Critical closing pressure during intracranial pressure plateau waves

Georgios V. Varsos*, Nicolás De Riva, Peter Smielewski, John D. Pickard, Kenneth Martin Brady, Matthias Reinhard, Alberto Avolio, Marek Czosnyka

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

30 Scopus citations


Background: Critical closing pressure (CCP) denotes a threshold of arterial blood pressure (ABP) below which brain vessels collapse and cerebral blood flow ceases. Theoretically, CCP is the sum of intracranial pressure (ICP) and arterial wall tension (WT). The aim of this study is to describe the behavior of CCP and WT during spontaneous increases of ICP, termed plateau waves, in order to quantify ischemic risk. Methods: To calculate CCP, we used a recently introduced multi-parameter method (CCPm) which is based on the modulus of cerebrovascular impedance. CCP is derived from cerebral perfusion pressure, ABP, transcranial Doppler estimators of cerebrovascular resistance and compliance, and heart rate. Arterial WT was estimated as CCPm-ICP. The clinical data included recordings of ABP, ICP, and transcranial Doppler-based blood flow velocity from 38 events of ICP plateau waves, recorded in 20 patients after head injury. Results: Overall, CCPm increased significantly from 51.89 ± 8.76 mmHg at baseline ICP to 63.31 ± 10.83 mmHg at the top of the plateau waves (mean ± SD; p < 0.001). Cerebral arterial WT decreased significantly during plateau waves by 34.3 % (p < 0.001), confirming their vasodilatatory origin. CCPm did not exhibit the non-physiologic negative values that have been seen with traditional methods for calculation, therefore rendered a more plausible estimation of CCP. Conclusions: Rising CCP during plateau waves increases the probability of cerebral vascular collapse and zero flow when the difference: ABP-CCP (the "collapsing margin") becomes zero or negative.

Original languageEnglish (US)
Pages (from-to)341-348
Number of pages8
JournalNeurocritical Care
Issue number3
StatePublished - Jun 2013


  • Critical closing pressure
  • Intracranial pressure
  • Mathematical modeling
  • Plateau waves
  • Wall tension

ASJC Scopus subject areas

  • Clinical Neurology
  • Critical Care and Intensive Care Medicine


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