MNM
PRx · DERIVED

Pressure reactivity index (PRx)

A moving correlation between ICP and MAP at slow-wave frequencies, used to grade autoregulation continuously at the bedside and to derive an individualised CPP target.

ReactivityBedside + researchPeds + adultInvasiveEmerging
BLast reviewed 2026-05-1714-min read

1. Bedside vignettes: why this matters in the PICU

Vignette A. Severe TBI day 2 in a 10-year-old, PRx says CPP is too low

A 10-year-old severe TBI day 2, post bifrontal decompressive craniectomy. ICP via parenchymal probe contralateral to the craniectomy reads 12 mmHg, CPP 60. Standard age-based protocol says CPP 50–60 is the floor and 60 is fine. The PRx trend over the past 4 hours has been +0.45 sustained. The CPPopt curve, fit to (CPP, PRx) data, gives a vertex at CPP 75 mmHg. The team lifts MAP with noradrenaline, CPP rises to 73, PRx falls to +0.05 within the hour. The default age-based target was inadequate for this child. Over the next 48 hours the team uses PRx-CPPopt as the operational CPP target and the patient's ICP-dose accumulates less than the matched cohort.

Vignette B. SAH day 5, PRx oscillating, real signal or artefact?

A 14-year-old with aneurysmal SAH post-coiling, day 5. PRx has been oscillating between 0.05 and +0.3 every 20 minutes for the past 4 hours. Is this fluctuating autoregulation (truly threshold-borderline) or is it artefact (motion, suctioning, sedation lightening)? The bedside team rejects 10-minute windows containing nursing care, looks at the clean overnight stretch when sedation was steady, and finds PRx +0.20 sustained. The CPPopt curve fits cleanly with a vertex at CPP 70. Lesson: PRx interpretation is window choice plus artefact rejection; you cannot trust a number computed across a suctioning episode.

Vignette C. Post-cardiac-arrest day 1, PRx not interpretable

A 7-year-old post-cardiac arrest day 1, targeted temperature 33°C. ICP-MAP correlation is near-zero with very low slow-wave power. The PRx number reads 0.05 but the underlying signal-to-noise is poor. The team holds off on PRx-guided targeting until day 3 when slow-wave power recovers, and uses COx (NIRS-MAP correlation) as the autoregulation surrogate in the interim. Lesson: PRx requires slow-wave content that is often absent in deep sedation, hypothermia, or non-pulsatile cardiac states. Have a fallback (Mx, COx) for these scenarios.

2. What PRx is, and what it is not

PRx is a moving Pearson correlation coefficient between mean ICP and mean MAP, computed in successive overlapping windows.

PRx=corr(ICP10-s avg,MAP10-s avg)\mathrm{PRx} = \mathrm{corr}(\mathrm{ICP}_{10\text{-s avg}}, \mathrm{MAP}_{10\text{-s avg}})

The standard implementation (Czosnyka 1997, refined by Smielewski's ICM+):

  1. Sample ICP and MAP at 100–200 Hz.
  2. Compute 10-second averages.
  3. Take 30 consecutive 10-second averages (5 minutes of data).
  4. Compute the Pearson correlation of the 30 paired (ICP, MAP) values.
  5. Update every minute by sliding the window forward.

The logic. When autoregulation is intact, a rise in MAP triggers cerebrovascular vasoconstriction (smaller vessel volume, lower cerebral blood volume, lower ICP) within seconds. So MAP and ICP move in opposite or unrelated directions at slow-wave frequencies and the correlation is negative or near zero. When autoregulation is impaired, the vasculature is a passive pipe; MAP and ICP rise and fall together at slow frequencies and the correlation is positive.

Why slow waves. The autoregulatory response operates over seconds-to-minutes, in the same frequency band as Mayer waves (~0.1 Hz) and B waves (~0.02 Hz). Heart-rate frequency (~1 Hz) and respiration (~0.2 Hz) are filtered out by the 10-second averaging.

What PRx is not. It is not a direct measurement of autoregulation; it is a continuous index correlated with the cerebrovascular reactivity that defines autoregulation. It is not robust to artefact: motion, suctioning, transducer drift, and rapid sedation changes pollute the correlation. It is not interpretable in pulseless flow states (VA-ECMO with non-pulsatile output, severe LV failure) because the slow-wave drive disappears.

Clinical pearl

PRx is a signal, not a measurement. Trust trends over hours, not single 5-minute values. The CPPopt fit needs ~4 hours of data to be useful; isolated PRx values are noise.

