Clinical applications of intracranial pressure monitoring in traumatic brain injury : report of the Milan consensus conference.
BACKGROUND
Intracranial pressure (ICP) monitoring has been for decades a cornerstone of traumatic brain injury (TBI) management. Nevertheless, in recent years, its usefulness has been questioned in several reports. A group of neurosurgeons and neurointensivists met to openly discuss, and provide consensus on, practical applications of ICP in severe adult TBI.


METHODS
A consensus conference was held in Milan on October 5, 2013, putting together neurosurgeons and intensivists with recognized expertise in treatment of TBI. Four topics have been selected and addressed in pro-con presentations: 1) ICP indications in diffuse brain injury, 2) cerebral contusions, 3) secondary decompressive craniectomy (DC), and 4) after evacuation of intracranial traumatic hematomas. The participants were asked to elaborate on the existing published evidence (without a systematic review) and their personal clinical experience. Based on the presentations and discussions of the conference, some drafts were circulated among the attendants. After remarks and further contributions were collected, a final document was approved by the participants. The group made the following recommendations: 1) in comatose TBI patients, in case of normal computed tomography (CT) scan, there is no indication for ICP monitoring; 2) ICP monitoring is indicated in comatose TBI patients with cerebral contusions in whom the interruption of sedation to check neurological status is dangerous and when the clinical examination is not completely reliable. The probe should be positioned on the side of the larger contusion; 3) ICP monitoring is generally recommended following a secondary DC in order to assess the effectiveness of DC in terms of ICP control and guide further therapy; 4) ICP monitoring after evacuation of an acute supratentorial intracranial hematoma should be considered for salvageable patients at increased risk of intracranial hypertension with particular perioperative features.
Department of Physiopathology and Transplant, Milan University, Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
Nino
N
Stocchetti
Edoardo
E
Picetti
Maurizio
M
Berardino
Andràs
A
Buki
Randall M
RM
Chesnut
Kostas N
KN
Fountas
Peter
P
Horn
Peter J
PJ
Hutchinson
Corrado
C
Iaccarino
Angelos G
AG
Kolias
Lars-Owe
LO
Koskinen
Nicola
N
Latronico
Andrews I R
AI
Maas
Jean-François
JF
Payen
Guy
G
Rosenthal
Juan
J
Sahuquillo
Stefano
S
Signoretti
Jean F
JF
Soustiel
Franco
F
Servadei
D000328:Adult; D001930:Brain Injuries / Q000150:complications / Q000503:physiopathology* / Q000601:surgery; D056424:Decompressive Craniectomy; D006801:Humans; D019586:Intracranial Hypertension / Q000209:etiology / Q000503:physiopathology* / Q000601:surgery; D007427:Intracranial Pressure / Q000502:physiology*; D008991:Monitoring, Physiologic