Revisiting the oxygen reactivity index in traumatic brain injury: the complementary value of combined focal and global autoregulation monitoring.

Background: The oxygen reactivity index (ORx) reflects the correlation between focal brain tissue oxygen (pbtO ₂ ) and the cerebral perfusion pressure (CPP). Previous, small cohort studies were conflicting on whether ORx conveys cerebral autoregulatory information and if it is related to outcome in traumatic brain injury (TBI). Thus, we aimed to investigate these issues in a larger TBI cohort.
Methods: 425 TBI patients with intracranial pressure (ICP)- and pbtO ₂ -monitoring for at least 12 h, who had been treated at Addenbrooke's Hospital, Cambridge, UK, were included. Association between ORx and ICP, pressure reactivity index (PRx), CPP, ΔCPPopt (actual CPP-CPPopt [PRx based optimal CPP]), and pbtO ₂ were evaluated with generalized additive models (GAMs). Association between ORx and outcome (Glasgow Outcome Scale [GOS]) was investigated with logistic regressions and heatmaps for those 239 patients with GOS data.
Results: GAMs showed that ORx increased with higher ICP, PRx above + 0.30, CPP below 60-70 mmHg, and negative ΔCPPopt. In contrast to PRx, ORx did not increase at higher CPP. In outcome heatmaps, there was a transition towards unfavourable outcome when ORx exceeded + 0.50, particularly for longer durations, and in combination with high ICP, high PRx, low CPP, negative ΔCPPopt, and low pbtO ₂ . In multivariable logistic regressions, higher ORx was associated with increased mortality.
Conclusions: ORx seemed to be sensitive to the lower, but not the upper, limit of autoregulation, in contrast to PRx which was sensitive to both. The combination of high values for both ORx and PRx was particularly associated with worse outcome and, thus, ORx may provide a complementary value to the global index PRx. ORx could also be useful to determine the safe and dangerous perfusion target intervals.
Competing Interests: Declarations. Competing interests: Peter Smielewski receives part of the licensing fees for ICM + software, licensed by Cambridge Enterprise Ltd, University of Cambridge, Cambridge. Ethics approval and consent to participate: The Brain Physics Lab research database was approved by the Research Ethics Committee (REC 23/YH/0085). Informed consent was waived in this retrospective, observational study.
(© 2025. The Author(s).)