In children

Pediatric slow-wave content differs. Younger children have higher heart rates and respiratory rates, shifting power in the slow-wave band. The standard adult window settings still work but signal-to-noise is sometimes lower. Pediatric validation studies (Tas 2021, Velle 2023) used adult-style windowing and demonstrated the same CPPopt U-curve relationship with outcome. PRx > +0.25 is the same threshold used in pediatric work, but the CPPopt value will be lower (operational CPP floor 50 in a toddler vs 60 in an adolescent).

3. The math, in a deep-dive

3.1 Window choice and signal preparation

  • Sampling: ICP and MAP sampled at 100–200 Hz from the patient monitor.
  • Averaging: 10-second non-overlapping averages reduce high-frequency content (HR, respiration).
  • Window: 30 paired 10-second averages = 5 minutes.
  • Update rate: slide the window by 60 seconds, recompute Pearson.

3.2 Pearson correlation

For paired vectors x⃗,y⃗\vec{x}, \vec{y} of length nn:

r=∑i=1n(xi−xˉ)(yi−yˉ)∑i=1n(xi−xˉ)2⋅∑i=1n(yi−yˉ)2r = \frac{\sum_{i=1}^{n}(x_i - \bar{x})(y_i - \bar{y})}{\sqrt{\sum_{i=1}^{n}(x_i - \bar{x})^2 \cdot \sum_{i=1}^{n}(y_i - \bar{y})^2}}

PRx is bounded [−1,+1][-1, +1].

3.3 Artefact rejection

ICM+ and other validated implementations reject windows when:

  • ICP variance is too low (flat trace, blocked catheter).
  • ICP variance is too high (catheter flush, suction artefact).
  • MAP variance is too low (arterial line damping).
  • The window contains nursing or procedural artefact flagged by clinician.

3.4 Why a 5-minute window

Short enough to be responsive to changes (suctioning, position) but long enough to capture slow-wave content. Shorter windows (1–2 minutes) are too noisy; longer (15+ minutes) lose temporal resolution.

3.5 The CPPopt fit

For each 5-minute window, plot the point (CPP, PRx). Accumulate ~4 hours of points. Bin CPP into 5-mmHg buckets, compute mean PRx in each bin. Fit a parabola; the vertex is CPPopt. The shaded "target band" is ±5 mmHg of CPPopt.

4. Thresholds: what counts as intact, impaired, and ambiguous

PRx rangeInterpretationAction
−0.3 to 0.0Intact autoregulationContinue current CPP target
0.0 to +0.25Ambiguous / borderlineLengthen window; check for artefact; re-evaluate in 30 min
> +0.25 sustainedImpaired autoregulationRe-target CPP; check CPPopt curve
Falling over hoursImproving autoregulationConsider weaning vasopressor support
Rising over hoursWorsening autoregulationInvestigate cause (ischaemia, oedema progression, seizures, sedation withdrawal)

The +0.25 threshold comes from a large body of outcome-association work, originally Steiner 2002 (mortality) and confirmed in many subsequent cohorts. Time spent with PRx > +0.25 correlates with 6-month outcome in adult severe TBI.

Caveat

A single PRx value is rarely actionable. The bedside team should look at a trend over the past 1–2 hours and ask "what changed?". A PRx jump from −0.1 to +0.3 over 30 minutes is more useful than a single +0.4 value.

