A critical event frequent lead to reversible spinal cord injury during vertebral column resection surgery.

OBJECTIVE: To report a "critical phase" (between osteotomy completion and correction beginning) that will frequently lead to the reversible intraoperative neurophysiological monitoring (IOM) change during posterior vertebral column resection (PVCR) surgery. METHODS: The study sample consisted of 120 patients with severe spine deformity who underwent PVCR and deformity correction surgeries. Those patients were recruited consecutively from 2010 to 2018 January in our spine center. The detailed IOM data (the amplitude of MEP & SEP) and its corresponding surgical points were collected prospectively. Early and long-term postoperative neurologic outcomes were assessed for the following functions: motor, sensory, and pain at immediate postoperative and 1-year post-operation in this cases series. RESULTS: A total of 105 (105/120) patients presented varying degrees of IOM reduction in the critical phase; the mean IOM amplitude retention vs rescue rate was 27% ± 11.2 versus 58% ± 16.9, P < 0.01 (MEP) & 34% ± 8.3 versus 66% ± 12.4 P < 0.01 (SEP). Patients with postoperative spinal deficits often had a significantly longer IOM-alerting duration than the patients without (p < 0.01, Mann-Whitney U-test), and IOM-alerting duration greater than 39.5 min was identified as an independent predictor of the risk of postoperative spinal deficits. CONCLUSIONS: The reversible IOM events probably often appear in the critical phase during PVCR surgery. The new postoperative spinal deficits are possible for patients without satisfied IOM recovery or alerting duration greater than 39.5 min. Timely and suitable surgical interventions are useful for rescuing the IOM alerts.

Coupled air lasing gain and Mie scattering loss: an aerosol effect in filament-induced plasma spectroscopy.

Femtosecond laser filament-induced plasma spectroscopy (FIPS) demonstrates great potential in remote sensing for identifying atmospheric pollutant molecules. Due to the widespread aerosols in the atmosphere, remote detection based on FIPS would be affected by both the excitation and the propagation of fingerprint fluorescence, which still remain elusive. Here the physical model of filament-induced aerosol fluorescence is established to reveal the combined effect of Mie scattering and amplification spontaneous emission, which is subsequently proven by experimental results, the dependence of the backward fluorescence on the interaction length between filaments and aerosols. These findings provide an insight into the complicated aerosol effect in the overall physical process of FIPS including propagation, excitation, and emission, paving the way to its practical application in atmospheric remote sensing.

Validity of evoked potential as biomarker for predicting early neural function changes after thoracic spinal decompression surgery in patients with neurological deficits.

OBJECTIVE: To evaluate the validity of intraoperative evoked potential (EP) including motor evoked potential (MEP) and somatosensory evoked potentials (SEP) as a biomarker for predicting neural function changes after thoracic spinal decompression (TSD) surgery. METHOD: A consecutive series of 336 TSD surgeries were reviewed between 2010 and 2021 from four spine center. All patients with TSD were divided into 3 groups according to different intraoperative EP results: group 1, EP alerts; group 2, no obvious EP deterioration; group 3, EP improvement compared with baselines. The lower limb Japanese Orthopedic Association (JOA) scores (as well as early and long-term JOA recovery rate) were utilized to quantitatively assess pre- and postoperative neural function change. RESULTS: Among the 3 subgroups according to the different EP changes, the early JOA recovery rate (RR%) in the EP improvement group was significantly better than the other two groups (51.3 ± 58.6* vs. 27.5 ± 31.2 and 33.3 ± 43.1; p < 0.01) after 3-month follow-up. The mean MEP and SEP amplitude were from 116 ± 57 µV to 347 ± 71 µV (p < 0.01) and from 1.86 ± 0.24 µV to 2.65 ± 0.29 µV (p < 0.01) between spinal cord pre-decompression and post-decompression. Moreover, multivariate logistic regression analysis revealed that risk factors of EP improvement were duration of symptom (p < 0.001, OR 10.9) and Preop. neurologic deficit degree (p = 0.013, OR 7.46). CONCLUSION: The intraoperative EP can predict postoperative neural function changes as a biomarker during TSD. Patient with EP improvement probably has better prognosis for early neural function recovery. The duration of symptom and preoperative neurologic deficit degree may be related to intraoperative EP improvement.

