Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring.
OBJECTIVE
Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe traumatic brain injury (TBI), but there is limited evidence that monitoring and treating intracranial hypertension reduces mortality. This study uses a large, prospectively collected database to examine the effect on 2-week mortality of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP monitor.


METHODS
From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score <9), 1446 patients were treated with ICP-lowering therapies. Of those, 1202 had an ICP monitor inserted and 244 were treated without monitoring. Patients were admitted to one of 20 Level I and two Level II trauma centers, part of a New York State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009. This database also contains information on known independent early prognostic indicators of mortality, including age, admission GCS score, pupillary status, CT scanning findings, and hypotension.


RESULTS
Age, initial GCS score, hypotension, and CT scan findings were associated with 2-week mortality. In addition, patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 0.02) than those treated without an ICP monitor, after adjusting for parameters that independently affect mortality.


CONCLUSIONS
In patients with severe TBI treated for intracranial hypertension, the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor. Based on these findings, the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring.
Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA.
Arash
A
Farahvar
Linda M
LM
Gerber
Ya-Lin
YL
Chiu
Nancy
N
Carney
Roger
R
Härtl
Jamshid
J
Ghajar
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001930:Brain Injuries / Q000150:complications* / Q000401:mortality* / Q000503:physiopathology; D056424:Decompressive Craniectomy; D055317:Evidence-Based Practice; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D019586:Intracranial Hypertension / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy*; D007427:Intracranial Pressure / Q000502:physiology*; D008297:Male; D008353:Mannitol / Q000627:therapeutic use; D008875:Middle Aged; D008991:Monitoring, Physiologic; D009518:New York; D011446:Prospective Studies; D012189:Retrospective Studies; D012462:Saline Solution, Hypertonic / Q000627:therapeutic use; D012720:Severity of Illness Index; D015996:Survival Rate; D014193:Trauma Centers / Q000706:statistics & numerical data; D016896:Treatment Outcome; D055815:Young Adult
D012462:Saline Solution, Hypertonic; D008353:Mannitol