5. The PRx trace and pattern library

Fig. 1
PRx PATTERN LIBRARY · FOUR CANONICAL TRACESEach panel spans a 4-hour window · y-axis PRx from -1 to +1 · threshold +0.25 (Sorrentino 2012)(a) INTACT+10-1+0.25PRx < 0.05 · continue current CPP(b) IMPAIRED+10-1+0.25PRx > 0.25 sustained · re-target CPPopt(c) OSCILLATING+10-1+0.25swings 0 to 0.4 every 20 to 40 min(d) ARTEFACTUAL+10-1+0.25reject from the CPPopt fitPRx 3-TIER< 0.05 intact (teal) · 0.05 to 0.25 ambiguous · > 0.25 impaired (red) · artefact spikes are rejected, not interpretedMNM-Edu original schematic · Sorrentino 2012 (+0.25 threshold) · Czosnyka 1997 (PRx)
Four canonical PRx patterns over a 4-hour window. (a) Intact: PRx oscillating near zero or slightly negative, signal quality good. (b) Impaired: PRx sustained above 0.25 for hours, often paired with a flat or shallow CPPopt curve. (c) Oscillating: PRx swinging between 0 and 0.4 every 20-40 minutes, often reflecting fluctuating autoregulation threshold or transient sedation changes. (d) Artefactual: PRx jumping to extreme values then back, classic for movement, suctioning, transducer flush; should be rejected from the CPPopt fit.
MNM-Edu, original schematic.
PatternBedside meaningWhat to do
Flat near zeroIntact autoregulationContinue current CPP
Sustained > +0.25Impaired; needs CPPopt re-evaluationRe-target CPP per CPPopt fit
Oscillating ±0.3Threshold-borderline or sedation-fluctuantLook for triggers; lengthen analysis window
Spikes to extremesArtefact (motion, flush, suction)Reject from CPPopt fit; verify with raw trace
Drifting positive over hoursWorsening autoregulation; new pathologyInvestigate (seizures, oedema, ischaemia, sedation withdrawal)
Drifting negative over hoursRecovering autoregulationConsider weaning interventions
Unstable / no signalLow slow-wave power, pulseless flow, sedation depthSwitch to COx or Mx; check signal quality

6. Try it: interactive widgets

PRxCalculator
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Interactive tool (view online).
CPPoptUCurve
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Interactive tool (view online).
MxCalculator
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Interactive tool (view online).
CoxCalculator
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Interactive tool (view online).
MultimodalDiscordance
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Interactive tool (view online).

7. CPPopt by PRx: the individualised target

The clinical payoff of PRx is CPPopt, the CPP at which PRx is minimised.

Fig. 2
PRx vs CPP · THE CPPopt U-CURVE4-hour window · each point a 5-min average · vertex = CPPoptCPPopt +/- 55060708090CPP (mmHg)+0.8+0.4+0.250-0.4PRxPRx +0.25LLA 55ULA 85CPPopt 70READING IT5-min PRx-CPP pointsleast-squares parabolavertex = CPPopt (70)LLA / ULA at +0.25target +/- 5 mmHgNON-FITTABLEA flat curve or unclearvertex means CPPopt isnot fittable; revert tothe age-based CPP target.Some authors use +0.30.paediatric CPPopt is lowerand age-dependentMNM-Edu schematic · Steiner 2002 · Aries 2012 · Sorrentino 2012 (+0.25) · adult severe-TBI values
PRx (vertical axis) plotted against CPP (horizontal axis) over the past 4 hours. Each point is a 5-minute window. The parabola fit shows a clear vertex at CPPopt, the CPP at which autoregulation is most efficient (PRx most negative). The lower limit of autoregulation (LLA) is where PRx crosses +0.25 on the descending limb; the upper limit (ULA) is where it crosses +0.25 on the ascending limb. The shaded green band is the recommended target range: ±5 mmHg of CPPopt. A flat curve or unclear vertex means CPPopt is non-fittable in that window; revert to default age-based CPP target.
MNM-Edu, schematic adapted from Aries 2012 and Beqiri 2025.

7.1 The five-step workflow

  1. Accumulate 4 hours of synchronised ICP and MAP recordings.
  2. Compute PRx in 5-minute moving windows updating every minute.
  3. Bin the (CPP, PRx) points into 5-mmHg CPP buckets.
  4. Fit a parabola (or U-curve) to the bin means; the vertex is CPPopt.
  5. Re-target MAP so that CPP sits within ±5 mmHg of CPPopt.

7.2 What COGiTATE showed

COGiTATE phase II (Beqiri 2025) was the first randomised feasibility trial of PRx-CPPopt-guided care in adult severe TBI. Compared to standard CPP 60–70 targeting:

  • Patients in the CPPopt arm spent a significantly larger fraction of monitored time within ±5 mmHg of their CPPopt target (median 46.5%, IQR 38.3-56.2, versus 30.3%, IQR 22.6-38.4, in the standard-CPP arm; p < 0.001).
  • No safety concerns; no excess fluid balance or vasopressor use.
  • Secondary endpoints (mortality, GOS-E at 6 months) trended favourably but were not powered for definitive conclusion.

The follow-on COGiTATE-3 (full-scale efficacy trial) is in design.

7.3 Pediatric CPPopt evidence

Tas 2021 (KidsBrainIT and Cambridge cohort, ~95 children) demonstrated:

  • A clear PRx-CPP U-curve in the majority of pediatric severe TBI patients.
  • CPPopt was age-dependent: younger children had lower CPPopt (mean CPPopt 55 in children < 8 years, vs 70 in adolescents).
  • Time spent below CPPopt correlated with 6-month GOS-E outcome, independent of mean CPP.

