Perceived Utility of Intracranial Pressure Monitoring in Traumatic Brain Injury: A Seattle International Brain Injury Consensus Conference Consensus-Based Analysis and Recommendations

Randall M Chesnut; Sergio Aguilera; Andras Buki; Eileen M Bulger; Giuseppe Citerio; D Jamie Cooper; Ramon Diaz Arrastia; Michael Diringer; Anthony Figaji; Guoyi Gao; Romergryko G Geocadin; Jamshid Ghajar; Odette Harris; Gregory W J Hawryluk; Alan Hoffer; Peter Hutchinson; Mathew Joseph; Ryan Kitagawa; Geoffrey Manley; Stephan Mayer; David K Menon; Geert Meyfroidt; Daniel B Michael; Mauro Oddo; David O Okonkwo; Mayur B Patel; Claudia Robertson; Jeffrey V Rosenfeld; Andres M Rubiano; Juain Sahuquillo; Franco Servadei; Lori Shutter; Deborah M Stein; Nino Stocchetti; Fabio Silvio Taccone; Shelly D Timmons; Eve C Tsai; Jamie S Ullman; Walter Videtta; David W Wright; Christopher Zammit

doi:10.1227/neu.0000000000002516

Perceived Utility of Intracranial Pressure Monitoring in Traumatic Brain Injury: A Seattle International Brain Injury Consensus Conference Consensus-Based Analysis and Recommendations

Neurosurgery. 2023 Aug 1;93(2):399-408. doi: 10.1227/neu.0000000000002516. Epub 2023 May 12.

Authors

Randall M Chesnut^{1

2

3

4}, Sergio Aguilera^{5

6}, Andras Buki⁷, Eileen M Bulger⁸, Giuseppe Citerio^{9

10}, D Jamie Cooper^{11

12}, Ramon Diaz Arrastia¹³, Michael Diringer^{14

15}, Anthony Figaji¹⁶, Guoyi Gao¹⁷, Romergryko G Geocadin¹⁸, Jamshid Ghajar¹⁹, Odette Harris²⁰, Gregory W J Hawryluk^{21

22

23}, Alan Hoffer²⁴, Peter Hutchinson²⁵, Mathew Joseph²⁶, Ryan Kitagawa²⁷, Geoffrey Manley^{28

29}, Stephan Mayer³⁰, David K Menon³¹, Geert Meyfroidt³², Daniel B Michael³³, Mauro Oddo³⁴, David O Okonkwo³⁵, Mayur B Patel³⁶, Claudia Robertson³⁷, Jeffrey V Rosenfeld^{38

39}, Andres M Rubiano^{40

41}, Juain Sahuquillo⁴², Franco Servadei⁴³, Lori Shutter⁴⁴, Deborah M Stein⁴⁵, Nino Stocchetti^{46

47}, Fabio Silvio Taccone⁴⁸, Shelly D Timmons⁴⁹, Eve C Tsai⁵⁰, Jamie S Ullman⁵¹, Walter Videtta⁵², David W Wright⁵³, Christopher Zammit⁵⁴

