Académique Documents
Professionnel Documents
Culture Documents
J Neurosurg 119:1248–1254, 2013 ©AANS, 2013
T
alving
s
KiaDa
, M.D., , M.D., P
h
l .D., yDia e
fsTaThios l
aM
, M.D., K
araManos h
owarD
B
, elzBerg M.D., P
, eDro
M.D., g. K
T
enji
eixeira i
naBa
, M.D.,
, M.D., anD
D
eMeTrios
D
eMeTriaDes
, M.D., P
h
.D.
Division of Acute Care Surgery (Trauma, Emergency Surgery and Surgical Critical Care), Department of Surgery, Keck School
of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California
Object. The Brain Trauma Foundation (BTF) has established guidelines for intracranial pressure (ICP) monitor- ing in
severe traumatic brain injury (TBI). This study assessed compliance with these guidelines and the effect on outcomes.
Methods. This is a prospective, observational study including patients with severe blunt TBI (Glasgow Coma Scale score ≤
8, head Abbreviated Injury Scale score ≥ 3) between January 2010 and December 2011. Demographics, clinical characteristics,
laboratory profile, head CT scans, injury severity indices, and interventions were collected. The study population was stratified
into 2 study groups: ICP monitoring and no ICP monitoring. Primary outcomes included compliance with BTF guidelines,
overall in-hospital mortality, and mortality due to brain herniation. Sec- ondary outcomes were ICU and hospital lengths of stay.
Multiple regression analyses were deployed to determine the effect of ICP monitoring on outcomes.
Results. A total of 216 patients met the BTF guideline criteria for ICP monitoring. Compliance with BTF guide- lines was
46.8% (101 patients). Patients with subarachnoid hemorrhage and those who underwent craniectomy/ craniotomy were
significantly more likely to undergo ICP monitoring. Hypotension, coagulopathy, and increasing age were negatively associated
with the placement of ICP monitoring devices. The overall in-hospital mortality was significantly higher in patients who did not
undergo ICP monitoring (53.9% vs 32.7%, adjusted p = 0.019). Similarly, mortality due to brain herniation was significantly
higher for the group not undergoing ICP monitoring (21.7% vs 12.9%, adjusted p = 0.046). The ICU and hospital lengths of stay
were significantly longer in patients subjected to ICP monitoring.
Conclusions. Compliance with BTF ICP monitoring guidelines in our study sample was 46.8%. Patients man- aged
according to the BTF ICP guidelines experienced significantly improved survival.
(http://thejns.org/doi/abs/10.3171/2013.7.JNS122255)
K
ey
w
orDs
• intracranial pressure monitoring • mortality • brain herniation • Brain Trauma Foundation guidelines •
traumatic brain injury T
RAUMATIC tality settings.7,14,22 and brain morbidity The injury incidence both is the in and major
civilian risk cause of and intracranial military of mor-
Abbreviations used in this paper: AIS = Abbreviated Injury Scale; AOR = adjusted odds ratio; AUC = area under the curve;
BTF = Brain Trauma Foundation; CPP = cerebral perfusion pres- sure; GCS = Glasgow Coma Scale; ICH = intracranial
hemorrhage; ICP = intracranial pressure; INR = international normalized ratio; IPH = intraparenchymal hemorrhage; ISS = Injury
Severity Score; LOS = length of stay; NTDB = National Trauma Data Bank; PT = prothrombin time; PTT = partial
thromboplastin time; SAH = subarachnoid hemorrhage; SBP = systolic blood pressure; SDH = subdural hematoma; TBI =
traumatic brain injury.