Velle 2023 extended this with a per-patient temporal analysis showing CPPopt is dynamic within the same patient over the course of an admission, often rising over the first 48 hours and falling thereafter.

In children

Pediatric CPPopt is often below the age-based default. A 4-year-old with CPPopt of 50 will be over-perfused if the team holds rigid to a "CPP > 60" default. This is the most important practical lesson from the pediatric data: the individualised target wins.

8. Clinical contexts: PRx across acute brain injuries

8.1 Severe TBI (the canonical indication)

The original validation context (Czosnyka 1997). Most outcome-association data come from severe-TBI adults. The CPPopt framework, COGiTATE evidence base, and the +0.25 threshold all originate here. Pediatric severe TBI follows the same physiology with age-banded targets.

8.2 Aneurysmal SAH

Increasingly studied. PRx during the spasm window (days 3–14) shows oscillation patterns that correlate with DCI risk. Where ICP via EVD is already in place for SAH, adding PRx-CPPopt is straightforward. The 2023 AHA/ASA SAH guidelines mention multimodal monitoring including autoregulation indices as a tier-2 modality.

8.3 Pediatric severe TBI

Tas 2021, Velle 2023, and the Cambridge group's KidsBrainIT analyses are the main evidence. A pediatric MMM review (Laws 2022) describes PRx as a specialist-centre monitoring modality in resourced centres.

8.4 Post-cardiac arrest

PRx in post-arrest patients is less validated. The signal often has low slow-wave power because of cooling, deep sedation, and reduced cerebral metabolic activity. COx (NIRS-MAP) is often more usable in the first 48 hours; PRx becomes interpretable on rewarming. Sparse

8.5 ECMO

VA-ECMO with non-pulsatile flow abolishes PRx interpretability. The slow-wave drive disappears. Mx (TCD-MFV-MAP correlation) is more usable because it relies on the residual pulsatility detectable on TCD; COx (NIRS-MAP) is the most robust autoregulation surrogate during ECMO.

8.6 Bacterial meningitis with raised ICP

Where ICP is being monitored invasively in pediatric meningitis with hydrocephalus, PRx can be computed. Evidence base is thin but pathophysiologically the principle applies. Sparse

8.7 Hepatic encephalopathy

ICP monitoring in acute liver failure is contentious (coagulopathy and bleed risk); where placed, PRx adds CPP individualisation. Evidence base is single-centre and small. Sparse

8.8 Pediatric stroke and post-thrombectomy

Individualised BP targeting using PRx (where ICP is invasive) or COx (when ICP cannot be placed) is emerging in adult post-thrombectomy management. Pediatric application is research-stage. Sparse

9. Multimodal integration: PRx alongside Mx, COx, and others

Fig. 3
PRx vs Mx vs COx · ONE PATIENT, THREE INDICESEach panel is an index-vs-CPP U-curve · shared scale -1 to +1 · threshold +0.25CONCORDANT · the three agree on CPPopt (~70)PRx · ICP+0.25+.8-.4CPPopt 70Mx · TCD MFV+0.25+.8-.4CPPopt 70COx · NIRS rSO2+0.25+.8-.4CPPopt 70DISCORDANT · different CPPopt per index (PRx 70 · Mx 60 · COx 82)PRx · ICP+0.25+.8-.4CPPopt 70Mx · TCD MFV+0.25+.8-.4CPPopt 60COx · NIRS rSO2+0.25+.8-.4CPPopt 82DISCORDANCE IS INFORMATIONPRx samples whole-brain (ICP) · Mx large-vessel (TCD MFV) · COx regional cortex (NIRS rSO2). Disagreement localises where autoregulation fails.MNM-Edu original schematic · Rivera-Lara 2017 · Czosnyka 1997 (PRx) / 1996 (Mx) · Brady 2010 (COx)
PRx, Mx (TCD-based), and COx (NIRS-based) on the same patient. In concordant intact autoregulation all three are near zero. In concordant impaired all three are positive and the CPPopt curves agree. In discordant cases, the indices give different CPPopt values, often because they sample different vascular beds (PRx whole-brain ICP, Mx large-vessel MFV, COx regional cortex). Discordance is not noise; it carries information about where the autoregulatory failure lies.
MNM-Edu, original schematic.
Pair with…What you gainWorked scenario
Mx (TCD)Non-invasive autoregulation when ICP unavailable; mutual validation when both are availableTCD page
COx (NIRS)Regional cortical autoregulation; works in ECMO and low-pulsatility statesCOx page, NIRS page
PbtO2Endpoint validation: low PbtO2 + high PRx = clear ischaemic-autoregulatory crisisPbtO2 page
MicrodialysisMetabolic endpoint: rising lactate/pyruvate ratio + high PRx = energy crisisMicrodialysis page
EEG / aEEGReactivity loss + impaired PRx = severe brain dysfunctionEEG page
ICP waveform (RAP)Compliance state alongside autoregulatory stateICP page, RAP page

