Time to Rethink Our Assumptions About ICP Monitoring for TBI.

A randomized trial finds no benefit from therapy guided by intracranial pressure monitoring rather than clinical and radiographic signs.

Guidelines recommend intracranial pressure (ICP) monitoring in the acute management of severe traumatic brain injury (TBI). However, only observational data support this recommendation, and not all clinicians follow it. Investigators have now performed the first randomized trial of ICP monitoring in patients with severe TBI.

Taking advantage of widespread equipoise in South America regarding the benefits of ICP monitoring, the trial involved six Bolivian and Ecuadorian hospitals with intensivist-staffed ICUs, 24-hour computed tomography availability, and neurosurgical coverage. Investigators enrolled patients older than 12 years with a Glasgow Coma Scale (GCS) score of 3–8, excluding those with unsurvivable injuries or a GCS score of 3 and bilateral fixed and dilated pupils. Those randomized to ICP monitoring received an intraparenchymal monitor and treatment to keep ICP <20 mm Hg. The other half of patients received treatment triggered by signs of increased ICP on clinical examination or imaging.

The 324 enrolled patients had characteristics of severe TBI, with a median GCS score of 4 and midline shift in about one third. Six months after their injury, patients in both groups had similar scores on a composite measure of functional status and cognition, and similar cumulative mortality (39% in the ICP-monitoring group vs. 41% in the imaging-examination group, a nonsignificant difference). Patients who underwent ICP monitoring received fewer specific treatments for cerebral edema.

Comment: This impressive study requires us to rethink how we define and measure intracranial hypertension. In the meantime, it should be noted that this trial did not test whether we should treat intracranial hypertension, which was treated aggressively in both groups. Instead, the authors found no benefit to ICP monitoring in guiding this treatment. These results indicate that the treatment of intracranial hypertension after TBI can be guided appropriately by either ICP monitoring or the clinical approach outlined in the trial protocol.

Source: Journal Watch Neurology



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