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Intracranial Pressure Monitoring Practice, Treatment, and Effect on Outcome in Aneurysmal Subarachnoid Hemorrhage

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Abstract

Background

Intracranial pressure (ICP) monitoring and its management in aneurysmal subarachnoid hemorrhage (aSAH) is variable worldwide. The present study aimed to explore the practice of ICP monitoring, its variability across countries, and the association with 6-month outcomes in aSAH.

Methods

This was a preplanned subanalysis of SYNAPSE-ICU, a multicenter, international, prospective, observational cohort study focused on patients diagnosed with aSAH. We evaluated the variability in ICP monitoring across countries through a logistic regression model adjusted for case-mix and considered countries as a random effect. The association between ICP probe insertion and 6-month mortality and a poor neurological outcome, defined as an Glasgow Outcome Score Extended ≤ 4, was assessed by using a propensity score approach.

Results

A total of 423 patients with aSAH from 92 centers across 32 countries were included in this analysis. ICP monitoring was used in 295 (69.7%) patients. Significant between-country variability in ICP insertion was observed, with an incidence ranging between 4.7% and 79.9% (median odd ratio 3.04). The median duration of ICP monitoring was 12 days (first quartile [Q1] through third quartile [Q3] range 8–18), with an overall daily median ICP value of 14 mm Hg (Q1–Q3 10–19) and a median maximum value of 21 mm Hg (Q1–Q3 16–30). Patients monitored with ICP received more aggressive therapy treatments compared with non-monitored patients (therapy intensity level, TIL, score 10.33 [standard deviation 3.61] vs. 6.3 [standard deviation 4.19], p < 0.001). In more severe patients, ICP monitoring was significantly associated with better 6-month outcome (poor neurological outcome: odds ratio 0.14, 95% confidence interval 0.02–0.53, p = 0.0113; mortality: hazard ratio 0.25, 95% confidence interval 0.13–0.49, p < 0.0001). However, no significant effect was observed in patients with both reactive pupils.

Conclusions

Our cohort demonstrated high variability in ICP insertion practice among countries. A more aggressive treatment approach was applied in ICP-monitored patients. In patients with severe aSAH, ICP monitoring might reduce unfavorable outcomes and mortality at 6 months.

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Abbreviations

ABI:

Acute brain injury

aSAH:

Aneurysmal subarachnoid hemorrhage

CI:

Confidence interval

CSF:

Cerebrospinal fluid

CT:

Computed tomography

GCS:

Glasgow Coma Scale

GOSE:

Glasgow Outcome Scale Extended

HICP:

Intracranial hypertension, High ICP, ICP ≥ 20 mmHg

HICs:

High-income countries

HR:

Hazard ratio

HU:

University Hospital

ICH:

Intracerebral hemorrhage

ICP:

Intracranial pressure

ICPm:

Patients with intracranial pressure monitoring

ICU:

Intensive care unit

LMICs:

Low- and middle-income countries

MOR:

Median odds ratio

MRI:

Magnetic resonance imaging

No-ICPm:

Patients without intracranial pressure monitoring

OR:

Odds ratio

SAH:

Subarachnoid hemorrhage

SD:

Standard deviation

TBI:

Traumatic brain injury

TIL:

Therapy intensity level

TTT:

Third-tier therapies

WFNS:

World Federation of Neurosurgical Societies

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Acknowledgements

The authors would like to thank Bicocca Clinical Research Office, University of Milano, Bicocca (Silvia Mori, silvia.mori@unimib.it, and Simona Erba, simona.erba@unimib.it) for administrative support relating to the trial; Francesca Elli, study coordinator and data manager; Sherihane Bensemmane (sherihane.bensemmane@esicm.org); and the European Society of Intensive Care Medicine, for help in the development of the electronic Case Report Form. The SYNAPSE-ICU Investigators are listed at the end of the electronic supplementary material as study collaborators (nonauthors contributors).

Funding

University of Milano, Bicocca is the sponsor of the SYNAPSE-ICU study. The European Society of Intensive Care Medicine endorsed and partially funded the study on January 31, 2017. The European Society of Intensive Care Medicine contributed to the electronic Case Report Form design and testing. No further funding was obtained for this subanalysis.

Author information

Authors and Affiliations

  1. Ospedale Maggiore della Carità di Novara, Università del Piemonte Orientale, Novara, Italy

    Marta Baggiani

  2. Department of Health Science, School of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900, Monza, Italy

    Francesca Graziano, Paola Rebora, Stefania Galimberti, Carlo Giussani & Giuseppe Citerio

  3. Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy

    Francesca Graziano, Paola Rebora & Stefania Galimberti

  4. Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, Istituto Di Ricovero E Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy

    Chiara Robba

  5. Anaesthesia and Intensive Care Unit , Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy

    Angelo Guglielmi

  6. Neurosurgery Unit, Neuroscience Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy

    Carlo Giussani

  7. Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Jose I. Suarez

  8. Neurocritical Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria

    Raimund Helbok

  9. Neurointensive Care Unit, Neuroscience Department, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy

    Giuseppe Citerio

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  1. Marta Baggiani
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Contributions

Marta Baggiani: participation in data interpretation, drafting, critical revision of the article, and final approval of the version to be published. Francesca Graziano Paola Rebora Stefania Galimberti: data analysis and verification of the data, interpretation, article drafting and critical revision of the article, final approval of the version to be published. Angelo Guglielmi, Carlo Giussani, Jose I. Suarez, and Raimund Helbok played an active part in article drafting and revision. Giuseppe Citerio: conception of the work (PI), funding application, enrolment of the participant centers, supervision of the data collection, participation in data analysis verification of the data and interpretation, revision of the article, critical revision of the article, final approval of the version to be published. GC is the guarantor of the entire article and is responsible for the decision to submit the article. All the authors have seen and approved the final text.

Corresponding author

Correspondence to Giuseppe Citerio.

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Source of support

GC reports grants and personal fees as Speakers' Bureau Member and Advisory Board Member from Integra and Neuroptics, all outside the submitted work. The other authors declare no competing interests.

Ethics approval and informed consent

The inclusion criteria were patients enrolled in the SYNAPSE-ICU study (ClinicalTrial.gov NCT03257904) (i.e., aged 18 years or older, diagnosed with traumatic brain injury or acute brain injury and an altered level of consciousness) with a diagnosis of aneurysmal subarachnoid hemorrhage. Approval at the sponsor site by the Ethics Committee, Brianza Azienda Socio Sanitaria Territoriale Monza, was obtained on November 21, 2017, according to the Helsinki Declaration and the International Conference on Harmonization for Good Clinical Practice. The enrolled patients were comatose and could not provide informed consent at recruitment. For this reason, centers referred to their local/national law regarding patients’ lack of capacity and participation in an observational study. Once patients regained capacity, they were required to provide informed consent on using personal data or refuse participation. No further ethical approval was needed for this subanalysis.

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SYNAPSE-ICU Investigators at listed at the end of the Electronic Supplementary Material (ESM) as study collaborators (non-authors contibutors).

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Baggiani, M., Graziano, F., Rebora, P. et al. Intracranial Pressure Monitoring Practice, Treatment, and Effect on Outcome in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 38, 741–751 (2023). https://doi.org/10.1007/s12028-022-01651-8

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