Predictors of intracranial hypertension in children undergoing ICP monitoring after severe traumatic brain injury

2020 ◽  
Vol 36 (7) ◽  
pp. 1453-1460
Author(s):  
Darryl K. Miles ◽  
Maria R. Ponisio ◽  
Ryan Colvin ◽  
David Limbrick ◽  
Jacob K. Greenberg ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Hypertension ◽  
Severe Traumatic Brain Injury ◽  
Icp Monitoring ◽  
Hypertension In Children

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

2012 ◽  
Vol 117 (4) ◽  
pp. 729-734 ◽  
Author(s):  
Arash Farahvar ◽  
Linda M. Gerber ◽  
Ya-Lin Chiu ◽  
Nancy Carney ◽  
Roger Härtl ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Intracranial Hypertension ◽  
Severe Traumatic Brain Injury ◽  
Lower Mortality ◽  
Icp Monitoring ◽  
Improvement Program ◽  
Severe Tbi ◽  
Gcs Score

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 [GCS] 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.

High-Dose Barbiturates for Refractory Intracranial Hypertension in Children With Severe Traumatic Brain Injury*

2013 ◽  
Vol 14 (3) ◽  
pp. 239-247 ◽  
Author(s):  
Sarah A. Mellion ◽  
Kimberly Statler Bennett ◽  
German L. Ellsworth ◽  
Kevin Moore ◽  
Jay Riva-Cambrin ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Hypertension ◽  
Severe Traumatic Brain Injury ◽  
High Dose ◽  
Hypertension In Children

scholarly journals Noninvasive screening for intracranial hypertension in children with acute, severe traumatic brain injury

2015 ◽  
Vol 16 (4) ◽  
pp. 420-425 ◽  
Author(s):  
Nicole F. O’Brien ◽  
Tensing Maa ◽  
Karin Reuter-Rice
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Hypertension ◽  
Flow Velocity ◽  
Severe Traumatic Brain Injury ◽  
Strong Relationship ◽  
Time Frame ◽  
Icp Monitoring ◽  
Mean Flow ◽  
Scale 8

OBJECT The aim of this study was to determine the relationship between transcranial Doppler (TCD) derived pulsatility index (PI), end diastolic flow velocity (Vd), and intracranial pressure (ICP). The subjects in this study were 36 children admitted after severe traumatic brain injury (TBI) (postresuscitation Glasgow Coma Scale ≤ 8) undergoing invasive ICP monitoring. METHODS Subjects underwent a total of 148 TCD studies. TCD measurements of systolic flow velocity (Vs), Vd, and mean flow velocity (Vm) were performed on the middle cerebral artery (MCA) ipsilateral to the ICP monitor. The PI was calculated by the TCD software (Vs-Vd/Vm). ICP registrations were made in parallel with TCD measurements. RESULTS Using a PI threshold of 1.3, postinjury Day 0–1 PI had 100% sensitivity and 82% specificity at predicting an ICP ≥ 20 mm Hg (n = 8). During this time frame, a moderately strong relationship was observed between the MCA PI and actual ICP (r = 0.611, p = 0.01). When using a threshold of < 25 cm/sec, postinjury Day 0-1 Vd had a 56% sensitivity to predict an ICP ≥ 20 mm Hg. Beyond the initial 24 hours from injury, the sensitivity of an MCA PI of 1.3 to detect an ICP ≥20 mm Hg was 47%, and a weak relationship between actual ICP values and MCA PI (r = 0.376, p = 0.01) and MCA Vd (r = -0.284, p = 0.01) was found. CONCLUSIONS Postinjury Day 0-1 MCA PI > 1.3 has good sensitivity and specificity at predicting an ICP ≥ 20 mm Hg. In those children with TBI who initially do not meet clear criteria for invasive ICP monitoring but who are at risk for development of intracranial hypertension, TCD may be used as a noninvasive tool to screen for the development of elevated ICP in the first 24 hours following injury.

scholarly journals A clinical decision rule to predict intracranial hypertension in severe traumatic brain injury

2019 ◽  
Vol 131 (2) ◽  
pp. 612-619 ◽  
Author(s):  
Aziz S. Alali ◽  
Nancy Temkin ◽  
Jason Barber ◽  
Jim Pridgeon ◽  
Kelley Chaddock ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Hypertension ◽  
Decision Rule ◽  
Severe Traumatic Brain Injury ◽  
Clinical Decision ◽  
Icp Monitoring ◽  
Clinical Decision Rule ◽  
Severe Tbi ◽  
Minor Criteria