A Simulation of Air Lasing Seeded by an External Wave in a Femtosecond Laser Filament.

Air lasers induced by femtosecond laser filaments play an important role in remote sensing applications. Few studies have been dedicated to the spatial distribution of external-seeded air laser radiation in the laser filament based on the numerical simulation method, which can pave the way to understanding the mechanism of the external-seeded air lasing process during filamentation. In this study, numerical simulations of the propagation of an air laser seeded by an external plane wave with a wavelength of 391 nm during femtosecond laser filamentation were performed. The results indicated that the air laser's beam intensity distribution varies from a ring pattern to a donut pattern when the filament length and nitrogen ion density are raised as a result of the defocusing and lasing effects of the filament plasma. Here, the ring pattern is formed by several thin rings, while the donut pattern refers to a notably thicker, ring-like structure. In addition, it has been demonstrated that the air laser's beam power would increase exponentially versus the filament length and the nitrogen ion density. The knowledge about the angular distribution of air lasing could be important for optimizing the detection geometry of the LIDAR setup, including the view angle and the size of the collecting optical component.

Sub-ppb NaCl aerosol detection at a distance of 30 meters by femtosecond laser induced plasma spectroscopy.

In this work, sub-ppb aerosol detection is achieved by femtosecond laser filament with a single pulse energy of 4 mJ at a distance of 30 m. A concave mirror with an open aperture of 41.4 cm is employed in an off-axis optical system to focus the femtosecond laser beam and collect the fluorescence of NaCl aerosol. The simulation and experimental results show that the astigmatism can be greatly reduced when femtosecond laser beam is incident non-symmetrically on the concave mirror. Compared with the case that femtosecond laser strikes at the center of the concave mirror, the intensity of acoustic signal emitted from the optical filament is increased by 69.5 times, and the detection of limit of sodium element in aerosol is reduced by 86%, which is down to 0.32 ppb. The improved excitation scheme in this work utilizes the nonsymmetrical beam spot on the concave mirror to compensate the non-symmetry induced by the off-axis setup, reducing the astigmatism of the focusing laser beam and decreasing the sodium chloride aerosol's detection of limit.

Suppressing turbulence-induced laser beam wandering by using an axicon.

Laser beam wandering induced by air turbulence could be crucial for applications such as free-space optical communications, LIDAR, and remote air lasing. In this study, the influence of air turbulence on the transverse wandering of a Gauss laser beam with and without an axicon as the focusing optical component has been investigated. It has been demonstrated that the turbulence-induced beam wandering could be dramatically suppressed by using an axicon. Further, the corresponding mechanism has been discussed. This work would bring great benefits to many practical applications relying on a stable laser beam in a turbulent atmosphere.

Anomalous transmission and Anderson localization for alternating propagated and evanescent waves at the deep-subwavelength scale.

Deep-subwavelength features have a minimal impact on wave transport in all dielectric systems; thus the homogenization approach was commonly adopted. Recently, the breakdown of effective medium theory (EMT) for the incident wave near the total reflection (TR) angle was demonstrated in a deep-subwavelength dielectric multilayer. Additionally, anomalous transmission was reported at angles exceeding the TR angle when introducing disorder and was attributed to Anderson localization. Here we firstly demonstrated that the alleged anomalous transmission also occurs in the disorder-free case, illustrating that attributing anomalous transmission to Anderson localization deserves a more in-depth study. To clarify the underlying physics of this asserted anomalous transmission, Anderson localization and broken EMT, the incident angle dependent reflectivity and modes for ordered and disordered deep-subwavelength multilayers were investigated systematically. Actually, the EMT is still convincing and the anomalous transmission is reasonable after a simple correction. However, the anomalous transmission is more accessible and the permittivity correction is more imperative in the disordered system due to the Anderson localization. These findings can be expanded to other wave systems such as acoustic waves and matter waves, providing insight into EMT and deepening our understanding of the intriguing transport phenomena in deep subwavelength systems.

Transcranial MEP threshold voltages and current densities simulated with finite element modelling.

