ABP and ICP, these TCD characteristics also implicitly carry information about ICP. This might explain the suitability of these characteristics for determining the simulation function. Our own earlier studies, in which we used Fourier coefficients of the FV curve as TCD characteristics, were less successful. The use of weight functions for the estimation of ICP allowed a precise prediction of the shapes of the ICP waveform modulations. Some parameter choices, such as the number of weight function coefficients and number of TCD parameters, are made after various different combinations are tested. The influence of these choices on the results should not be overestimated. We found that small changes of these parameters, eg, 5 instead of 6 TCD characteristics, 20 instead of 25 weight function coefficients, led to similar results.
Clear limitations appertaining to the procedure's feasibility arise from the type of patients studied. All patients suffered from severe head injuries. From the patients' performances on the tests, we determined impaired autoregulation.24 25 At the time of recording, no cerebral vasospasm or intracranial stenosis was detected. The PaCO2 ranged from 30 to 35 mm Hg. Any changes in these conditions might affect the interdependencies of the three parameters FV, ABP, and ICP and lead to differing results. In a patient with a pronounced vasospasm and correspondingly increased FV values,34 35 the ICP simulation would result in an erroneously low predicted ICP. Therefore, the described ICP simulation may not be assumed to be valid in patients differing in any of the aforementioned points from the studied group. Changes in parameters such cerebral vasoreactivity, vasomotor tone, and vessel diameter would influence hemodynamics and affect the accuracy of ICP prediction. A rising ABP, for example, would cause an increase of ICP in the case of impaired autoregulation, while the opposite would happen in the case of intact autoregulation. On the other hand, the chosen restrictions for the studied patients seem to be weak enough to still be of practical use.
As a possible step toward a broader applicability of the ICP simulation, it is planned to group patients into different categories of diseases and vascular status and to develop specific simulation procedures. One potential problem will be to ensure that these categories are not too specific, so they can be established by simple clinical tests during routine examinations. When the degree of autoregulation is considered, two or three subdivisions seem reasonable. If a clinician had to go to great lengths (perhaps even invasive tests) to determine to which category a patient belongs, then the predictive value of the ICP simulation would be lost. Further studies must show how many subdivisions of disease categories will be needed and whether, for example, it is possible to design a procedure that works in patients with vasospasm as well as in those without, or whether separate simulation procedures are needed. In our study we used a Doppler CO2 test24 to assess the CO2-induced vasomotor reactivity. In view of the fact that in patients with head injuries in particular the relationship between autoregulation and CO2 reactivity is problematic, which was the subject of different studies,36 37 we also performed the autoregulation test of Czosnyka et al25 to obtain further information regarding vasoreactivity. In continuing studies we are additionally performing the cuffs test,38 39 using thigh blood pressure cuffs.
Whereas former studies were concerned either with estimating mean values of ICP1 2 3 4 5 6 7 8 or with constructing technical analogues that were of theoretical interest but too complex for a general clinical application,9 10 11 12 13 14 15 the aim of our study was to introduce a procedure that determines the continuous ICP curves and can be used as a bedside procedure. It produces both mean ICP values and the continuous course of ICP, including pulse and respiratory waveform modulations. All of these properties may be of clinical relevance. Although additional extensive testing is necessary to further validate this method, it seems to be a promising approach in the development of a useful tool in the management of patients with increased ICP.
|
Selected Abbreviations and Acronyms |
|---|
|
|
Acknowledgments |
|---|
This study was supported by the Deutsche Forschungsgemeinschaft (KL 960/1–1).
|
Footnotes |
|---|
Reprint requests to Prof Dr med Dipl-Ing J. Klingelhöfer, Department of Neurology, Technical University of Munich, Möhlstraße 28, 81675 München, Germany.
|
Appendix 1 |
|---|
|
TopAbstractIntroductionTheoretical ConsiderationsSubjects and MethodsResultsDiscussionAppendix 1References |
|---|
Generating the Procedure of Noninvasive ICP Simulation
Step 1: Computing the Weight Function From the Given ABP and ICP Curves
To calculate the relationship between the TCD characteristics and the weight function (from the ABP to the ICP curves), ABP is considered the input signal and ICP the output signal of the intracranial compartment.
