Intracranial pressure monitoring in severe head injury: compliance with Brain Trauma Foundation guidelines and effect on outcomes: a prospective study

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The Brain Trauma Foundation (BTF) has established guidelines for intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI). This study assessed compliance with these guidelines and the effect on outcomes.


This is a prospective, observational study including patients with severe blunt TBI (Glasgow Coma Scale score ≤ 8, head Abbreviated Injury Scale score ≥ 3) between January 2010 and December 2011. Demographics, clinical characteristics, laboratory profile, head CT scans, injury severity indices, and interventions were collected. The study population was stratified into 2 study groups: ICP monitoring and no ICP monitoring. Primary outcomes included compliance with BTF guidelines, overall in-hospital mortality, and mortality due to brain herniation. Secondary outcomes were ICU and hospital lengths of stay. Multiple regression analyses were deployed to determine the effect of ICP monitoring on outcomes.


A total of 216 patients met the BTF guideline criteria for ICP monitoring. Compliance with BTF guidelines was 46.8% (101 patients). Patients with subarachnoid hemorrhage and those who underwent craniectomy/craniotomy were significantly more likely to undergo ICP monitoring. Hypotension, coagulopathy, and increasing age were negatively associated with the placement of ICP monitoring devices. The overall in-hospital mortality was significantly higher in patients who did not undergo ICP monitoring (53.9% vs 32.7%, adjusted p = 0.019). Similarly, mortality due to brain herniation was significantly higher for the group not undergoing ICP monitoring (21.7% vs 12.9%, adjusted p = 0.046). The ICU and hospital lengths of stay were significantly longer in patients subjected to ICP monitoring.


Compliance with BTF ICP monitoring guidelines in our study sample was 46.8%. Patients managed according to the BTF ICP guidelines experienced significantly improved survival.

Abbreviations used in this paper:AIS = Abbreviated Injury Scale; AOR = adjusted odds ratio; AUC = area under the curve; BTF = Brain Trauma Foundation; CPP = cerebral perfusion pressure; GCS = Glasgow Coma Scale; ICH = intracranial hemorrhage; ICP = intracranial pressure; INR = international normalized ratio; IPH = intraparenchymal hemorrhage; ISS = Injury Severity Score; LOS = length of stay; NTDB = National Trauma Data Bank; PT = prothrombin time; PTT = partial thromboplastin time; SAH = subarachnoid hemorrhage; SBP = systolic blood pressure; SDH = subdural hematoma; TBI = traumatic brain injury.

Article Information

Address correspondence to: Peep Talving, M.D., Ph.D., Department of Surgery, Division of Acute Care Surgery, (Trauma, Emergency Surgery and Surgical Critical Care), Keck School of Medicine, LAC + USC Medical Center, 2051 Marengo St., Rm. IPT-C5L100, Los Angeles, CA 90033. email:

Please include this information when citing this paper: published online August 23, 2013; DOI: 10.3171/2013.7.JNS122255.

© AANS, except where prohibited by US copyright law.



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