OBJECTIVE: The aim of this study was to compare stimulation thresholds and current densities in the brain for transcranial motor evoked potentials (tcMEPs) from the hands and feet with linked quadripolar (LQP), M3-M4 and C1-C2 electrode montages. METHODS: Twenty-five patients underwent cerebral vascular surgery with tcMEP monitoring. tcMEP voltage thresholds were compared between LQP (C1, M3, C2, M4), C1-C2, and M3-M4 montages. In a finite element model (FEM), hand, arm, and leg regions of interest (ROIs) on the cortical motor homunculus were segmented. Current densities in these ROIs at tcMEP thresholds were compared across tcMEP electrode montages. RESULTS: LQP tcMEP thresholds were 61.5 volts for hands and 95.2 volts for feet. Thresholds were higher for M3-M4 (hands, 89.4 V; feet, 141.3 V) and C1-C2 (hands: 137.3 V; feet: 194.7 V). Total current at threshold voltage was greater for LQP (hands, 210.9 mA; feet, 311.3 mA) compared to M3-M4 (hands, 166.8 mA; feet, 256.6 mA), but similar to C1-C2 (hands, 246.7 mA; feet, 341.1 mA). In FEM simulations, current density and local current density topography in the hand ROI at threshold were very similar for LQP, M3-M4 and C1-C2. CONCLUSIONS: TcMEP voltage thresholds were least for LQP, and lesser for M3-M4 compared to C1-C2. In FEM simulations, resistance to current to hand ROI was ordered the same (LQP < M3-M4 < C1-C2). The local distribution of current density in motor cortex with tcMEP was mainly determined by cortical geometry. SIGNIFICANCE: Current densities and resistance to current simulated with FEM may explain threshold requirements for tcMEP electrode montages.

Detection of 1.4 µg/m3 Na+ in aerosol at a 30 m distance using 1 kHz femtosecond laser filamentation in air.

An optimized remote material detection scheme based on the laser filament-induced plasma spectroscopy and light detection and ranging (FIPS-LIDAR) is proposed in this work. The elemental composition and concentration of aerosol are measured by FIPS-LIDAR. By focusing the femtosecond laser with a large aperture (Φ41 cm) concave mirror and coaxial fluorescence collection scheme, the remote detection of aerosol in air at µg/m3 level has been realized at a distance of 30 m. The limit of detection for Na+ in aerosol droplets is 8 ppm (3 µg/m3 in air), which is the lowest detection limit that has been reported using millijoule femtosecond laser pulse (4.4 mJ). Furthermore, using spectral preprocessing and optimization of the proposed significance of peak (SOP) algorithm, feature peak signals are extracted from weak signals and the limit of detection can be further decreased to 1.4 µg/m3.

Giant enhancement of acoustic and fluorescence emission from an off-axis reflective femtosecond laser filamentation system.

Femtosecond laser filamentation propagating tens of meters to several kilometers with high intensity in the atmosphere has been demonstrated as a powerful tool for remote sensing. In contrast to the refractive systems, the reflective optical systems possess a variety of advantages including broad bandwidth, large aperture, light weight and low energy loss. However, astigmatic aberration is inevitably introduced by off-axis reflective mirrors. It can greatly affect the filament quality, which is critical for exciting and detecting the fluorescence of target molecules. Here we elaborately design a free-form phase plate to correct the astigmatism in off-axis reflective optical systems. It is demonstrated that the free-form surface exhibits excellent performance, significantly reducing the astigmatic difference from 44 cm to 4 cm and increasing the maximum acoustic intensity by a factor of 53. In addition, extremely strong nitrogen fluorescence spectra have been detected. These results indicate that the free-form phase plate can effectively compensate for astigmatic aberration in off-axis reflective system, providing a guiding significance for the optimal control of filamentation and remote sensing.

Interdigitated photoconductive antenna-based two-color femtosecond laser filamentation THz time-domain spectral detection.

Two-color femtosecond (fs) laser filamentation in the gas medium is an effective way to generate broadband and high intensity terahertz (THz) pulse. The interdigitated photoconductive antenna (iPCA) has the advantages of both broadband detection and high signal-to-noise ratio (SNR), which is a very effective way to detect the THz pulse produced by two-color fs laser filamentation. The THz signal from two-color fs laser filamentation is comprehensively characterized by the iPCA, which achieves high SNR, high sensitivity, and polarization detection. This work provides a new idea for high power broadband THz coherent detection.

Sensing with Femtosecond Laser Filamentation.