The weight function between the ABP and the ICP curve may be regarded
as a vector of numbers (f0, f1,. . .,
fn-1). Its coefficients f0, f1,. .
., fn-1 are computed by using the approach
 | (1) |
Equation 1 states that the kth value of the ICP curve ICPk
is estimated by a number of n former values of the ABP curve
ABPk, ABPk-1, ABPk-2,. . .,
ABPk-n+1. The weight function is characterized by its
property to give the best possible estimation of the ICPk.
Assuming the computed values
(ICPk) to be the best possible
estimations of the actual (measured) ICP values (ICPk)
during a time period of p points means that the expression
 | (2) |
for Equation 2 leads to
 | (3) |
G/fi=0.
Straightforward computation results in the equation system
 | (4) |
 |
 |
 |
 |
From Equation 1 it can be seen that the parameter n
describes the time period in which the ABP is considered to influence
the current ICP value. In this study we use n=25. The length of time
steps (the distance in time between the sample points k-1 and k)
depends on the length of the cardiac cycles. The 25 sample points
ABPk, ABPk-1, ..., ABPk-n+1
are equally spread over three cardiac cycles. This means that in our
model the current ICP value is determined by ABP over a period of three
heart cycles. The idea of using a heart rate–dependent technique for
calculating the weight functions is to make them independent of the
heart rate. This might at first sound paradoxical, but imagine a sudden
increase of heart rate with remaining shapes of ABP and ICP waveforms,
just compressed by the decreasing waveform length. Then the time steps
used in the weight functions would become smaller, and the calculated
weight function would be exactly the same as the weight function
calculated at a lower heart rate. Equation 2 shows that p sets the time
period during which the computed ICP curve should be the best
approximation of the original (measured) curve. p is chosen in such a
way that the length of this period is 14 cardiac cycles. From Equation 4' the weight function coefficients fj are computed. Until
now the (nxn) matrix
 |
' leads to the weight function f= (f0,
f1,. . ., fn-1) and establishes the
relationship between ABP and ICP by means of the formula
 |
These properties of the weight function seem plausible in view of its use in the ICP simulation. Property 1 could be achieved by a high number of coefficients of the weight function and a small step length for its calculation, while properties 2 and 3 need large intervals for minimization of the estimation errors and also large estimation periods. During the development of this procedure a couple of parameter combinations had been tested, and the shown parameters were chosen.
Step 2: Calculation of TCD Characteristics
In this study the coefficients of a weight
function between FV and ABP curves are used as TCD characteristics. The
computation is similar to the one described in step 1 and performed at
the same times. For technical reasons six coefficients are used here to
define the weight function instead of 25. It describes the relationship
between FV and ABP with sufficient precision and reduces the complexity
of the statistical process in step 3. For reasons similar to those
described in step 1, a heart rate–dependent step length (6 points
spread equally over one cardiac cycle) for calculating the weight
function is used. The FV weight function should not only describe the
relationship between MFV and mean ABP but also relate short time
changes during a cardiac cycle interval of both signals, ie, relate the
pulse waveform shapes of FV and ABP. This should be done depending only
on the shapes of ABP and FV pulse waves and should not depend on the
heart rate. Otherwise we had to create different patient groups for
different heart rates. A further distinction between step 1 and step 2
is that the six coefficients (f0, f1, ...,
f5) are calculated from the noncausal approach
ABPk=f0*FVk+f1*FVk+1+ ... +f4*FVk+4+f5*FVk+5.
This approach is noncausal in the sense that the ABP is considered to
be determined by FV values of later times (FVk,
FVk+1, ..., FVk+5). It accounts for the
physiological fact that blood pressure causes blood
flow. Therefore, the current FV value depends on former ABP values,
which, formally expressed, means that the current ABP value is
determined by FV values of later times.
To be suitable for the approximation of the weight function between ABP and ICP, the following properties of the TCD characteristics are important: (1) They should be independent of pulse rate. (2) They should precisely describe the relationship between MFV and mean ABP and also the relationship between short time changes of the FV and ABP values during a cardiac cycle. This provides the control information for estimating the weight function between ABP and ICP and is therefore essential. (3) Artifacts or single irregularities of the ABP and FV curves should have little influence on the estimated ICP. (4) The number of TCD characteristics should be small. They are used as independent variables during a multiple linear regression, and there should not be too many degrees of freedom to keep the number of needed data pairs small.
