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Intracranial pressure: current perspectives on physiology and monitoring

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A Correction to this article was published on 03 February 2023

A Correspondence to this article was published on 23 January 2023

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Abstract

Intracranial pressure (ICP) monitoring is now viewed as integral to the clinical care of many life-threatening brain insults, such as severe traumatic brain injury, subarachnoid hemorrhage, and malignant stroke. It serves to warn of expanding intracranial mass lesions, to prevent or treat herniation events as well as pressure elevation which impedes nutrient delivery to the brain. It facilitates the calculation of cerebral perfusion pressure (CPP) and the estimation of cerebrovascular autoregulatory status. Despite advancements in our knowledge emanating from a half century of experience with this technology, important controversies remain related even to fundamental aspects of ICP measurements, including indications for monitoring, ICP treatment thresholds, and management of intracranial hypertension. Here, we review the history of ICP monitoring, the underlying pathophysiology as well as current perspectives on why, when and how ICP monitoring is best used. ICP is typically assessed invasively but a number of emerging, non-invasive technologies with inherently lower risk are showing promise. In selected cases, additional neuromonitoring can be used to assist in the interpretation of ICP monitoring information and adapt directed treatment accordingly. Additional efforts to expand the evidence base relevant to ICP monitoring, related technologies and management remain a high priority in neurosurgery and neurocritical care.

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Fig. 1
Fig. 2

Adapted from Tadevosyan & Kornbluth, 2021 [70]

Fig. 3

Adapted from Budohoski et al., 2013 [71]

Fig. 4

Adapted from Rosner et al., 1995 [54]

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Change history

Abbreviations

AUC:

Area under the curve

BEST TRIP:

Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure

BTF:

Brain Trauma Foundation

CPP:

Cerebral perfusion pressure

CSF:

Cerebrospinal fluid

DC:

Decompressive craniectomy

EVD:

External ventricular drain

gPI:

Gosling Pulsatility Index

ICH:

Intracerebral hemorrhage

ICP:

Intracranial pressure

ICU:

Intensive care unit

MAP:

Mean arterial blood pressure

MOR:

Median odds ratio

nICP:

Non-invasively measured ICP

NPi:

Neurological pupillary index

ONS:

Optic nerve sheath

ONSD:

Optic nerve sheath diameter

PRx:

Pressure reactivity index

SAH:

Subarachnoid hemorrhage

SIBICC:

Seattle International severe traumatic Brain Injury Consensus Conference

TBI:

Traumatic brain injury

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Funding

PH is supported by the NIHR Biomedical Research Centre, Cambridge, NIHR Senior Investigator Award, NIHR Medtech Co-operative for Brain Injury, NIHR Research Group on Global Neurotrauma and the Royal College of Surgeons of England. AK is supported by the NIHR Cambridge Biomedical Research Centre (BRC-1215-20014), Wellcome Trust Institutional Strategic Support Fund (University of Cambridge), NIHR Medtech Co-operative for Brain Injury, and NIHR Global Health Research Group on Neurotrauma.

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Authors and Affiliations

  1. Section of Neurosurgery, University of Manitoba, GB1, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada

    Gregory W. J. Hawryluk

  2. School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy

    Giuseppe Citerio

  3. Neuro-Intensive Care, Department of Neurosciences, San Gerardo Hospital, ASST-MONZA, Monza, Italy

    Giuseppe Citerio

  4. Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK

    Peter Hutchinson & Angelos Kolias

  5. Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Herestraat 49, Box 7003, 63 3000, Leuven, Belgium

    Geert Meyfroidt

  6. Anaesthesia and Intensive Care, San Martino Research Hospital, Genoa, Italy

    Chiara Robba

  7. Anesthesia and Intensive Care, Department of Physiopathology and Transplantation, Milan University, Milan, Italy

    Nino Stocchetti

  8. Department of Anaesthesia and Critical Care, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy

    Nino Stocchetti

  9. Neurosurgery, Neurotrauma, Department of Neurological Surgery, Department of Orthopaedic Surgery, School of Global Health, Harborview Medical Center, University of Washington, 325 Ninth Ave, Mailstop 359766, Seattle, WA, 98104-2499, USA

    Randall Chesnut

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Hawryluk, G.W.J., Citerio, G., Hutchinson, P. et al. Intracranial pressure: current perspectives on physiology and monitoring. Intensive Care Med 48, 1471–1481 (2022). https://doi.org/10.1007/s00134-022-06786-y

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