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Visualizing the pressure and time burden of intracranial hypertension in adult and paediatric traumatic brain injury

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Abstract

Purpose

To assess the impact of the duration and intensity of episodes of increased intracranial pressure on 6-month neurological outcome in adult and paediatric traumatic brain injury.

Methods

Analysis of prospectively collected minute-by-minute intracranial pressure and mean arterial blood pressure data of 261 adult and 99 paediatric traumatic brain injury patients from multiple European centres. The relationship of episodes of elevated intracranial pressure (defined as a pressure above a certain threshold during a certain time) with 6-month Glasgow Outcome Scale was visualized in a colour-coded plot.

Results

The colour-coded plot illustrates the intuitive concept that episodes of higher intracranial pressure can only be tolerated for shorter durations: the curve that delineates the duration and intensity of those intracranial pressure episodes associated with worse outcome is an approximately exponential decay curve. In children, the curve resembles that of adults, but the delineation between episodes associated with worse outcome occurs at lower intracranial pressure thresholds. Intracranial pressures above 20 mmHg lasting longer than 37 min in adults, and longer than 8 min in children, are associated with worse outcomes. In a multivariate model, together with known baseline risk factors for outcome in severe traumatic brain injury, the cumulative intracranial pressure–time burden is independently associated with mortality. When cerebrovascular autoregulation, assessed with the low-frequency autoregulation index, is impaired, the ability to tolerate elevated intracranial pressures is reduced. When the cerebral perfusion pressure is below 50 mmHg, all intracranial pressure insults, regardless of duration, are associated with worse outcome.

Conclusions

The intracranial pressure–time burden associated with worse outcome is visualised in a colour-coded plot. In children, secondary injury occurs at lower intracranial pressure thresholds as compared to adults. Impaired cerebrovascular autoregulation reduces the ability to tolerate intracranial pressure insults. Thus, 50 mmHg might be the lower acceptable threshold for cerebral perfusion pressure.

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Acknowledgments

We wish to acknowledge the non-co-author members of the BrainIT steering group: Barbara Gregson, Tim Howells, Karl Kiening, Julia Mattern, Arminas Ragauskas and Juan Sahuquillo, for collecting data and granting permission through the steering group to use them for this project. Similarly, we would also like to acknowledge the contributors to the original study resulting in the paediatric database used here: R.J. Forsyth, B. Fulton, P.J.D. Andrews, A.D. Mendelow and R.A. Minns. The present study was supported by the Foundation for Scientific Research Flanders (FWO) (Research project G. 0904.11). Geert Meyfroidt receives funding from FWO as senior clinical investigator (1846113N). Greet Van den Berghe receives long-term structural research financing via the Methusalem program funded by the Flemish Government (METH/08/07). BrainIT was funded by the European Framework Programme (FP5-QLRI-2000-00454, QLGT-2002-00160 AND FP7-IST-2007-217049). The NEMO project in the University Hospital Edegem (Antwerp), Belgium was funded by the Flemish Government Agency for Innovation by Science and Technology (IWT)—Applied Biomedical Research (TBM) program.

Conflicts of interest

We declare that we have no conflicts of interest.

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Author notes

    Authors and Affiliations

    1. Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium

      Fabian Güiza, Greet Van den Berghe & Geert Meyfroidt

    2. Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium

      Bart Depreitere

    3. Department of Clinical Physics, Southern General Hospital, Glasgow, UK

      Ian Piper

    4. San Gerardo Hospital, Monza, Italy

      Giuseppe Citerio

    5. James Cook University Hospital, Medical Physics, Middlesbroughnza, UK

      Iain Chambers

    6. Department of Paediatric Neurology, Royal Hospital for Sick Children, Edinburgh, UK

      Patricia A. Jones

    7. Department of Paediatric Intensive Care, Royal Hospital for Sick Children, Edinburgh, UK

      Tsz-Yan Milly Lo

    8. Department of Neuroscience, Neurosurgery, Uppsala, Sweden

      Per Enblad & Pelle Nillson

    9. Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium

      Bart Feyen & Andrew Maas

    10. Department of Intensive Care Medicine, Antwerp University Hospital, Edegem, Belgium

      Philippe Jorens

    11. Klinik für Neurochirurgie, Universitätsklinikum Tübingen, Tübingen, Germany

      Martin U. Schuhmann

    12. School of Mathematics and Statistics, University of Glasgow, Glasgow, UK

      Rob Donald

    13. Department of Clinical Physics and Bioengineering, NHS Greater Glasgow & Clyde, Glasgow, UK

      Laura Moss

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    1. Fabian Güiza
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    Correspondence to Geert Meyfroidt.

    Additional information

    F. Güiza and B. Depreitere contributed equally.

    Take-home message: In adult and paediatric patients suffering from severe traumatic brain injury, an approximately exponential curve describes the relationship between intensity and duration of episodes of increased intracranial pressure (ICP) and worse clinical outcomes. In children, compared to adults, this occurs at lower ICP thresholds of shorter duration.

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    Güiza, F., Depreitere, B., Piper, I. et al. Visualizing the pressure and time burden of intracranial hypertension in adult and paediatric traumatic brain injury. Intensive Care Med 41, 1067–1076 (2015). https://doi.org/10.1007/s00134-015-3806-1

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