Journal Reading

dr.Lenny Arinda FH
Purpose of review
 ICP monitoring and treatment is central in the management TBI
 Indications for ICP and treatment options still controversial

Recent findings
 Decompression tested for ICP refractory to conventional treatment
 reduced mortality, but more disability.
 Hypothermia as an alternative to conventional medical therapy.
 stopped because of a worse outcome

Summary
 Aggressive strategies for ICP control, surgical decompression or hypothermia,
have controversial effects on outcome.
 INTRODUCTION
 ICP monitoring & therapy are based more on consolidated clinical
experience than scientific evidence.

 The value of ICP monitoring has been questioned

 This review looks at two major investigations: surgical decompression

and moderate hypothermia selected from the recent literature (last 18
months)
 SURGICAL DECOMPRESSION
 The RESCUEicp trial  408 TBI patients
 ICP> 25mmHg
 Medical therapy : conventional treatment or surgical decompression.
 Patients with a wide spectrum of brain damage
 Severe on admission (GCS motor score of 1–2, 29% pupillary
abnormalities)
 Follow-up at 6 and 12 months

 Decompression
 markedly reduced mortality (22% more survivors)
 more patients remained in a vegetative state or with severe disability
 SURGICAL DECOMPRESSION cont...
DECRA trial
 Only patients with diffuse injury
 Randomized after a cumulative time of 15min, ICP >20mmHg
 no outcome improvement due to decompression
 similar mortality in the two groups

 18% mortality in conventional group (49% in RESCUEicp)

 After decompression (patient stable) repair of the cranial defect is
very useful  clinical improvement in 43% of 54 patients
 HYPOTHERMIA
 Hypothermia tested in the last 20 years  conflicting – often disappointing –
results.
 A new multicenter trial:
 Cases were ventilated and sedated in the ICU
 ICP>20mmHg for at least 5 min
 Randomized to standard care (control group) or hypothermia (32–35ºC) +
standard care.
 No conventional therapies against ICP rises before randomization

 6 months after injury evaluated with the Glasgow Outcome Scale 

significantly worse in the hypothermia

 This trial was stopped for safety concerns

 IS INTRACRANIAL PRESSURE MONITORING USEFUL? GUIDELINES,
INDICATIONS, SIDE EFFECTS, AND POSSIBLE BENEFITS

 High ICP is associated with worse outcome and increased mortality.

 This was confirmed by a recent analysis, pediatric & adult TBI patients
from multiple European centers.

 As ICP is dangerous, it’s rational to measure it  cost and side effects

 In developing countries, the costs of ICP monitoring may not be

bearable, especially for intraparenchymal probes
ICP monitoring
1. Intraparenchymal probes
 have the lowest incidence of infection
 give reliable and accurate pressure & recordings

2. Intraventricular/Subdural Catheter.

3. Resterilized Intraparenchymal Strain Gauge Catheters

 Catheters resterilized with ethylene oxide.
 Not associated with an increases in the incidence of meningitis or fever
 The accuracy was not scientifically tested
 In difficult situations with financial restrains
Intracranial pressure monitoring techniques

Probe for intraparenchymal monitoring ICP

Indications for ICP monitoring
 Have changed from previous editions

 New guideline: ICP monitoring ‘with the recommendation that

management of severe TBI patients using information from ICP
monitoring may reduce in-hospital and 2-week post injury mortality’.

 This recommendation leaves undefined who may benefit from ICP

measurement.
Indications for ICP monitoring cont’...

 A critical point  the outcome depends on the interplay between

severity and therapies (which may be guided by monitoring) and not
directly on the monitoring modalities employed.

 It is hard to prove a direct link between specific monitoring and

outcome improvement.

 A systematic review and meta-analysis found:

 no positive effect of ICP monitoring on hospital mortality
 possible ‘benefits’ in reducing rates of electrolyte disturbances, renal
failure
 not clearly defined ‘favorable’ prognosis
 A subsequent meta-analysis found significantly lower mortality in
the ICP-monitored group

 The limitations of the meta-analyses:

 the size of the samples
 based on a partially different selection of articles
 reaching different conclusions.
Retrospective analysis
 India  indicated a modest reduction (8%) in mortality in
patients who underwent ICP monitoring
 China ICP monitoring significantly associated with lower 6-
month mortality but not with favorable outcome.

