Intracranial pressure monitoring

Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

Authors: Farahvar A, Gerber LM, Chiu YL, Carney N, Härtl R, Ghajar J.

Object Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe traumatic brain injury (TBI), but there is limited evidence that monitoring and treating intracranial hypertension reduces mortality. This study uses a large, prospectively collected database to examine the effect on 2-week mortality of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP monitor. Methods From a population of 2134 patients with severe TBI (Glasgow Coma Scale Score <9), 1446 patients were treated with ICP-lowering therapies. Of those, 1202 had an ICP monitor inserted and 244 were treated without monitoring. Patients were admitted to one of 20 Level I and two Level II trauma centers, part of a New York State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009. This database also contains information on known independent early prognostic indicators of mortality, including age, admission GCS score, pupillary status, CT scanning findings, and hypotension. Results Age, initial GCS score, hypotension, and CT scan findings were associated with 2-week mortality. In addition, patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 0.02) than those treated without an ICP monitor, after adjusting for parameters that independently affect mortality. Conclusions In patients with severe TBI treated for intracranial hypertension, the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor. Based on these findings, the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring.

Variation in Intracranial Pressure Monitoring and Outcomes in Pediatric Traumatic Brain InjuryTBI Intracranial Pressure Monitoring and Outcomes

Authors: Bennett TD, Riva-Cambrin J, Keenan HT, Korgenski EK, Bratton SL.

OBJECTIVES To describe between-hospital and patient-level variation in intracranial pressure (ICP) monitoring and to evaluate ICP monitoring in association with hospital features and outcome in children with traumatic brain injury (TBI). DESIGN Retrospective cohort study. SETTING Children's hospitals participating in the Pediatric Health Information System database (January 2001 to June 2011). PARTICIPANTS Children (aged &lt;18 years) with TBI and head Abbreviated Injury Scale scores of at least 3 who were ventilated for at least 96 consecutive hours or who died in the first 4 days after hospital admission. MAIN OUTCOME MEASURES Monitoring of ICP. RESULTS A total of 4667 children met the study criteria. Hospital mortality was 41% (n = 1919). Overall, 55% of patients (n = 2586) received ICP monitoring. Expected hospital ICP monitoring rates after adjustment for patient age, cardiac arrest, inflicted injury, craniotomy or craniectomy, head Abbreviated Injury Scale score, and Injury Severity Score were 47% to 60%. Observed hospital ICP monitoring rates were 14% to 83%. Hospitals with more observed ICP monitoring, relative to expected, and hospitals with higher patient volumes had lower rates of mortality or severe disability. After adjustment for between-hospital variation and patient severity of injury, ICP monitoring was independently associated with age 1 year and older (odds ratio, 3.1; 95% CI, 2.5-3.8) vs age younger than 1 year. CONCLUSIONS There was significant between-hospital variation in ICP monitoring that cannot be attributed solely to differences in case mix. Hospitals that monitor ICP more frequently and hospitals with higher patient volumes had better patient outcomes. Infants with TBI are less likely to receive ICP monitoring than are older children.

Concomitant intracranial pressure monitoring during venous sinus stenting for intracranial hypertension secondary to venous sinus stenosis

Authors: Fargen KM, Velat GJ, Lewis SB, Hoh BL, Mocco J, Lawson MF.

BackgroundThere is a growing body of literature supporting venous sinus stenosis as a causative etiology for many patients diagnosed with idiopathic intracranial hypertension. Recent series have documented improvement in the pre- and post-stenosis venous pressure gradient as well as clinical symptoms after stenting. Concomitant real time intracranial pressure (ICP) monitoring has not been previously described during venous sinus stenting.Case reportA woman in her twenties presented with rapidly progressive visual loss and cranial neuropathies with an MRI revealing high grade right transverse sinus stenosis. Lumbar puncture demonstrated an opening pressure >55 cm H(2)O. Her vision and cranial neuropathies continued to worsen despite ventriculoperitoneal shunting. A parenchymal ICP monitoring wire was placed, revealing ICP persistently >70 cm H(2)O. She underwent venography and a pre- to post-stenosis pressure gradient of 55 mm Hg was measured. The patient underwent sinus stenting resulting in a near immediate reduction in her ICP from 70 to 20 cm H(2)O within 30 s after deployment. Her ICP completely normalized within 24 h of stenting.ConclusionsA case is presented of severe intracranial hypertension with rapidly progressive neurologic decline despite CSF diversion secondary to venous sinus stenosis that resolved following venous sinus stenting. This is the first report of real time ICP monitoring during venous sinus stenting.

Placement of Intracranial Pressure Monitors by Nonneurosurgeons: Good Outcomes are Achieved

Authors: Marcus A Barber, MD, Stephen D Helmer, PhD, Jonathan TMorgan, DO, James M Haan, MD.

Invited Discussant: J. Wayne Meredith

Introduction: Traumatic Brain Injury remains one of the most prevalent and costly injuries encountered. Traditionally, neurosurgeons have placed intracranial pressure (ICP) monitors. However, neurosurgery coverage problems may result in delayed placement. This study sought to confirm ICP monitors may be safely inserted by non-neurosurgeons. Methods: A 10-year retrospective review of ICP placements at a Level 1 Trauma Center. Results represent demographic variables, the incidence of complications between monitors placed by general surgical residents, trauma surgeons and neurosurgeons, and mortality. Results: Patients in this study totaled 557. Average age, hospital length of stay and injury severity score were 38.2 + -  22.3 yrs., 15.9 + - 19.1 days and 27.6 + - 11.6, respectively. The majority of patients were male (71.6%), and injured in motor vehicle crashes (51.5%), or falls (20.1%). The majority of ICP monitors were placed by residents under trauma attending supervision (83.3%), neurosurgeons (11.3%), and trauma surgeons (5.4%). One CNS infection occurred in a patient treated by a resident. Type of physician placing the monitor had no effect on complications. Of the three patients with iatrogenic bleed, no morbidity or mortality was attributed to monitor placement.

Two-depth transcranial Doppler: a novel approach for non-invasive absolute intracranial pressure measurement

Authors: Nusbaum DM. (Baylor College of Medicine, Department of Medicine, USA.)

There is a real need in healthcare for a way to rapidly yet safely measure intracranial pressure. The two-depth transcranial Doppler technology shows promise in its ability to measure ICP non-invasively, with accuracy and without the need for individual calibration. With time and improvement, this technology may prove valuable in multiple settings, including aviation, space, and emergency medicine.

Prevalence, management and outcomes of traumatic brain injury patients admitted to an Irish intensive care unit

Authors: S. Frohlich, P. Johnson and J. Moriarty.

Background: Traumatic brain injury is one of the leading causes of death and disability among young people. However outcomes from traumatic brain injury can be improved by use of parameters such as intracranial pressure monitoring (ICP) to guide treatment, early surgical intervention and management of these patients in a neurosurgical centre.
Aims: To examine the incidence of traumatic brain injury, compliance with best practice guidelines and outcomes in patients admitted to an intensive care unit in a major teaching hospital in Ireland.
Methods: Retrospective chart review.
Results: Forty-six patients were admitted over a 3-year period, half of whom had GCS <8. Medical management was appropriate but only two patients were transferred to a neurosurgical centre and none received ICP monitoring. Overall mortality of 37% was higher than international norms.
Conclusions: Irish patients with severe head injury do not currently receive care in accordance with international evidence-based guidelines.

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