Abstract
Based on continuous monitoring of the pressure reactivity index (PRx), we defined individualized intracranial pressure (ICP) thresholds by graphing the relationship between ICP and PRx. We hypothesized that an “ICP dose” based on individually assessed ICP thresholds might correlate more closely with 6-month outcome compared with ICP doses derived from the recommended universal thresholds of 20 and 25 mmHg. Data from 327 patients with severe traumatic brain injury (TBI) were analyzed. ICP doses were computed as the cumulative area under the curve above the defined thresholds in graphing ICP versus time. The term Dose 20 (D20) was used to refer to an ICP threshold of 20 mm Hg. The markers D25 and DPRx were calculated similarly. The discriminative ability of each dose with regard to mortality was assessed by receiver operating characteristics analysis using fivefold cross-validation (CV). DPRx was found to be the best discriminator of mortality, despite the fact that D20 was twice as large as DPRx. Individualized doses of intracranial hypertension were stronger predictors of mortality than doses derived from the universal thresholds of 20 and 25 mm Hg. The PRx could offer a method of individualizing the ICP threshold.
This work was performed in the Academic Neurosurgical Unit and the Neurosciences Critical Care Unit of Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
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References
Balestreri M, Czosnyka M, Hutchinson PJ, Steiner LA, Hiler M, Smielewski P, Pickard JD (2006) Impact of intracranial pressure and cerebral perfusion pressure on severe disability and mortality after head injury. Neurocrit Care 4:8–13
Barton CW, Hemphill JC, Morabito D, Manley G (2005) A novel method of evaluating the impact of secondary brain insults on functional outcomes in traumatic brain-injured patients. Acad Emerg Med 12:1–6
Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R et al (2007) Guidelines for the management of severe traumatic brain injury. VIII. Intracranial pressure thresholds. J Neurotrauma 24(Suppl 1):S55–S58
Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W et al (2012) A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med 367(26):2471–2481
Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D'Urso P, DECRA Trial Investigators, Australian and New Zealand Intensive Care Society Clinical Trials Group et al (2011) Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 364:1493–1502
Czosnyka M, Smielewski P, Kirkpatrick P, Laing RJ, Menon D, Pickard JD (1997) Continuous assessment of the cerebral vasomotor reactivity in head injury. Neurosurgery 41(1):11–17
Czosnyka M, Smielewski P, Kirkpatrick P, Piechnik S, Laing R, Pickard JD (1998) Continuous monitoring of cerebrovascular pressure-reactivity in head injury. Acta Neurochir Suppl 71:74–77
Eisenberg H, Frankowski R, Contant C, Marshall LF, Walker MD (1998) High-dose barbiturate control of elevated intracranial pressure in patients with severe head injury. J Neurosurg 69:15–23
Hemphill JC III, Barton CW, Morabito D, Manley GT (2005) Influence of data resolution and interpolation method on assessment of secondary brain insults in neurocritical care. Physiol Meas 26:373–386
Jennett B, Bond M (1975) Assessment of outcome after severe brain damage. Lancet 1:480–484
Kahraman S, Dutton RP, Hu P, Xiao Y, Aarabi B, Stein DM, Scalea TM (2010) Automated measurement of “pressure times time dose” of intracranial hypertension best predicts outcome after severe traumatic brain injury. J Trauma 69(1):110–118
Marmarou A, Anderson RL, Ward JD, Choi SC, Young HF, Eisenberg HM et al (1991) Impact of ICP instability and hypotension on outcome in patients with severe head trauma. J Neurosurg 75:S59–S66
Paulson OB, Strandgaard S, Edvinsson L (1990) Cerebral autoregulation. Cerebrovasc Brain Metab Rev 2:161–192
Schreiber MA, Aoki N, Scott B, Beck JR (2002) Determination of mortality in patients with severe blunt head injury. Arch Surg 137:285–290
Smielewski P, Lavinio A, Timofeev I, Radolovich D, Perkes I, Pickard JD, Czosnyka M (2008) ICM+, a flexible platform for investigations of cerebrospinal dynamics in clinical practice. Acta Neurochir Suppl 102:145–151
Sorrentino E, Diedler J, Kasprowicz M, Budohoski KP, Haubrich C, Smielewski P et al (2012) Critical thresholds for cerebrovascular reactivity after traumatic brain injury. Neurocrit Care 16(2):258–266
Steiner LA, Czosnyka M, Piechnik SK, Smielewski P, Chatfield D, Menon DK, Pickard JD (2002) Continuous monitoring of cerebrovascular pressure reactivity allows determination of optimal cerebral perfusion pressure in patients with traumatic brain injury. Crit Care Med 30(4):733–738
Vik A, Nag T, Fredriksli OA, Skandsen T, Moen KG, Schirmer-Mikalsen K, Manley GT (2008) Relationship of “dose” of intracranial hypertension to outcome in severe traumatic brain injury. J Neurosurg 109(4):678–684
Acknowledgments
The authors acknowledge great support from Addenbrooke’s Hospital Neurocritical Care Unit staff and Academic Neurosurgical Unit registrars, without whose help the collection of computerized data would never have succeeded. We also acknowledge Ming Yang MS for statistical assistance.
Conflicts of Interest and Source of Funding
The software for brain monitoring ICM+ (http://www.neurosurg.cam.ac.uk/icmplus) is licensed by the University of Cambridge (Cambridge Enterprise). Mr Czosnyka and Mr Smielewski have a financial interest in part of the licensing fee. Mr Hutchinson is supported by an Academy of Medical Sciences/Health Foundation Senior Scientist Fellowship and grants from the Medical Research Council/NIHR. Mr Menon is supported by funding from the Medical Research Council, the NIHR Cambridge Biomedical Centre, and an NIHR Senior Investigator award. Mr Pickard is a NIHR senior investigator awardee and a principal investigator within the NIHR Biomedical Research Centre (Cambridge University Hospital Foundation Trust) and lead principal investigator for the Medical Research Council “Acute Brain Injury Programme” grant. The remaining authors have not disclosed any potential conflict of interest.
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Lazaridis, C., Smielewski, P., Menon, D.K., Hutchinson, P., Pickard, J.D., Czosnyka, M. (2016). Patient-Specific Thresholds and Doses of Intracranial Hypertension in Severe Traumatic Brain Injury. In: Ang, BT. (eds) Intracranial Pressure and Brain Monitoring XV. Acta Neurochirurgica Supplement, vol 122. Springer, Cham. https://doi.org/10.1007/978-3-319-22533-3_23
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