# Exploring the Upper Limits of Cerebral Perfusion Pressure in Pediatric Traumatic Brain Injury: A STARSHIP Analysis

## TL;DR

This study explores whether high cerebral perfusion pressure in children with traumatic brain injury is harmful, finding no strong evidence of worse outcomes with higher pressures.

## Contribution

The study identifies potential differences in cerebral autoregulation thresholds in pediatric traumatic brain injury patients compared to adults.

## Key findings

- No clear upper autoregulation limit was identified below 100 mm Hg CPP.
- Higher CPP above 90 mm Hg showed a trend toward worse outcomes but not significant.
- Heatmap analyses revealed CPP ranges with differing risk levels.

## Abstract

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.

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.

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.

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.

The online version contains supplementary material available at 10.1007/s12028-025-02358-2.