fiberoptic catheter Camino Advanced Monitor (bolt) (In- tegra LifeSciences Corp.) was placed in 41
patients (41%). All patients subjected to fiberoptic monitor placement re- mained with the fiberoptic
monitor the entire critical phase
1250 J Neurosurg / Volume 119 / November 2013 of care. However, 58% of patients subjected to
ventriculos- tomy were changed subsequently to a fiberoptic monitoring device. The most common
reason for not placing an ICP monitoring device was the treating physician’s decision
Intracranial pressure monitoring in severe blunt TBI
TABLE 2: Independent predictors of ICP monitoring*
Step of Forward Logistic
Regression Analysis Variable Cumulative R2 AOR (95% CI) Adjusted p Value
1 decompressive craniectomy ≤4 hrs 0.113 3.85 (1.82–8.14) <0.001 2 extremity AIS score ≥3 0.171 3.01 (1.09–8.32) 0.033 3
increasing age 0.213 0.97 (0.96–0.99) 0.001 4 increasing PTT on admission 0.256 0.96 (0.92–0.99) 0.021 5 best GCS score w/in
24 hrs of admission 0.298 0.81 (0.71–0.93) 0.002 6 hypotension on admission 0.329 0.13 (0.02–0.86) 0.034 7 SAH 0.353 2.07
(1.09–8.32) 0.033
* Other variables entered in the model were sex, presence of IPH on CT, loss of gray and white differential on CT, presence of
reactive pupils during the first physical examination, PT and INR values on admission, initiation of nutrition in the first 7 days,
head AIS score of 3, head AIS score of 5, and evacuation of a mass lesion within the first 24 hours. AUC 0.807 (95% CI
0.746–0.867), p < 0.001.
higher in patients not subjected to ICP monitoring after ad- justing for relevant confounders between the
groups (age, presence of hypotension on admission, head AIS score of 5, extremity AIS score ≥ 3,
presence of IPH or SAH on CT, PTT on admission, early nutrition, decompressive craniec-
tomy/craniotomy in ≤ 4 hours, decompressive craniectomy/ craniotomy in ≤ 24 hours, and probability of
receiving ICP monitoring; 53.9% vs 32.7%, adjusted p = 0.019). Simi- larly, mortality due to brain
herniation was significantly higher in patients not subjected to ICP monitoring (21.7% vs 12.9% (adjusted
p = 0.046 [adjusting for the cofounders mentioned above]). Early deaths (< 48 hours) were equally
distributed among the study groups.
The hospital and ICU LOSs were significantly longer for the group subjected to ICP monitoring
before and af- ter exclusion of deaths (Table 5).
Discussion The BTF guidelines support ICP monitoring in all salvageable patients with
severe TBI (GCS score of 3–8 after resuscitation) with an abnormal CT scan depicting ICH, brain edema,
herniation, or compressed basal cis- terns (Level II evidence). In addition, patients with a GCS score of
3–8 with no CT-identified lesion featuring 2 of 3 variables (unilateral/bilateral posturing, patient age ≥ 40
years, and presence of hypotension) are also candidates for ICP monitoring (Level III evidence1). In brain
injuries that are likely to require aggressive ICP management, a ventriculostomy is placed, which can also
provide CSF drainage. Patients not likely to require CSF drainage are subjected to placement of a
fiberoptic ICP monitoring de- vice, allowing continuous ICP monitoring.
The BTF guidelines are based on retrospective and limited prospective observational data; thus, the
ICP com-
1252 J Neurosurg / Volume 119 / November 2013 pliance varies widely in neurocritical care, and the out-
comes related to the intervention are conflicting.2–4,8,10,20,21 The BTF provides guidelines for
physicians with regard to the type of patients who should receive ICP monitor- ing. It is worth noting,
however, that these guidelines do not constitute a universal protocol and thus treating physi- cians
commonly use their own experience and judgment to decide which patient will be subjected to ICP
monitoring. Previous surveys of ICP monitoring in Europe and North America have noted utilization of
ICP monitoring in 50%– 75% of patients with severe head injury in institutions pro- viding neurocritical
care.6,9,17,19,20,23
Cremer et al.4 performed a retrospective cohort study with prospective follow-up (≥ 12 months) in 2
trauma centers providing supportive therapy only compared with ICP/CPP-targeted management in the