Similar to step 1, these properties and a couple of performed tests of parameter combinations lead to the choice of six TCD characteristics, the step length of 6 points spread equally over one cardiac cycle, and the interval of 14 cardiac cycles for minimizing the estimation error of the weight function between FV and ABP.
Step 3: Statistical Processing to Calculate the
Relationship Between Weight Functions and TCD Characteristics
A linear relationship between given pairs of weight
functions (f0, f1, ..., fn-1)
and TCD characteristics (tcd0, tcd1, ...,
tcdm-1) shall be established. This gives rise to the
search of a (nxm) matrix A and n dimensional vector
B; thus, on average over all data pairs, the calculated data
(
0, 1, ...,
n-1)=A*(TCD0,
TCD1, ..., TCDm-1)+B is the
best estimation for (f0, f1, ...,
fn-1). The above expression is equivalent to the n
equations
 | (5) |
 |
 |
j=Aj0*tcd0+Bj),
then Aj0 and Bj would be
computed by a linear regression analysis relating the dependent
variable fj to the independent variable
tcd0. In equation (1''), fj has to be related
to m independent variables tcd0,
tcd1, ..., tcdm-1. This is done by a
generalized linear regression called multiple regression. For each of
the coefficients fj a multiple regression analysis
is performed calculating the parameters
Aj0, Aj1, ...,
Ajm-1, and Bj, resulting in
the desired (nxm) matrix A and the n dimensional vector
B. Received June 20, 1997; accepted August 24, 1997.
|
References |
|---|
|
TopAbstractIntroductionTheoretical ConsiderationsSubjects and MethodsResultsDiscussionAppendix 1References |
|---|
- Aaslid R, Lundar T, Lindegaard KF, Nornes H. Estimation of cerebral perfusion pressure from arterial blood pressure and transcranial Doppler recordings. In Miller JD, Teasdale GM, Rowan JO, Galbraith SL, Mendelow AD, eds. Intracranial Pressure VI. New York, NY: Springer-Verlag; 1993:226–229.
- Klingelhöfer J, Conrad B, Benecke R, Sander D. Intracranial flow patterns at increasing intracranial pressure. Klin Wochenschr. 1987;65:542–545.[Medline] [Order article via Infotrieve]
- Klingelhöfer J, Conrad B, Benecke R, Sander D. Relationship between intracranial pressure and intracranial flow patterns in patients suffering from cerebral diseases. J Cardiovasc Ultrasonogr. 1987;6:249–254.
- Klingelhöfer J, Conrad B, Benecke R, Sander D, Markakis E. Evaluation of intracranial pressure from transcranial Doppler studies in cerebral disease. J Neurol. 1988;235:159–162.[Medline] [Order article via Infotrieve]
- Chan KH, Miller JD, Dearden NM, Andrews PJ, Midgley S. The effect of changes in cerebral perfusion pressure upon middle cerebral artery blood flow velocity and jugular bulb venous oxygen saturation after severe brain injury. J Neurosurg. 1992;77:117–130.
