Intracranial pressure monitoring for severe traumatic brain injury [Neurosurgery Wiki]

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====== Intracranial pressure monitoring for severe traumatic brain injury ======

Although the current [[guideline]]s recommend the use of [[intracranial pressure monitoring]] in patients with [[severe traumatic brain injury]] (sTBI), the evidence indicating benefit is limited. 

Patient data from the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury China Registry, a prospective, multicenter, longitudinal, observational, cohort study. Patients with sTBI who were admitted to 52 ICUs across China, managed with ICP monitoring or without, monitoring showed a better outcome in overall survival. Nevertheless, the use of ICP monitoring makes the management of sTBI more complex and increases the costs of medical care by prolonging the patient's stay in the ICU or hospital
((Yang C, Ma Y, Xie L, Wu X, Hui J, Jiang J, Gao G, Feng J. Intracranial Pressure Monitoring in the Intensive Care Unit for Patients with Severe Traumatic Brain Injury: Analysis of the [[CENTER-TBI]] China Registry. Neurocrit Care. 2022 Mar 4. doi: 10.1007/s12028-022-01463-w. Epub ahead of print. PMID: 35246788.)).

===== Guidelines =====

The [[Brain Trauma Foundation]] (BTF) [[guideline]]s published in [[2014]]:{{ ::guidelines_for_management_of_severe_tbi_4th_edition.pdf|4th edition}}

A mainstay of the [[care]] of the patients with the most severe brain injuries has been the
[[monitoring]] of—and treatment of—[[intracranial pressure]] ([[ICP]]). Decades ago, it was recognized
that [[cerebral swelling]] after traumatic [[injury]] to the [[brain]] can lead to [[brain herniation syndromes]], with the brain being forced under pressure into abnormal anatomical spaces, which leads first to death of those areas of the brain and ultimately of the brain itself. At the advent of contemporary
critical care, technological advances to measure intracranial pressure by placement of [[device]]s
within the brain became available, which allowed clinicians to titrate therapies based on
objective information from [[intracranial pressure monitor]]s
((Lundberg N, Troupp H, Lorin H. Continuous recording of the ventricular-fluid
pressure in patients with severe acute traumatic brain injury. A preliminary
report. J Neurosurg. 1965 Jun;22(6):581-90. PubMed PMID: 5832775.
)).

Because of its fundamental place in the [[care]] of [[patient]]s with [[severe traumatic brain injury]]
(TBI) and its relationship to overall [[outcome]]s, ICP [[monitoring]] has been included in every
guideline for severe TBI published by the [[Brain Trauma Foundation]]. In the developed world,
ICP monitoring is routinely used, leading to a lack of equipoise for assigning patients to a “nonmonitored”
arm of potential interventional trials. Therefore, in many studies, the evidence
supporting the utility of ICP monitoring was observational in nature and largely found that ICP
crises led to poorer outcomes
((Alali AS, Fowler RA, Mainprize TG, et al. Intracranial pressure monitoring in severe
traumatic brain injury: results from the American College of Surgeons Trauma Quality
Improvement Program. J Neurotrauma. Oct 15 2013;30(20):1737-1746. PMID:
23731257.))
((Farahvar A, Gerber LM, Chiu YL, Carney N, Hartl R, Ghajar J. Increased mortality in
patients with severe traumatic brain injury treated without intracranial pressure
monitoring. J Neurosurg. Oct 2012;117(4):729-734. PMID: 22900846.))
((Gerber LM, Chiu YL, Carney N, Hartl R, Ghajar J. Marked reduction in mortality in
patients with severe traumatic brain injury. J Neurosurg. Dec 2013;119(6):1583-1590.
PMID: 24098983.))
((Talving P, Karamanos E, Teixeira PG, et al. Intracranial pressure monitoring in severe
head injury: compliance with Brain Trauma Foundation guidelines and effect on
outcomes: a prospective study. J Neurosurg. Nov 2013;119(5):1248-1254. PMID:
23971954.)).

A study has challenged this paradigm by randomizing patients to protocols to treat intracranial hypertension therapies based on either an invasive ICP monitor or a clinical/radiological examination
((Chesnut RM, Temkin N, Carney N, et al. A trial of intracranial-pressure monitoring in
traumatic brain injury. N Engl J Med. Dec 2012;367(26):2471-2481. PMID: 23234472.)).

This study, performed in a region of the world where equipoise existed for a non-monitored group of patients, failed to find differences between the groups. What is clear from the [[literature]] is that
[[intracranial hypertension]] is an important secondary [[insult]] after severe TBI, and its alleviation
plays a pivotal role in providing good patient care to achieve optimal outcomes
((https://braintrauma.org/uploads/03/12/Guidelines_for_Management_of_Severe_TBI_4th_Edition.pdf)).

===== Recommendations =====

[[Level I]] and [[Level II A]]

• There was insufficient evidence to support a Level I or II A recommendation for this topic.

[[Level II B]]

• Management of severe TBI patients using information from ICP monitoring is recommended to reduce in-hospital and 2-week post-injury mortality.

As noted above in the introduction to this “Part II. Monitoring” section, the Level II and III recommendations from the 3rd Edition of these guidelines were not carried forward because they
were derived from descriptive studies, or from studies that do not meet the current inclusion
criteria for this topic. While no evidence is available from comparative studies to support a
formal recommendation, the Committee chose to re-state here the 3rd Edition recommendations.
The rationale for doing so is to maintain sufficient recognition of the patient characteristics
associated with risk of increased intracranial pressure. (Refer to the 3rd Edition for summary of
supporting studies.).