Femtosecond laser filamentation is a unique nonlinear optical phenomenon when high-power ultrafast laser propagation in all transparent optical media. During filamentation in the atmosphere, the ultrastrong field of 1013-1014 W/cm2 with a large distance ranging from meter to kilometers can effectively ionize, break, and excite the molecules and fragments, resulting in characteristic fingerprint emissions, which provide a great opportunity for investigating strong-field molecules interaction in complicated environments, especially remote sensing. Additionally, the ultrastrong intensity inside the filament can damage almost all the detectors and ignite various intricate higher order nonlinear optical effects. These extreme physical conditions and complicated phenomena make the sensing and controlling of filamentation challenging. This paper mainly focuses on recent research advances in sensing with femtosecond laser filamentation, including fundamental physics, sensing and manipulating methods, typical filament-based sensing techniques and application scenarios, opportunities, and challenges toward the filament-based remote sensing under different complicated conditions.

Intraoperative neuromonitoring during surgery for lumbar stenosis.

The indications for neuromonitoring during lumbar stenosis surgery are defined by the risks associated with patient positioning, the approach, decompression of neural elements, deformity correction, and instrument implantation. The routine use of EMG and SEP alone during lumbar stenosis surgery is no longer supported by the literature. Lateral approach neuromonitoring with EMG only is also suspect. Lumbar stenosis patients often present with multiple co-morbidities which put them at risk during routine pre-surgical positioning. Frequently encountered morbid obesity and/or diabetes mellitus may play a role in monitorable and preventable brachial plexopathy after "superman" positioning or femoral neuropathy from groin pressure after prone positioning, for example. Deformity correction in lumbar stenosis surgery often demands advanced implementation of multiple neuromonitoring modalities: EMG, SEP, and MEP. Because the bulbocavernosus reflex detects the function of the conus medullaris and sacral somato afferent/efferent fibers of the cauda equina, it may also be recorded. The recommendation to record pedicle screw thresholds has become more nuanced as surgeon dependence on 3D imaging, navigation, and robotics has increased. Neuromonitoring in lumbar stenosis surgery has been subject mainly to uncontrolled case series; prospective cohort trials are also needed.

Monitoring spinal surgery for extramedullary tumors and fractures.

Meningiomas are the most common intradural extramedullary tumors, followed by nerve sheath tumors that can also grow extradurally. Metastases are the most frequent extradural tumors and most commonly affect the thoracic vertebrae. Spinal fractures with column dislocation and/or instability require surgical fixation. Spine surgery for an extramedullary tumor or fracture usually involves decompression of neural elements and instrumentation for stabilization. These procedures risk spinal cord and nerve root injury. The incidence of nerve root deficits after resection of nerve sheath tumors is particularly high since the tumor grows from the rootlets. Intraoperative neurophysiologic monitoring and mapping techniques have been introduced to prevent iatrogenic neurologic deficits. These include motor and sensory evoked potentials, electromyography, compound muscle action potentials, and the bulbocavernosus reflex. The combination of techniques chosen for a particular procedure depends on the surgical level and the character of the lesion.

The Minimal Subcortical Electronic Threshold Predicts the Motor Deficit and Survivals in Non-Awake Surgery for Gliomas Involving the Motor Pathway.

Purpose: Direct subcortical motor mapping is the golden criterion to detect and monitor the motor pathway during glioma surgery. Minimal subcortical monopolar threshold (MSCMT) means the minimal distance away from the motor pathway and is critical to decide to continue or interrupt glioma resection. However, the optimal cutoff value of MSCMT for glioma resection in non-awake patients has not been reported discreetly. In this study, we try to establish the safe cutoff value of MSCMT for glioma resection and analyzed its relationship with postoperative motor deficit and long-term survivals. Methods: We designed this prospective study with high-frequency electronic stimulus method. The cutoff MSCMT of postoperative motor deficits was statistically calculated by receiver operating characteristic (ROC) curve, and its relationship with motor deficit and survivals was analyzed by logistic and Cox regression, respectively. Results: The cutoff MSCMT to predict motor deficit after surgery was 3.9 mA on day 1, 3.7 mA on day 7, 5.2 mA at 3 months, and 5.2 mA at 6 months. MSCMT ≤3.9 mA and MSCMT ≤5.2 mA independently predicted postoperative motor deficits at four times after surgery (P < 0.05) but had no effect on the removal degree of tumor (P > 0.05). In high-grade gliomas, MSCMT ≤3.9 mA independently predicted shorter progression-free survival [odds ratio (OR) = 3.381 (1.416-8.076), P = 0.006] and overall survival [OR = 3.651 (1.336-9.977), P = 0.012]. Power model has the best fitness for paired monopolar and bipolar high-frequency thresholds. Conclusions: This study showed strong cause-effect relation between MSCMT and postoperative motor deficit and prognoses. The cutoff MSCMT was dug out to avoid postoperative motor deficit. Further studies are needed to establish the results above.