- Homburg AM, Jakobsen M, Enevoldsen E. Transcranial Doppler recordings in raised intracranial pressure. Acta Neurol Scand. 1993;87:488–493.[Medline] [Order article via Infotrieve]
- Shigemori M, Nakashima H, Moriyama T, Tokutomi, T, Nishio N, Harada K, Kuramoto S. Noninvasive study of critical thresholds of intracranial pressure and cerebral perfusion pressure for cerebral circulation and brain function. Neurol Res. 1989;11:165–168.[Medline] [Order article via Infotrieve]
- Shigemori M, Kikuchi N, Tokutomi, T, Ochiai S, Harada K, Kikuchi T, Kuramoto S. Monitoring of severe head-injured patients with transcranial Doppler (TCD) ultrasonography. Acta Neurochir Suppl (Wien).. 1992;55:6–7.[Medline] [Order article via Infotrieve]
- Hoffman H. Biomathematics of intracranial CSF and hemodynamics, simulation and analysis with the aid of a mathematical model. Acta Neurochir Suppl (Wien).. 1987;40:117–130.[Medline] [Order article via Infotrieve]
- Marmarou A, Shulman K, LaMorgese J. Compartmental analysis of compliance and outflow resistance of the cerebrospinal fluid system. J Neurosurg. 1975;43:523–534.[Medline] [Order article via Infotrieve]
- Marmarou A, Shulman K, Rosende RM. A nonlinear analysis of cerebrospinal fluid system and intracranial pressure dynamics. J Neurosurg. 1978;48:332–344.[Medline] [Order article via Infotrieve]
- Marmarou A, Maset AL, Ward JD, Choi S, Brooks D, Lutz HA, Moulton RJ, Muizelaar JP, DeSalles A, Young HF. Contribution of CSF and vascular factors to elevation of ICP in severely head-injured patients. J Neurosurg. 1987;66:883–890.[Medline] [Order article via Infotrieve]
- Sorek S, Bear J, Karni Z. Resistances and compliances of a compartmental model of the cerebrovascular system. Ann Biomed Eng. 1989;17:1–12.[Medline] [Order article via Infotrieve]
- Takemae T, Kosugi Y, Ikebe J, Kumagai Y, Matsyama K, Saito H. A simulation study of intracranial pressure using an electrical circuit model of cerebral circulation. IEEE Trans Biomed Eng.. 1987;34:958–962.[Medline] [Order article via Infotrieve]
- Ursino M, Iezzi M, Stocchetti N. Intracranial pressure dynamics in patients with acute brain damage: a critical analysis with the aid of a mathematical model. IEEE Trans Biomed Eng. 1995;42:529–540.[Medline] [Order article via Infotrieve]
- Ursino M. A mathematical study of human intracranial hydrodynamics, part 1: the cerebrospinal fluid pulse pressure. Ann Biomed Eng. 1988;16:379–401.[Medline] [Order article via Infotrieve]
- Ursino M. A mathematical study of human intracranial hydrodynamics, part 2: simulation of clinical tests. Ann Biomed Eng. 1988;16:379–401.
-
Strandgaard S, Paulsen OB. Cerebral autoregulation.
Stroke. 1984;15:413–416.
[Free Full Text] - Ursino M, Di Giammarco P. A mathematical model of the relationship between cerebral blood volume and intracranial pressure changes. Ann Biomed Eng. 1991;19:15–42.[Medline] [Order article via Infotrieve]
- Lundberg N. Continous recording and control of ventricular fluid pressure in neurosurgical practice. Acta Psychol Neurol Scand (Suppl). 1960;149:1–193.
- Ursino M, Belardinelli E. Knowledge-oriented modeling of cerebrovascular control mechanisms. Comments Theoretical Biol. 1991;2:211–237.
- Kasuga Y, Nagai H, Hasegawa Y, Nitta M. Transmission characteristics of pulse waves in the intracranial cavity of dogs. J Neurosurg. 1987;66:907–914.[Medline] [Order article via Infotrieve]
- Marmarelis P, Marmarelis V. Analysis of Physiological Systems. New York, NY: Plenum Press; 1978:1–221.
-
Klingelhöfer J, Sander D. Doppler
CO2 test as an indicator of cerebral vasoreactivity and
prognosis in severe intracranial hemorrhages.
Stroke. 1992;23:962–966.
[Abstract/Free Full Text] -
Czosnyka M, Smielewski P, Kirkpatrick P, Menon DK,
Pickard JD. Monitoring of cerebral autoregulation in head-injured
patients. Stroke. 1996;27:1829–1834.
[Abstract/Free Full Text] - Aaslid R, Markwalder TM, Nornes H. Non-invasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg. 1982;57:769–774.[Medline] [Order article via Infotrieve]
- Dietrich K, Gaab M, Knoblich OF, Schupp J, Ott B. A new miniaturized system for monitoring the intracranial pressure in children and adults. Neuropadiatrie. 1977;8:21–28.[Medline] [Order article via Infotrieve]
- Schwarz N, Matuschka H, Meznik A. The Spiegelberg device for epidural ICP control. Unfallchirurg. 1992;95:113–117.[Medline] [Order article via Infotrieve]
- Weinstabl C, Richling B, Plainer B, Czech T, Spiss CK. Comparative analysis between epidural and subdural intracranial pressure probes. J Clin Monit. 1992;8:116–120.[Medline] [Order article via Infotrieve]
- Brown E. Intracranial Pressure Monitoring Devices. Arlington, Va: Association for the Advancement of Medical Instrumentation; 1988.