**Recommendations from the Prior Third Edition Not Supported by Evidence Meeting Current
Standards**

• Intracranial pressure (ICP) should be monitored in all salvageable patients with a severe
traumatic brain injury (TBI) (GCS 3-8 after resuscitation) and an abnormal computed
tomography (CT) scan. An abnormal CT scan of the head is one that reveals hematomas,
contusions, swelling, herniation, or compressed basal cisterns.

• ICP monitoring is indicated in patients with severe TBI with a normal CT scan if two or
more of the following features are noted at admission: age over 40 years, unilateral or
bilateral motor posturing, or systolic blood pressure (BP) <90 mm Hg.

=== Changes from Prior Edition ===

New Class 2 studies provide evidence for recommendations that replace those of the 3rd
Edition of these guidelines. See the introduction to this “Part II. Monitoring” section (above) for
details about changes from the 3rd Edition.
----
With lack of strong evidence, it is not surprising that the use of ICP monitoring in both adults and children is variable. Although it seems intuitively obvious that having this data point would be beneficial, large observational studies in adults and now in children do not clearly support the benefit. Current guidelines for pediatric patients state that although elevated ICP is associated with poorer outcomes, it is only a level III recommendation to use ICP monitoring in children with severe TBI
((Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, Bratton S, Carson S,
Chesnut RM, Ghajar J, Goldstein B, Grant GA, Kissoon N, Peterson K, Selden NR,
Tasker RC, Tong KA, Vavilala MS, Wainwright MS, Warden CR; American Academy of
Pediatrics-Section on Neurological Surgery; American Association of Neurological 
Surgeons/Congress of Neurological Surgeons; Child Neurology Society; European
Society of Pediatric and Neonatal Intensive Care; Neurocritical Care Society;
Pediatric Neurocritical Care Research Group; Society of Critical Care Medicine;
Paediatric Intensive Care Society UK; Society for Neuroscience in Anesthesiology 
and Critical Care; World Federation of Pediatric Intensive and Critical Care
Societies. Guidelines for the acute medical management of severe traumatic brain 
injury in infants, children, and adolescents--second edition. Pediatr Crit Care
Med. 2012 Jan;13 Suppl 1:S1-82. doi: 10.1097/PCC.0b013e31823f435c. Erratum in:
Pediatr Crit Care Med. 2012 Mar;13(2):252. PubMed PMID: 22217782.)).

Recommendations from adult guidelines are slightly more firm, using level IIb evidence, stating that ICP should be monitored in patients with Glasgow Coma Scale less than 8 and an abnormal computed tomography (CT) scan or a normal CT scan in patients who meet 2 of the 3 following criteria: age >40, unilateral or bilateral motor posturing, or systolic blood pressure less than 90 mm Hg
((Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, 
Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS,
Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe
Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80(1):6-15. doi:
10.1227/NEU.0000000000001432. PubMed PMID: 27654000.
)).
====Trials====
[[Randall Chesnut]] et al., conducted a [[multicenter]], [[controlled trial]] in which 324 patients 13 years of age or older who had [[severe traumatic brain injury]] and were being treated in [[intensive care unit]]s (ICUs) in [[Bolivia]] or [[Ecuador]] were randomly assigned to one of two specific protocols: guidelines-based management in which a protocol for monitoring intraparenchymal intracranial pressure was used (pressure-monitoring group) or a protocol in which treatment was based on imaging and clinical examination (imaging-clinical examination group). The primary outcome was a composite of survival time, impaired [[consciousness]], and [[functional]] status at 3 months and 6 months and neuropsychological status at 6 months; neuropsychological status was assessed by an examiner who was unaware of protocol assignment. This composite measure was based on performance across 21 measures of functional and cognitive status and calculated as a percentile (with 0 indicating the worst performance, and 100 the best performance).

There was no significant between-group difference in the primary outcome, a composite measure based on percentile performance across 21 measures of functional and cognitive status (score, 56 in the pressure-monitoring group vs. 53 in the imaging-clinical examination group; P=0.49). Six-month mortality was 39% in the pressure-monitoring group and 41% in the imaging-clinical examination group (P=0.60). The median length of stay in the ICU was similar in the two groups (12 days in the pressure-monitoring group and 9 days in the imaging-clinical examination group; P=0.25), although the number of days of brain-specific treatments (e.g., administration of hyperosmolar fluids and the use of [[hyperventilation]]) in the ICU was higher in the imaging-clinical examination group than in the pressure-monitoring group (4.8 vs. 3.4, P=0.002). The distribution of serious adverse events was similar in the two groups.

For patients with [[severe traumatic brain injury]], care focused on maintaining monitored intracranial pressure at 20 mm Hg or less was not shown to be superior to care based on imaging and clinical examination. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT01068522.)
((Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W, Petroni G,
Lujan S, Pridgeon J, Barber J, Machamer J, Chaddock K, Celix JM, Cherner M,
Hendrix T; Global Neurotrauma Research Group.. A trial of intracranial-pressure
monitoring in traumatic brain injury. N Engl J Med. 2012 Dec 27;367(26):2471-81. 
doi: 10.1056/NEJMoa1207363. Erratum in: N Engl J Med. 2013 Dec 19;369(25):2465.
PubMed PMID: 23234472; PubMed Central PMCID: PMC3565432.)).

===== Systematic Review and Meta-Analysis =====

[[Intracranial pressure monitoring for severe traumatic brain injury Systematic Review and Meta-Analysis]]


===== Case series =====

see [[Intracranial pressure monitoring for severe traumatic brain injury case series]].