title: A trial of intracranial-pressure monitoring in traumatic brain injury.
abstract: BACKGROUND
  Intracranial-pressure monitoring is considered the standard of care for severe traumatic brain injury and is used frequently, but the efficacy of treatment based on monitoring in improving the outcome has not been rigorously assessed.
  
  
  METHODS
  We conducted a multicenter, controlled trial in which 324 patients 13 years of age or older who had severe traumatic brain injury and were being treated in intensive care units (ICUs) in Bolivia or Ecuador were randomly assigned to one of two specific protocols: guidelines-based management in which a protocol for monitoring intraparenchymal intracranial pressure was used (pressure-monitoring group) or a protocol in which treatment was based on imaging and clinical examination (imaging-clinical examination group). The primary outcome was a composite of survival time, impaired consciousness, and functional status at 3 months and 6 months and neuropsychological status at 6 months; neuropsychological status was assessed by an examiner who was unaware of protocol assignment. This composite measure was based on performance across 21 measures of functional and cognitive status and calculated as a percentile (with 0 indicating the worst performance, and 100 the best performance).
  
  
  RESULTS
  There was no significant between-group difference in the primary outcome, a composite measure based on percentile performance across 21 measures of functional and cognitive status (score, 56 in the pressure-monitoring group vs. 53 in the imaging-clinical examination group; P=0.49). Six-month mortality was 39% in the pressure-monitoring group and 41% in the imaging-clinical examination group (P=0.60). The median length of stay in the ICU was similar in the two groups (12 days in the pressure-monitoring group and 9 days in the imaging-clinical examination group; P=0.25), although the number of days of brain-specific treatments (e.g., administration of hyperosmolar fluids and the use of hyperventilation) in the ICU was higher in the imaging-clinical examination group than in the pressure-monitoring group (4.8 vs. 3.4, P=0.002). The distribution of serious adverse events was similar in the two groups.
  
  
  CONCLUSIONS
  For patients with severe traumatic brain injury, care focused on maintaining monitored intracranial pressure at 20 mm Hg or less was not shown to be superior to care based on imaging and clinical examination. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT01068522.).
authors.affiliation: Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, WA 98104, USA. chesnutr@uw.edu
authors.forename: Randall M
authors.initials: RM
authors.lastname: Chesnut
authors.forename: Nancy
authors.initials: N
authors.lastname: Temkin
authors.forename: Nancy
authors.initials: N
authors.lastname: Carney
authors.forename: Sureyya
authors.initials: S
authors.lastname: Dikmen
authors.forename: Carlos
authors.initials: C
authors.lastname: Rondina
authors.forename: Walter
authors.initials: W
authors.lastname: Videtta
authors.forename: Gustavo
authors.initials: G
authors.lastname: Petroni
authors.forename: Silvia
authors.initials: S
authors.lastname: Lujan
authors.forename: Jim
authors.initials: J
authors.lastname: Pridgeon
authors.forename: Jason
authors.initials: J
authors.lastname: Barber
authors.forename: Joan
authors.initials: J
authors.lastname: Machamer
authors.forename: Kelley
authors.initials: K
authors.lastname: Chaddock
authors.forename: Juanita M
authors.initials: JM
authors.lastname: Celix
authors.forename: Marianna
authors.initials: M
authors.lastname: Cherner
authors.forename: Terence
authors.initials: T
authors.lastname: Hendrix
mesh_terms: D000328:Adult; D001921:Brain / Q000000981:diagnostic imaging* / Q000503:physiopathology; D001930:Brain Injuries / Q000150:complications / Q000401:mortality / Q000503:physiopathology*; D005260:Female; D006801:Humans; D019586:Intracranial Hypertension / Q000175:diagnosis* / Q000209:etiology; D007427:Intracranial Pressure; D053208:Kaplan-Meier Estimate; D007902:Length of Stay; D008297:Male; D008991:Monitoring, Physiologic / Q000295:instrumentation / Q000379:methods; D009460:Neurologic Examination; D015996:Survival Rate; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D055815:Young Adult