The three-index synthesis: when PRx, Mx, and COx all point to impaired autoregulation, the conclusion is robust. When they disagree, ask which vascular bed each samples (whole brain vs large vessel vs regional cortex) and trust the one most relevant to the clinical question.

10. Pitfalls and artefacts

  • Signal quality is everything. A noisy ICP transducer or poorly-zeroed arterial line produces nonsense PRx. Validate every shift.
  • Sedation lightening shifts PRx: deep propofol reduces ICP slow-wave power; lightening raises it. Re-baseline after sedation changes.
  • Suctioning, position change, agitation: classic short-window artefact. Reject from CPPopt fit.
  • Non-pulsatile flow (ECMO): PRx becomes uninterpretable. Use COx or Mx.
  • Hypothermia: reduces slow-wave power; PRx less interpretable.
  • Age-related differences: pediatric thresholds are similar but slow-wave content can be lower; pediatric validation studies used adult-style windowing.
  • Short window (single 5-min value): not actionable. Always look at hours.
  • Flat or shallow CPPopt curve: when the U-curve cannot be fit, do not invent a CPPopt; revert to age-based default.
  • Time-varying CPPopt: CPPopt drifts within a single patient over hours. The 4-hour moving window is a compromise.
  • PRx vs Mx vs COx disagreement: not noise, it is information about which vascular bed is failing. Investigate, do not average.

11. Combine with…

12. Evidence summary and recent literature

12.1 Evidence summary

TopicSourceGrade
Original PRx descriptionA (foundational)
Pediatric piglet validation B
COx (NIRS-based)B
Mx (TCD-based)B
Mortality outcome association B
CPPopt derivationB
CPPopt vs PRx vs outcomeB
MAPopt extensionB
Pediatric CPPopt B
COGiTATE phase IIA
ICM+ implementation referenceexpert
Autoregulation methods reviewreview
Pediatric MMM review (Laws 2022) review
NCS MMM consensusexpert
PBTF 4 ICP / CPP recommendationsexpert

12.2 Recent literature (2022–2025)

  • Beqiri 2025 (COGiTATE phase II): feasibility and safety established for PRx-CPPopt-guided care in adult severe TBI. Patients in the CPPopt arm achieved their individualised target a median 46.5% of monitored time (IQR 38.3-56.2) versus 30.3% (IQR 22.6-38.4) in the standard arm, p < 0.001.
  • Velle 2023 (pediatric CPPopt): per-patient temporal analysis showing CPPopt dynamism over admission course; pediatric application of the CPPopt framework.
  • Pediatric MMM review (Laws 2022): describes PRx as specialist-centre monitoring, used where ICP is in place and computational resources allow.
  • Rivera-Lara 2017 (autoregulation methods review): contemporary methodological reference for comparing PRx, Mx, COx and their pitfalls.
  • Smielewski 2005 (ICM+ reference): implementation reference for PRx computation and CPPopt fitting in clinical software.
  • Donnelly 2017 (MAPopt): extension from CPP-targeted to MAP-targeted optimisation, useful when ICP changes throughout the day.

13. Self-check

Retrieval check
A 10-year-old severe TBI day 2 post-decompression. ICP 12 mmHg, CPP 60 mmHg, PRx +0.45 sustained over 4 hours. CPPopt fit shows a clear vertex at CPP 75 mmHg. Most appropriate next step?
A 7-year-old post-cardiac arrest day 1, target temperature 33°C, propofol infusion. The PRx reads 0.05 but the slow-wave power in ICP is very low and the signal is noisy. Best interpretation?
A 14-year-old SAH day 5 post-coiling. PRx has been oscillating between +0.05 and +0.30 every 20 minutes for the past 4 hours. The CPPopt fit shows a flat curve with no clear vertex. Best next step?

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