Utilization of intraoperative neuromonitoring during the Woodward procedure for treatment of Sprengel deformity.

BACKGROUND: Brachial plexus injury (BPI) leading to palsy of the upper extremities is the most serious complication of the Woodward procedure for treatment of Sprengel deformity. Intraoperative neuromonitoring (IONM) is widely used for detecting emerging spinal cord or peripheral nerve injury during spinal and shoulder surgery. However, to date, its utilization in pediatric patients with Sprengel deformity is limited. Furthermore, it remains unclear whether IONM can help prevent BPI during surgery. The purpose of the current study was to assess the feasibility and effectiveness of IONM for early identification and prevention of nerve injury during the Woodward procedure. METHODS: We retrospectively reviewed the records of patients who underwent the Woodward procedure for Sprengel deformity at our institution between January 2017 and January 2020. IONM, including somatosensory evoked potentials (SEP) and motor evoked potentials (MEPs), was performed in all patients. Detailed IONM data were collected and analyzed. Preoperative and postoperative cosmetic appearance (according to the Cavendish classification), shoulder joint abduction function, and radiologic evaluation of the scapula were reviewed. Surgical complications were recorded. RESULTS: Forty-six patients (19 girls, 27 boys) were included (mean age, 5.1 ± 2.1 years). Both SEP and MEP (amplitude of the abductor pollicis) were successfully performed (100%). MEP alerts occurred in 3 patients (6.5%). After scapula position adjustment, signals recovered in 2 patients and remained unchanged in 1 patient-this patient exhibited postoperative motor deficits that resolved completely by 4 months recovery. The SEP amplitudes decreased in all 3 patients but did not reach the warning criteria. Forty patients were classified as grade III and 6 as grade IV in the Cavendish classification, whereas 35 patients were classified as grade II and 11 as grade III in the Rigault scale. The preoperative Cavendish grade was III (III, IV) and the postoperative Cavendish grade was I (I, II) (χ2 = 88.098, P < .001). The preoperative Rigault grade was II (II, III) and the postoperative Rigault grade was I (I, II) (χ2 = 62.133, P < .001). The mean arc of shoulder joint abduction improved from 99° ± 8° to 167° ± 7° (t = -45.871, P < .001) after surgery. Except for temporary motor deficits detected in 1 patient, no other postoperative complications were observed through the time of final follow-up. CONCLUSION: IONM during the Woodward procedure for Sprengel deformity is feasible and effective in detecting intraoperative neurologic changes and may be effective in preventing BPI associated with surgery.

Effect of laser repetition rate on the fluorescence characteristic of a long-distance femtosecond laser filament.

In this paper, the effect of the laser repetition rate on the long-distance femtosecond laser filament in air is investigated by measuring the fluorescence characteristic of the filament. A femtosecond laser filament emits fluorescence due to the thermodynamical relaxation of the plasma channel. Experimental results show that as the repetition rate of femtosecond laser increases, the fluorescence of the filament induced by a single laser pulse weakens, and the position of the filament moves away from the focusing lens. These phenomena may be attributed to the slow hydrodynamical recovery process of air after being excited by a femtosecond laser filament, whose characteristic time is on the millisecond time scale and comparable to the inter-pulse duration of the femtosecond laser pulse train. This finding suggests that at a high laser repetition rate, to generate an intense laser filament, the femtosecond laser beam should scan across the air to eliminate the adverse effect of slow air relaxation, which is beneficial to laser filament remote sensing.

Utility of intraoperative neuromonitoring and outcomes of neurological complication in lower cervical and upper thoracic posterior-based three-column osteotomies for cervical deformity.