OBJECTIVEWhile existing guidelines support the treatment of intracranial hypertension in severe traumatic brain injury (TBI), it is unclear when to suspect and initiate treatment for high intracranial pressure (ICP). The objective of this study was to derive a clinical decision rule that accurately predicts intracranial hypertension.METHODSUsing Delphi methods, the authors identified a set of potential predictors of intracranial hypertension and a clinical decision rule a priori by consensus among a group of 43 neurosurgeons and intensivists who have extensive experience managing severe TBI without ICP monitoring. To validate these predictors, the authors used data from a Latin American trial (n = 150; BEST TRIP). To report on the performance of the rule, they calculated sensitivity, specificity, and positive and negative predictive values with 95% confidence intervals. In a secondary analysis, the rule was validated using data from a North American trial (n = 131; COBRIT).RESULTSThe final predictors and the clinical decision rule were approved by 97% of participants in the consensus working group. The predictors are divided into major and minor criteria. High ICP would be considered suspected in the presence of 1 major or ≥ 2 minor criteria. Major criteria are: compressed cisterns (CT classification of Marshall diffuse injury [DI] III), midline shift > 5 mm (Marshall DI IV), or nonevacuated mass lesion. Minor criteria are: Glasgow Coma Scale (GCS) motor score ≤ 4, pupillary asymmetry, abnormal pupillary reactivity, or Marshall DI II. The area under the curve for the logistic regression model that contains all the predictors was 0.86. When high ICP was defined as > 22 mm Hg, the decision rule performed with a sensitivity of 93.9% (95% CI 85.0%–98.3%), a specificity of 42.3% (95% CI 31.7%–53.6%), a positive predictive value of 55.5% (95% CI 50.7%–60.2%), and a negative predictive value of 90% (95% CI 77.1%–96.0%). The sensitivity of the clinical decision rule improved with higher ICP cutoffs up to a sensitivity of 100% when intracranial hypertension was defined as ICP > 30 mm Hg. Similar results were found in the North American cohort.CONCLUSIONSA simple clinical decision rule based on a combination of clinical and imaging findings was found to be highly sensitive in distinguishing patients with severe TBI who would suffer intracranial hypertension. It could be used to identify patients who require ICP monitoring in high-resource settings or start ICP-lowering treatment in environments where resource limitations preclude invasive monitoring.Clinical trial registration no.: NCT02059941 (clinicaltrials.gov).

Relationship of “dose” of intracranial hypertension to outcome in severe traumatic brain injury

2008 ◽  
Vol 109 (4) ◽  
pp. 678-684 ◽  
Author(s):  
Anne Vik ◽  
Torbjørn Nag ◽  
Oddrun Anita Fredriksli ◽  
Toril Skandsen ◽  
Kent Gøran Moen ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Hypertension ◽  
Scale Score ◽  
Severe Traumatic Brain Injury ◽  
Injury Severity ◽  
Area Under The Curve ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Scale Scores

Object It has recently been suggested that the degree of intracranial pressure (ICP) above the treatment goal can be estimated by the area under the curve (AUC) of ICP versus time in patients with severe traumatic brain injury (TBI). The objective of this study was to determine whether the calculated “ICP dose”—the ICP AUC—is related to mortality rate, outcome, and Marshall CT classification. Methods Of 135 patients (age range 1–82 years) with severe TBI treated during a 5-year period at the authors' institution, 113 patients underwent ICP monitoring (84%). Ninety-three patients with a monitoring time > 24 hours were included for analysis of ICP AUC calculated using the trapezoidal method. Computed tomography scans were assessed according to the Marshall TBI classification. Patients with Glasgow Outcome Scale scores at 6 months and > 3 years were separated into 2 groups based on outcome. Results Sixty patients (65%) had ICP values > 20 mm Hg, and 12 (13%) developed severe intracranial hypertension and died secondary to herniation. A multiple regression analysis adjusting for Glasgow Coma Scale score, age, pupillary abnormalities and Injury Severity Scale score demonstrated that the ICP AUC was a significant predictor of poor outcome at 6 months (p = 0.034) and of death (p = 0.035). However, it did not predict long-term outcome (p = 0.157). The ICP AUC was significantly higher in patients with Marshall head injury Categories 3 and 4 (24 patients) than in those with Category 2 (23 patients, p = 0.025) and Category 5 (46 patients, p = 0.021) TBIs using the worst CT scan obtained. Conclusions The authors found a significant relationship between the dose of ICP, the worst Marshall CT score, and patient outcome, suggesting that the AUC method may be useful in refining and improving the treatment of ICP in patients with TBI.

scholarly journals Experimental model of intracranial hypertension with continuous multiparametric monitoring in swine

2013 ◽  
Vol 71 (10) ◽  
pp. 802-806 ◽  
Author(s):  
Almir Ferreira de Andrade ◽  
Matheus Schmidt Soares ◽  
Gustavo Cartaxo Patriota ◽  
Alessandro Rodrigo Belon ◽  
Wellingson Silva Paiva ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Animal Model ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Intracranial Hypertension ◽  
Severe Traumatic Brain Injury ◽  
Transcranial Doppler ◽  
Porcine Model ◽  
Cerebral Oximetry ◽  
Suitable Animal Model

Objective Intracranial hypertension (IH) develops in approximately 50% of all patients with severe traumatic brain injury (TBI). Therefore, it is very important to identify a suitable animal model to study and understand the pathophysiology of refractory IH to develop effective treatments. Methods We describe a new experimental porcine model designed to simulate expansive brain hematoma causing IH. Under anesthesia, IH was simulated with a balloon insufflation. The IH variables were measured with intracranial pressure (ICP) parenchymal monitoring, epidural, cerebral oximetry, and transcranial Doppler (TCD). Results None of the animals died during the experiment. The ICP epidural showed a slower rise compared with parenchymal ICP. We found a correlation between ICP and cerebral oximetry. Conclusion The model described here seems useful to understand some of the pathophysiological characteristics of acute IH.

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