# Cerebral perfusion pressure

Cerebral perfusion pressure, or CPP, is the net pressure gradient causing cerebral blood flow to the brain (brain perfusion). It must be maintained within narrow limits because too little pressure could cause brain tissue to become ischemic (having inadequate blood flow), and too much could raise intracranial pressure (ICP).

## Definitions

The cranium is a box with three components, Blood, Cerebral Spinal Fluid, and very soft tissue (brain). While both the blood and CSF have poor compression capacity, the brain is easily compressible. Every increase of ICP can cause a change in tissue perfusion and an increase in stroke events. Comparisons of the relation between brain and body weights among extant mammals show that brain sizes have not increased as much as body sizes.[1]

### From resistance

CPP can be defined as the pressure gradient causing cerebral blood flow (CBF) such that

$CBF = CPP/CVR$

where:

CVR is cerebrovascular resistance

### By intracranial pressure

An alternative definition of CPP is:[2]

$CPP=MAP-ICP$

where:

MAP is mean arterial pressure
ICP is intracranial pressure

This definition may be more appropriate if considering the circulatory system in the brain as a Starling resistor, where an external pressure (in this case, the intracranial pressure) causes decreased blood flow through the vessels. In this sense, more specifically, the cerebral perfusion pressure can be defined as either:

$CPP = MAP - ICP$ (if ICP is higher than JVP)

or

$CPP = MAP - JVP$ (if JVP is higher than ICP).

Physiologically, increased intracranial pressure (ICP) causes decreased blood perfusion of brain cells by mainly two mechanisms:

FLOW Ranging from 20ml 100g-1 min-1 in white matter to 70ml 100g-1 min-1 in grey matter.

## Autoregulation

Static autoregulation: Under normal circumstances (MAP between 60 to 150 mmHg and ICP about 10 mmHg), average cerebral blood flow (e.g. the average recorded over 5 minutes or over hours) is relatively constant due to protective autoregulation.[2][3] However, although the classic 'autoregulation curve' proposed by Lassen et al. suggests that CBF is fully stable between these blood pressure values (known also as the limits of autoregulation), in fact CBF may vary as much as 10% below and above its average within this range.[4] Outside of the limits of autoregulation, raising MAP raises CPP and raising ICP lowers it (this is one reason that increasing ICP in traumatic brain injury is potentially deadly). CPP is normally between 70 and 90 mmHg in an adult human, and cannot go below 70 mmHg (interruption production of Cerebral Spinal Fluid) for a sustained period without causing ischemic brain damage,[5][6] although some authorities regard 50-150 mmHg as a normal range for adults.[2] Children require pressures of at least 60 mmHg.[5]

Within the autoregulatory range, as CPP falls there is, within seconds, vasodilatation of the cerebral resistance vessels, a fall in cerebrovascular resistance and a rise in cerebral-blood volume (CBV), and therefore CBF will return to baseline value within seconds (see as ref. Aaslid, Lindegaard, Sorteberg, and Nornes 1989: http://stroke.ahajournals.org/cgi/reprint/20/1/45.pdf). These adaptations to rapid changes in blood pressure (in contrast with changes that occur over periods of hours or days) are known as dynamic cerebral autoregulation.[4]

## Footnotes

1. ^ Armstron, E. "Relative brain size and metabolism in mammals". Science 220 (4603): 1302–4. doi:10.1126/science.6407108. PMID 6407108.
2. ^ a b c Steiner, LA; Andrews, PJ (2006). "Monitoring the injured brain: ICP and CBF". British Journal of Anaesthesia 97 (1): 26–38. doi:10.1093/bja/ael110. PMID 16698860.
3. ^ Duschek, S; Schandry, R (2007). "Reduced brain perfusion and cognitive performance due to constitutional hypotension". Clinical Autonomic Research 17 (2): 69–76. doi:10.1007/s10286-006-0379-7. PMC 1858602. PMID 17106628.
4. ^ a b van Beek, AH; Claassen, JA; Rikkert, MG; Jansen, RW (June 2008). "Cerebral autoregulation: An overview of current concepts and methodology with special focus on the elderly". Journal of Cerebral Blood Flow & Metabolism 28 (6): 1071–85. doi:10.1038/jcbfm.2008.13. PMID 18349877.
5. ^ a b Tolias, C; Sgouros, S (2003). "Initial evaluation and management of CNS injury". Emedicine.com. Retrieved 2007-03-19.
6. ^ Czosnyka, M; Pickard, JD (2004). "Monitoring and interpretation of intracranial pressure". Journal of Neurology, Neurosurgery, and Psychiatry 75 (6): 813–21. doi:10.1136/jnnp.2003.033126. PMC 1739058. PMID 15145991.