severe head injury population. The ICP/CPP-guided therapy did not improve in-hospital survival, and the
follow-up Glasgow Outcome Scale score was similar in both study groups. At the cen- ter relying on
ICP/CPP-targeted therapy, the prevalence of ICP monitoring was 67%.4 Shafi et al. performed a Na-
tional Trauma Data Bank (NTDB) analysis and noted that ICP monitoring was applied in 43% of patients
who met BTF criteria.20 Likewise, we observed the prevalence of ICP monitoring in patients meeting
BTF guideline cri- teria at 46.8%. In our prospective study we documented reasons for omission of ICP
monitoring, which included neurosurgeon’s discretion, decompressive craniotomy/ craniectomy
precluding the need for an ICP device, and expectation of rapid neurological recovery. The indepen- dent
predictors of ICP monitoring included SAH, early decompressive craniectomy, and severe extremity
injury with AORs of 2.07, 3.85, and 3.01, respectively (Table 2). Patients with increasing age, those
experiencing coagu- lopathy, those with an elevated GCS score, or those pre-
Intracranial pressure monitoring in severe blunt TBI
TABLE 5: Outcome measures
ICP Monitoring
No ICP Monitoring Variable
(n = 101)
(n = 115) OR (95% CI) p Value AOR (95% CI)*
1253 Adjusted p Value*
overall in-hospital mortality 33 (32.7%) 62 (53.9%) 0.42 (0.24 to 0.72) 0.002 0.15 (0.03 to 0.74) 0.019 mortality due to brain
herniation 13 (12.9%) 25 (21.7%) 0.53 (0.26 to 1.11) 0.107 0.34 (0.10 to 0.87) 0.046
Variable
ICP Monitoring (n = 101)
No ICP Monitoring (n = 115)
Mean Difference
(95% CI) p Value
Adjusted Mean Difference (95% CI)*
Adjusted p Value*
mean ICU LOS in days 16.8 ± 1.3 8.2 ± 1.0 −8.62 (−11.83 to −5.41) <0.001 −6.04 (−9.46 to −1.69) <0.001 mean hospital LOS in
days 19.4 ± 1.6 10.1 ± 1.2 −9.26 (−13.10 to −5.42) <0.001 −7.14 (−11.14 to −2.08) 0.001 after exclusion of deaths
mean ICU LOS in days 21.7 ± 1.5 13.0 ± 1.8 −8.74 (−13.36 to −4.13) <0.001 −2.78 (−11.58 to −2.78) 0.007 mean hospital LOS
in days 25.8 ± 1.8 18.2 ± 2.1 −7.61 (−13.13 to −2.09) <0.001 −2.34 (−9.56 to −2.34) 0.022
* Controlled for age, presence of hypotension on admission, head AIS of 5, extremity AIS ≥ 3, presence of IPH or SAH on CT,
PTT on admission, early nutrition, decompressive craniectomy/craniotomy in ≤ 4 hours and decompressive
craniectomy/craniotomy in ≤ 24 hours, and probability of receiving ICP monitoring.
senting with hypotension on admission were less likely to be subjected to ICP monitoring (AOR 0.97,
0.96, 0.81, and 0.13, respectively). The univariate analysis compar- ing the patients who received ICP
monitoring with those who did not revealed some differences in their basic characteristics, which,
however, did not impact outcomes. Even though patients with hypotension were significantly more likely
not to receive an ICP monitoring device, the mean SBP did not differ between the groups (142 ± 3 mm
Hg vs 137 ± 3 mm Hg, p = 0.267). In addition, injury severity indices were not statistically different
between the groups. Likewise, the severity of head injury based on head AIS and GCS score was equally
distributed between the groups. When specific injury patterns of TBI were analyzed, again, there was no
difference except in the in- cidence of SAH and IPH. Finally, patients with admission coagulopathy were
less likely to undergo ICP monitor- ing placement, not because of the severity of injury but to avoid
potential bleeding due to the intervention. The main reason for not receiving an ICP monitoring device
was at the discretion of the neurosurgical attending. Pa- tients who were moribund or were assessed to
have poor outcome on admission were excluded from the study per study design. In addition, a small
percentage of patients who did not receive ICP monitoring were expected by the neurosurgeon to improve
rapidly. That contrasts with the idea that ICP monitoring was not used in sicker patients and emphasizes
the fact that BTF guidelines are not uni- versally applied and each patient is treated based on phy- sician
preference. In 41% of all ICP devices a fiberoptic ICP monitoring device, that is, a fiberoptic monitor,
was placed with no difference in overall mortality and mortal- ity due to brain herniation when compared
with ventricu- lostomy (Table 3).