Serial Case analysis

• ICP monitoringreduced mortality and a more favorable outcome
COMPUTERIZED ANALYSIS FOR PREDICTING INTRACRANIAL
PRESSURE CRISES
 Possible to extracting more information and detecting warning
signals of further deterioration

 Retrospective study in 817 TBI patients  predicting ICP crises in

the next 30min  the main predictor of these crises was a previous
high ICP

 As part of the BRAIN–IT effort, a model for better prediction of

increases in ICP, but its clinical value remains unclear.
 In clinical reality, very often ICP rises because of nursing (suctions,
movements, cleaning), and is controlled/blunted by therapies.
 should be clearly identified and separate from spontaneous, dangerous
ICP crises.

 This information is not provided in the studies reviewed.

NONINVASIVE AND INNOVATIVE METHODS FOR ESTIMATING
INTRACRANIAL PRESSURE
 Have been developed in the last 3 decades
 Have the obvious advantage of minimizing the risks of brain injury
and infection

1. Transcranial Doppler ultrasonography (TCD)

 well tolerated bedside technique to detect cerebral blood flow
velocity in the large cerebral arteries.
 Analyses of the flow velocity waveform implemented to estimate ICP
and autoregulation.
 three out of four analytical methods found a significant relationship
between ICP and TCD
2. The optic nerve sheath diameter (ONSD)
 The optic nerve sheath contains CSF and communicates with
intracranial CSF spaces.
 changes in ICP and CSF pressure influence its volume & diameter

 ONSD can be examined by ultrasound, MRI, CT has promising

correlations with ICP

 Recent study introduced a new parameter : the ONSD-to-eyeball

diameter ratio as an indicator of ICP.
3. Device for ICP and brain temperature monitoring
 A bioresorbable and biocompatible silicon sensor that performs to a level
of accuracy similar to commercial probes

 Data collection is wireless, excluding the system from any direct external
connection

 Could reduce the risk of infection and displacement related to

percutaneous wires and make ICP monitoring safer

 The sensor has been tested on rats, further development in human

INTRACRANIAL PRESSURE THERAPY: OSMOTIC THERAPY AND
THERAPY INTENSITY LEVEL

 Osmotic agents (mannitol) or hypertonic solutions have been used

to lower ICP.
 A Canadian group retrospectively reviewed: continuous infusion of
3% HTS was used  effectively lowered ICP but caused
hypernatremia.

 Any given ICP value, for instance 25mmHg, has a quite different
meaning if recorded without therapy or during maximal
treatment.
 This observation led to the ‘therapy intensity level’ (TIL) concept.
 CONCLUSION
 Despite conflicting evidence, ICP monitoring is still a cornerstone in treating
TBI
 Helping to reduce mortality, even though not influence the outcome.

 To improve the ICP cost–benefit ratio in everyday practice studies have been
published
 Noninvasive approaches to ICP measurement still has a long way to go.

 Two major RCTs showing debatable advantages (decompressive craniectomy)

or harmful effects (therapeutic hypothermia).

 Management of intracranial hypertension to rely on solid clinical experience,

with prudent use of aggressive therapies.
Thank you
 (A) Low and stable intracranial pressure (ICP).
 (B) Stable and elevated ICP—this can be seen most of the
time in head injury patients.
 (C) “B” waves of ICP. They are seen both in mean ICP and
spectrally resolved pulse amplitude of ICP (AMP, upper
panel). They are also usually seen in plots of time averaged
ABP, but not always.
 (D) Plateau waves of ICP. Cerebrospinal compensatory
reserve is usually low when these waves are recorded
(RAP (correlation coefficient (R) between AMP amplitude
(A) and mean pressure (P)) close to +1; index of
compensatory reserve). At the height of the waves, during
maximal vasodilatation, integration between pulse
amplitude and mean ICP fails as is indicated by fall in RAP.
After the plateau wave, ICP usually falls below baseline
level and cerebrospinal compensatory reserve improves.
(E) High, spiky waves of ICP caused by sudden increases in
ABP. (F) Increase in ICP caused by temporary decrease in
ABP. (G) Increase in ICP of “hyperaemic nature”. Both
blood flow velocity and jugular venous oxygen saturation
(Sjo2--) increased in parallel with ICP. (H) Refractory
intracranial hypertension. ICP increased within a few
hours to above 100 mm Hg. The vertical line denotes the
moment when the ischaemic wave probably reached the
vasomotor centres in the brain stem: heart rate increased
and ABP (cerebral perfusion pressure) decreased abruptly.
Note that the pulse amplitude of ICP (AMP) disappeared
around 10 minutes before this terminal event.