Clinical applications of intracranial pressure monitoring in traumatic brain injury

Report of the Milan consensus conference

Abstract

Background

Intracranial pressure (ICP) monitoring has been for decades a cornerstone of traumatic brain injury (TBI) management. Nevertheless, in recent years, its usefulness has been questioned in several reports. A group of neurosurgeons and neurointensivists met to openly discuss, and provide consensus on, practical applications of ICP in severe adult TBI.

Methods

A consensus conference was held in Milan on October 5, 2013, putting together neurosurgeons and intensivists with recognized expertise in treatment of TBI. Four topics have been selected and addressed in pro-con presentations: 1) ICP indications in diffuse brain injury, 2) cerebral contusions, 3) secondary decompressive craniectomy (DC), and 4) after evacuation of intracranial traumatic hematomas. The participants were asked to elaborate on the existing published evidence (without a systematic review) and their personal clinical experience. Based on the presentations and discussions of the conference, some drafts were circulated among the attendants. After remarks and further contributions were collected, a final document was approved by the participants.

Summary and conclusions

The group made the following recommendations: 1) in comatose TBI patients, in case of normal computed tomography (CT) scan, there is no indication for ICP monitoring; 2) ICP monitoring is indicated in comatose TBI patients with cerebral contusions in whom the interruption of sedation to check neurological status is dangerous and when the clinical examination is not completely reliable. The probe should be positioned on the side of the larger contusion; 3) ICP monitoring is generally recommended following a secondary DC in order to assess the effectiveness of DC in terms of ICP control and guide further therapy; 4) ICP monitoring after evacuation of an acute supratentorial intracranial hematoma should be considered for salvageable patients at increased risk of intracranial hypertension with particular perioperative features.

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Acknowledgments

We gratefully acknowledge the financial support by Codman (a division of Ethicon Ltd.)

Conflicts of interest

RMC received past support for meeting organization from Codman Surtlief, Integra Neurosciences, Sofisa, Orsan, Neuroptics, Raumedic, InnerSpace, Synthes, and Moberg Medical with no benefit. RMC is currently the Integra Endowed Professor of Neurotrauma at the University of Washington, Harborview Medical Centre through an endowment from the Integra Foundation. RMC received honoraria from Synthes, Medtronic, Integra Neurosciences, and numerous non-industrial organisations for consultancy and education, all of which are routinely channeled into research. PJH is supported by a National Institute for Health Research (NIHR) professorship and the NIHR Cambridge Biomedical Research Centre, and has been appointed as the Surgical Specialty Lead for Neurosurgery, Royal College of Surgeons of England Clinical Research Initiative. PJH has delivered lectures sponsored by Codman and is a Director of Technicam Ltd., Newton Abbot, Devon, UK (a manufacturer of cranial access devices for neuro-monitoring). AGK is supported by a Royal College of Surgeons of England Research Fellowship, a National Institute for Health Research Academic Clinical Fellowship, and a Sackler Studentship. AGK is chair of the British Neurosurgical Trainee Research Collaborative, which has been supported with an educational grant from Codman, UK. AB holds a key opinion leader contract with-, and receives consultation fees from Codman. KNF is a consultant and a research grant recipient for DePuy Codman. JFP received fees as consultant for Codman SA and Integra Lifesciences. NS received fees for consultations from ORSAN medical technologies.

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Correspondence to Edoardo Picetti.

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Stocchetti, N., Picetti, E., Berardino, M. et al. Clinical applications of intracranial pressure monitoring in traumatic brain injury. Acta Neurochir 156, 1615–1622 (2014). https://doi.org/10.1007/s00701-014-2127-4

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Keywords

  • Traumatic brain injury
  • Intracranial pressure
  • Monitoring
  • Management