Affiliations

¹ Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.
² Department of Orthopaedic Surgery, University of Washington, Seattle, Washington, USA.
³ School of Global Health, University of Washington, Seattle, Washington, USA.
⁴ Harborview Medical Center, University of Washington, Seattle, Washington, USA.
⁵ Almirante Nef Naval Hospital, Valparaiso University, Viña Del Mar, Chile.
⁶ Valparaiso University, Valparaiso, Chile.
⁷ Department of Neurosurgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
⁸ Department of Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA.
⁹ School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
¹⁰ Neuroscience Department, NeuroIntensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Monza, Italy.
¹¹ Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.
¹² Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia.
¹³ Department of Neurology, Penn Presbyterian Medical Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
¹⁴ Department of Neurology, Washington University School of Medicine, St Louis, USA.
¹⁵ Department of Neurology, Barnes-Jewish Hospital, St Louis, Missouri, USA.
¹⁶ Division of Neurosurgery and Neuroscience Institute, Groote Schuur Hospital, University of Cape Town, Observatory 7925, South Africa.
¹⁷ Department of Neurosurgery, Renji Hospital, Shanghai Institute of Head Trauma, Shanghai Jiaotong University School of Medicine, Shanghai, China.
¹⁸ Departments of Neurology, Neurological Surgery, Anesthesiology-Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
¹⁹ Department of Neurosurgery, Stanford Neuroscience Health Center, Palo Alto, California, USA.
²⁰ Department of Neurosurgery, Stanford University School of Medicine, Center for Academic Medicine, Stanford, California, USA.
²¹ Cleveland Clinic Akron General Neurosciences Center, Fairlawn, Ohio, USA.
²² Uniformed Services University, Bethesda, Maryland, USA.
²³ Brain Trauma Foundation, New York City, New York, USA.
²⁴ UH Cleveland Medical Center, Cleveland, Ohio, USA.
²⁵ Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge and Cambridge Biomedical Campus, Cambridge, UK.
²⁶ Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India.
²⁷ Vivian L Smith Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas, USA.
²⁸ Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
²⁹ Department of Neurosurgery, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA.
³⁰ Westchester Health Network, New York Medical College, Valhalla, New York, USA.
³¹ Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK.
³² Department of Intensive Care Medicine, University Hospitals Leuven and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.
³³ Department of Neurosurgery, Beaumont Health, Michigan Head and Spine Institute, Oakland University William Beaumont School of Medicine, Southfield, Michigan, USA.
³⁴ CHUV Medical Directorate and Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
³⁵ Department of Neurosurgery, University of Pittsburgh Medical Center Presbyterian, Pittsburgh, Pennsylvania, USA.
³⁶ Department of Surgery, Division of Acute Care Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
³⁷ Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, Texas, USA.
³⁸ Department of Neurosurgery, Alfred Hospital, Melbourne, Australia.
³⁹ Department of Surgery, Monash University, Melbourne, Australia.
⁴⁰ INUB/MEDITECH Research Group, Neurosciences Institute, El Bosque University, Bogotá, Colombia.
⁴¹ MEDITECH Foundation, Clinical Research, Cali, Colombia.
⁴² Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona: Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.
⁴³ Department of Biomedical Sciences, Humanitas University and IRCCS Humanitas Research Hospital, Milano, Italy.
⁴⁴ Department of Critical Care Medicine, Neurology and Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
⁴⁵ University of Maryland School of Medicine, Adult Critical Care Services, University of Maryland Medical Center, Baltimore, Maryland, USA.
⁴⁶ Department of Physiopathology and Transplantation, Milan University, Milan, Italy.
⁴⁷ Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
⁴⁸ Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium.
⁴⁹ Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.
⁵⁰ Suruchi Bhargava Chair in Spinal Cord and Brain Regeneration Research, The Ottawa Hospital, Department of Surgery, Division of Neurosurgery, University of Ottawa, Civic Campus, Ottawa, Ontario, Canada.
⁵¹ Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York, USA.
⁵² Intensive Care, Posadas Hospital, Buenos Aires, Argentina.
⁵³ Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.
⁵⁴ Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA.

Abstract

Background: Intracranial pressure (ICP) monitoring is widely practiced, but the indications are incompletely developed, and guidelines are poorly followed.

Objective: To study the monitoring practices of an established expert panel (the clinical working group from the Seattle International Brain Injury Consensus Conference effort) to examine the match between monitoring guidelines and their clinical decision-making and offer guidance for clinicians considering monitor insertion.

Methods: We polled the 42 Seattle International Brain Injury Consensus Conference panel members' ICP monitoring decisions for virtual patients, using matrices of presenting signs (Glasgow Coma Scale [GCS] total or GCS motor, pupillary examination, and computed tomography diagnosis). Monitor insertion decisions were yes, no, or unsure (traffic light approach). We analyzed their responses for weighting of the presenting signs in decision-making using univariate regression.

Results: Heatmaps constructed from the choices of 41 panel members revealed wider ICP monitor use than predicted by guidelines. Clinical examination (GCS) was by far the most important characteristic and differed from guidelines in being nonlinear. The modified Marshall computed tomography classification was second and pupils third. We constructed a heatmap and listed the main clinical determinants representing 80% ICP monitor insertion consensus for our recommendations.

Conclusion: Candidacy for ICP monitoring exceeds published indicators for monitor insertion, suggesting the clinical perception that the value of ICP data is greater than simply detecting and monitoring severe intracranial hypertension. Monitor insertion heatmaps are offered as potential guidance for ICP monitor insertion and to stimulate research into what actually drives monitor insertion in unconstrained, real-world conditions.

MeSH terms

Brain Injuries*
Brain Injuries, Traumatic* / diagnosis
Glasgow Coma Scale
Humans
Intracranial Hypertension* / diagnosis
Intracranial Pressure / physiology
Monitoring, Physiologic / methods