We performed a regression analysis to elucidate inde- pendent predictors for both overall and head
injury–related outcomes. The deployed model noted multiple sig nificant independent predictors for
overall in-hospital mor tality including devastating head injury (head AIS score of 5) and subdural
hematoma (SDH) with AORs for poor out-
come of 79.81 and 10.70, respectively (Table 4). We noted that patients subjected to ICP monitoring
experienced a significant overall mortality reduction effect of 69% after adjustment for most clinically
relevant confounders includ- ing head injury severity (Table 5). Similar to our findings, previous
examinations have observed survival advantage in ICP-targeted therapy, but with less marked survival ef-
fect.3,5,15,16 However, a recent NTDB-based investigation by Shafi et al. observed a significantly
worsened survival in patients subjected to ICP monitoring.20 These authors in- terpreted the BTF
guidelines to be inadequate to identify patients who benefit from ICP monitoring. Furthermore, these
investigators suggested that the interventions in pa- tients subjected to ICP monitoring may be associated
with worsened outcomes. Such interventions include ICP moni- toring device insertion in a coagulopathic
state, utilization of vasoactive medication, osmotic diuresis with mannitol, furosemide utilization,
hyperventilation, and use of para- lytics. We documented all of the above interventions in our study group
subjected to ICP monitoring; nevertheless, de- spite all these potentially harmful interventions, these pa-
tients experienced significantly improved outcomes.
We noted extended ICU and hospital LOSs when ICP monitoring was instituted before and after
exclusion of deaths. This finding may relate to improved survival in patients subjected to the intervention.
Our study has multiple limitations including the lack of randomization, long-term follow-up of
outcome, and functional impairment measures. First, we attempted to compensate for the lack of
randomization with multiple regression models adjusting for an extensive number of clinically relevant
confounders introducing propensity score into our analysis. Second, the patients were selected for all
interventions at the discretion of the attending neu- rosurgeon without any strict protocol. Finally, it is
likely that some of those patients in the group not receiving ICP monitoring were being treated
differently—and perhaps less intensively—than those in the ICP monitoring group. Nevertheless, our data
were collected prospectively and our study is, to the best of our knowledge, the first to
J Neurosurg / Volume 119 / November 2013
P. Talving et al.
document reasons for omission of ICP monitoring with respective outcomes. Our findings support the
need for prospective randomized trials to settle the debate.
10. Lane PL, Skoretz TG, Doig G, Girotti MJ: Intracranial pressure monitoring and outcomes after traumatic brain injury. Can J
Surg 43:442–448, 2000 11. Lee TT, Galarza M, Villanueva PA: Diffuse axonal injury (DAI) is not associated with elevated
intracranial pressure (ICP). Acta Conclusions Compliance with the BTF ICP monitoring guidelines in our study sample was
46.8%. Compliance with these guidelines was associated with improved survival.
Neurochir (Wien) 140:41–46, 1998 12. Lobato RD, Sarabia R, Rivas JJ, Cordobes F, Castro S, Muñoz MJ, et al: Normal
computerized tomography scans in severe head injury. Prognostic and clinical management implica- tions. J Neurosurg
65:784–789, 1986 13. Miller MT, Pasquale M, Kurek S, White J, Martin P, Bannon K, et al: Initial head computed tomographic
scan characteris- Disclosure
tics have a linear relationship with initial intracranial pressure
The authors report no conflict of interest concerning the mate- rials or methods used in this study or the findings specified in
this paper.
Author contributions to the study and manuscript preparation include the following. Conception and design: Talving,
Demetriades. Acquisition of data: Karamanos, Skiada. Analysis and interpretation of data: Karamanos, Inaba. Drafting the
article: Talving, Karamanos, Lam. Critically revising the article: all authors. Reviewed submitted version of manuscript: all
authors. Approved the final version of the manuscript on behalf of all authors: Talving. Statistical analysis: Karamanos, Teixeira.
Study supervision: Talving, Demetriades.