- Aaslid R, Huber P, Nornes H. Evaluation of cerebrovascular spasm with transcranial Doppler ultrasound. J Neurosurg. 1984;60:37–41.[Medline] [Order article via Infotrieve]
- Hennerici M, Rautenberg W, Sitzer G, Schwarz A. Transcranial Doppler ultrasound for the assessment of intracranial arterial flow velocity, part I: examination technique and normal values. Surg Neurol. 1987;27:439–448.[Medline] [Order article via Infotrieve]
- Ringelstein EB, Kahlscheuer B, Niggemeyer E, Otis SM. Transcranial Doppler ultrasonography: anatomical landmarks and normal velocity values. Ultrasound Med Biol. 1990;16:745–761.[Medline] [Order article via Infotrieve]
- Klingelhöfer J, Sander D, Holzgraefe M, Bischoff C, Conrad B. Cerebral vasospasm evaluated by transcranial Doppler ultrasonography at different intracranial pressures. J Neurosurg. 1991;75:752–758.[Medline] [Order article via Infotrieve]
- Sander D, Klingelhöfer J. Cerebral vasospasm following posttraumatic subarachnoid hemorrhage evaluated by transcranial Doppler ultrasonography. J Neurol Sci. 1993;119:1–7.[Medline] [Order article via Infotrieve]
- Steiger HJ, Aaslid R, Stoos R, Seiler RW. Transcranial Doppler monitoring in head injury: relations between type of injury, flow velocities, vasoreactivity, and outcome. Neurosurg. 1994;34:79–86.[Medline] [Order article via Infotrieve]
- Newell DW, Weber JP, Watson R, Aaslid R, Winn HR. Effect of transient moderate hyperventilation on dynamic cerebral autoregulation after severe head injury. Neurosurgery. 1996;39:35–44.[Medline] [Order article via Infotrieve]
-
Aaslid R, Lindegaard KF, Sorteberg W, Nornes H.
Cerebral autoregulation dynamics in humans. Stroke. 1989;20:45–52.
[Abstract/Free Full Text] - Tiecks FP, Lam AM, Aaslid R, Newell DW. Comparison of static and dynamic cerebral autoregulation measurements. Stroke. 1995;26:1012–1019.
This article has been cited by other articles:
 |
|
 |
|
  J. Marti-Fabregas, R. Belvis, E. Guardia, D. Cocho, and J.-L. Marti-Vilalta Relationship between Transcranial Doppler and CT Data in Acute Intracerebral Hemorrhage AJNR Am. J. Neuroradiol., January 1, 2005; 26(1): 113 - 118. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M Czosnyka and J D Pickard Monitoring and interpretation of intracranial pressure J. Neurol. Neurosurg. Psychiatry, June 1, 2004; 75(6): 813 - 821. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Marti-Fabregas, R. Belvis, E. Guardia, D. Cocho, J. Munoz, L. Marruecos, and J.-L. Marti-Vilalta Prognostic value of Pulsatility Index in acute intracerebral hemorrhage Neurology, October 28, 2003; 61(8): 1051 - 1056. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. Schmidt, M. Czosnyka, A. Raabe, H. Yahya, J. J. Schwarze, D. Sackerer, D. Sander, and J. Klingelhofer Adaptive Noninvasive Assessment of Intracranial Pressure and Cerebral Autoregulation Stroke, January 1, 2003; 34(1): 84 - 89. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. J. Alperin, S. H. Lee, F. Loth, P. B. Raksin, and T. Lichtor MR-Intracranial Pressure (ICP): A Method to Measure Intracranial Elastance and Pressure Noninvasively by Means of MR Imaging: Baboon and Human Study Radiology, December 1, 2000; 217(3): 877 - 885. [Abstract] [Full Text]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||