OBJECTIVE: For severe and rigid adult cervical deformity, posterior-based three-column osteotomies (3COs) are warranted, but neurological complications are relatively high with such procedures. The performance measures of intraoperative neuromonitoring (IONM) during cervicothoracic 3CO have yet to be studied, and there remains a paucity of literature regarding the topic. Therefore, the authors of this study examined the performance of IONM in predicting new neurological weakness following lower cervical and upper thoracic 3CO. In addition, they report the 6-month, 1-year, and 2-year outcomes of patients who experienced new postoperative weakness. METHODS: The authors performed a retrospective review of a single surgeon's experience from 2011 to 2018 with all patients who had undergone posterior-based 3CO in the lower cervical (C7) or upper thoracic (T1-4) spine. Medical and neuromonitoring records were independently reviewed. RESULTS: A total of 56 patients were included in the analysis, 38 of whom had undergone pedicle subtraction osteotomy and 18 of whom had undergone vertebral column resection. The mean age was 61.6 years, and 41.1% of the patients were male. Among the study cohort, 66.1% were myelopathic and 33.9% had preoperative weakness. Mean blood loss was 1565.0 ml, and length of surgery was 315.9 minutes. Preoperative and postoperative measures assessed were cervical sagittal vertical axis (6.5 and 3.8 cm, respectively; p < 0.001), cervical lordosis (2.3° and -6.7°, p = 0.042), and T1 slope (48.6° and 35.8°, p < 0.001). The complication rate was 49.0%, and the new neurological deficit rate was 17.9%. When stratifying by osteotomy level, there were significantly higher rates of neurological deficits at C7 and T1: C7 (37.5%), T1 (44.4%), T2 (16.7%), T3 (14.3%), and T4 (0.0%; p = 0.042). Most new neurological weakness was the nerve root pattern rather than the spinal cord pattern. Overall, there were 16 IONM changes at any threshold: 14 at 50%, 8 at 75%, and 13 if only counting patients who did not return to baseline (RTB). Performance measures for the various thresholds were accuracy (73.2% to 77.8%), positive predictive value (25.0% to 46.2%), negative predictive value (81.3% to 88.1%), sensitivity (18.2% to 54.5%), and specificity (77.8% to 86.7%). Sensitivity to detect a spinal cord pattern of weakness was 100% and 28.6% for a nerve root pattern of weakness. In patients with a new postoperative deficit, 22.2% were unchanged, 44.4% improved, and 33.3% had a RTB at the 2-year follow-up. CONCLUSIONS: Complication rates are high following posterior 3CO for cervical deformity. 3CO at C7 and T1 has the highest rates of neurological deficit. Current IONM modalities have modest performance in predicting postoperative deficits, especially for nerve root neuropraxia. A large prospective multicenter study is warranted.

Intraoperative Neurophysiology and Transcranial Doppler for Detection of Cerebral Ischemia and Hyperperfusion During Carotid Endarterectomy.

OBJECTIVE: To evaluate and compare efficacy of intraoperative neurophysiological monitoring (IONM) and intraoperative transcranial Doppler (TCD) techniques for identification of hypoperfusion during carotid artery clamp and hyperperfusion after release of occlusion during carotid endarterectomy. METHODS: This was a retrospective, consecutive case series of 152 patients undergoing carotid endarterectomy between June 2018 and March 2020. Somatosensory evoked potentials, motor evoked potentials, electroencephalogram, and TCD were obtained. RESULTS: Three patient cohorts were observed after clamping the carotid artery: A, in 132 of 152 patients (87%), TCD blood flow velocity decreased by <50% and there were no changes in IONM; B, in 5 of 152 (3%) patients, TCD blood flow rate was reduced 50%-100% with no changes in IONM; C, in 15 patients (10%), blood flow velocity was reduced by 50%-100% and all IONM modalities met warning criteria. With increased blood pressure, IONM and blood flow velocities improved to less than warning criteria in 8 of 15 patients. In 6 of the 7 remaining patients, IONM modalities recovered to baseline immediately after clamps were removed from the carotid artery. The 1 patient with persistent motor evoked potential deterioration experienced postoperative proximal muscle weakness, which recovered 48 hours later. In 22 patients, TCD detected hyperperfusion at the moment of clamp release. CONCLUSIONS: TCD blood flow velocity is correlated with motor evoked potential and somatosensory evoked potential amplitude changes after clamping. After declamping, TCD can detect hyperperfusion and help regulate blood pressure to prevent hyperperfusion.