after trauma. J Trauma 56:967–973, 2004 14. Myburgh JA, Cooper DJ, Finfer SR, Venkatesh B, Jones D, Higgins A, et al:
Epidemiology and 12-month outcomes from traumatic brain injury in Australia and New Zealand. J Trau- ma 64:854–862, 2008
15. Narayan RK, Kishore PR, Becker DP, Ward JD, Enas GG, Greenberg RP, et al: Intracranial pressure: to monitor or not to
monitor? A review of our experience with severe head injury. J Neurosurg 56:650–659, 1982 16. Palmer S, Bader MK, Qureshi
A, Palmer J, Shaver T, Borzatta M, et al: The impact on outcomes in a community hospital setting of using the AANS traumatic
brain injury guidelines. J Trauma 50:657–664, 2001 References
1. Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, et al: Guidelines for the management of
severe traumatic brain injury. VIII. Intracranial pressure thresholds. J Neurotrauma 24 (Suppl 1):S55–S58, 2007 (Er- ratum in J
Neurotrauma 25:276–278, 2008) 2. Bulger EM, Nathens AB, Rivara FP, Moore M, MacKenzie EJ, Jurkovich GJ: Management
of severe head injury: insti- tutional variations in care and effect on outcome. Crit Care Med 30:1870–1876, 2002 3. Chesnut RM,
Temkin N, Carney N, Dikmen S, Rondina C, Videtta W, et al: A trial of intracranial-pressure monitoring in traumatic brain
injury. N Engl J Med 367:2471–2481, 2012 4. Cremer OL, van Dijk GW, van Wensen E, Brekelmans GJ,
17. Patel HC, Menon DK, Tebbs S, Hawker R, Hutchinson PJ, Kirkpatrick PJ: Specialist neurocritical care and outcome from
head injury. Intensive Care Med 28:547–553, 2002 18. Poca MA, Sahuquillo J, Báguena M, Pedraza S, Gracia RM, Rubio E:
Incidence of intracranial hypertension after severe head injury: a prospective study using the Traumatic Coma Data Bank
classification. Acta Neurochir Suppl 71:27–30, 1998 19. Sahjpaul R, Girotti M: Intracranial pressure monitoring in se- vere
traumatic brain injury—results of a Canadian survey. Can J Neurol Sci 27:143–147, 2000 20. Shafi S, Diaz-Arrastia R, Madden
C, Gentilello L: Intracra- nial pressure monitoring in brain-injured patients is associ- ated with worsening of survival. J Trauma
64:335–340, 2008 21. Stocchetti N, Penny KI, Dearden M, Braakman R, Cohadon F, Moons KG, Leenen LP, et al: Effect of
intracranial pressure monitoring and targeted intensive care on functional outcome
Iannotti F, et al: Intensive care management of head-injured patients in Europe: a survey from the European Brain Injury after
severe head injury. Crit Care Med 33:2207–2213, 2005
Consortium. Intensive Care Med 27:400–406, 2001
5. Fakhry SM, Trask AL, Waller MA, Watts DD: Management of brain-injured patients by an evidence-based medicine pro-
22. Thurman DJ, Alverson C, Dunn KA, Guerrero J, Sniezek JE: Traumatic brain injury in the United States: a public health
tocol improves outcomes and decreases hospital charges. J
perspective. J Head Trauma Rehabil 14:602–615, 1999
Trauma 56:492–500, 2004
23. Wilkins IA, Menon DK, Matta BF: Management of
comatose 6. Hesdorffer DC, Ghajar J, Iacono L: Predictors of compliance
head-injured patients: are we getting any better?
Anaesthesia with the evidence-based guidelines for traumatic brain injury
56:350–352, 2001 care: a survey of United States
trauma centers. J Trauma 52: 1202–1209, 2002 7. Hukkelhoven CW, Steyerberg EW, Rampen AJ, Farace E, Habbema JD,
Marshall LF, et al: Patient age and outcome following severe traumatic brain injury: an analysis of 5600
Manuscript submitted December 20, 2012. patients. J
Neurosurg 99:666–673, 2003
Accepted July 22, 2013. 8. Idris Z, Ghani RI, Musa KI,
Ibrahim MI, Abdullah M, Nyi
Please include this information when citing this paper:
pub- NN, et al: Prognostic study of using different monitoring
lished online August 23, 2013; DOI:
10.3171/2013.7.JNS122255. modalities in treating severe traumatic brain injury. Asian J
Address correspondence to: Peep Talving, M.D., Ph.D.,
Depart- Surg 30:200–208, 2007
ment of Surgery, Division of Acute Care Surgery,
(Trauma, Emer- 9. Jeevaratnam DR, Menon DK: Survey of intensive care of se-
gency Surgery and Surgical Critical Care), Keck School of
Medicine, verely head injured patients in the United Kingdom. BMJ
LAC + USC Medical Center, 2051 Marengo St., Rm.
IPT-C5L100, 312:944–947, 1996
Los Angeles, CA 90033. email: peep.talving@surgery.usc.edu.
1254 J Neurosurg / Volume 119 / November 2013