Neurotraumatology

Invasive intracranial pressure monitoring in severe traumatic brain injury

According to current guidelines [1] by the Brain Trauma Foundation in traumatic brain injury (TBI), intracranial pressure monitoring (ICP) is still recommended in management to reduce in-hospital and 2-week post-injury mortality.

According to current guidelines [1] by the Brain Trauma Foundation in traumatic brain injury (TBI), intracranial pressure monitoring (ICP) is still recommended in management to reduce in-hospital and 2-week post-injury mortality.

This current review [2] of 13,188 patients in the Trauma Quality Improvement Program Database reveals a poor compliance with current guidelines on severe TBI, but also restates the findings by Chesnut's et al. pivotal RCT [3] that despite current guideline recommendations, invasive ICP monitoring showed no benefit on 30-day mortality. Instead, ICP monitoring was independently associated with increased overall rate of complications (including infectious and thromboembolic events) and poor functional independence.

The only RCT on the subject of invasive ICP monitoring by Chesnut et al. [3] showed no benefit on survival or functional status at 3 and 6 months (evaluated by a composite outcome of 21 measures of functional and cognitive status) on 324 patients evaluated in 6 hospitals in Bolivia and Ecuador (this region was selected as a group of intensivists was identified who routinely managed severe TBI without using available monitors thus eliminating the ethical constraint precluding RCT's up until then). The control group was administered treatment based solely on clinical-radiologic assessment with no difference on the primary outcome, length of ICU stay or serious adverse events.

The current evidence shows an eagerness for obtaining objective physiological measurements without a truly measurable impact on outcome but by paying the price of increased complications associated with invasive management.

1. Carney, N., Totten, A. M., O'reilly, C., Ullman, J. S., Hawryluk, G. W., Bell, M. J., ... & Rubiano, A. M. (2017). Guidelines for the management of severe traumatic brain injury. Neurosurgery, 80(1), 6-15. https://www.ncbi.nlm.nih.gov/pubmed/27654000

2. Aiolfi, A., Benjamin, E., Khor, D., Inaba, K., Lam, L., & Demetriades, D. (2017). Brain Trauma Foundation Guidelines for Intracranial Pressure Monitoring: Compliance and Effect on Outcome. World Journal of Surgery, 41(6), 1543-1549. doi:10.1007/s00268-017-3898-6 https://www.ncbi.nlm.nih.gov/pubmed/28188356

3. Chesnut, R. M., Temkin, N., Carney, N., Dikmen, S., Rondina, C., Videtta, W., . . . Hendrix, T. (2012). A Trial of Intracranial-Pressure Monitoring in Traumatic Brain Injury. New England Journal of Medicine, 367(26), 2471-2481. doi:10.1056/nejmoa1207363 https://www.ncbi.nlm.nih.gov/pubmed/23234472