A clinical decision rule to predict intracranial hypertension in severe traumatic brain injury

Restricted access


While existing guidelines support the treatment of intracranial hypertension in severe traumatic brain injury (TBI), it is unclear when to suspect and initiate treatment for high intracranial pressure (ICP). The objective of this study was to derive a clinical decision rule that accurately predicts intracranial hypertension.


Using Delphi methods, the authors identified a set of potential predictors of intracranial hypertension and a clinical decision rule a priori by consensus among a group of 43 neurosurgeons and intensivists who have extensive experience managing severe TBI without ICP monitoring. To validate these predictors, the authors used data from a Latin American trial (n = 150; BEST TRIP). To report on the performance of the rule, they calculated sensitivity, specificity, and positive and negative predictive values with 95% confidence intervals. In a secondary analysis, the rule was validated using data from a North American trial (n = 131; COBRIT).


The final predictors and the clinical decision rule were approved by 97% of participants in the consensus working group. The predictors are divided into major and minor criteria. High ICP would be considered suspected in the presence of 1 major or ≥ 2 minor criteria. Major criteria are: compressed cisterns (CT classification of Marshall diffuse injury [DI] III), midline shift > 5 mm (Marshall DI IV), or nonevacuated mass lesion. Minor criteria are: Glasgow Coma Scale (GCS) motor score ≤ 4, pupillary asymmetry, abnormal pupillary reactivity, or Marshall DI II. The area under the curve for the logistic regression model that contains all the predictors was 0.86. When high ICP was defined as > 22 mm Hg, the decision rule performed with a sensitivity of 93.9% (95% CI 85.0%–98.3%), a specificity of 42.3% (95% CI 31.7%–53.6%), a positive predictive value of 55.5% (95% CI 50.7%–60.2%), and a negative predictive value of 90% (95% CI 77.1%–96.0%). The sensitivity of the clinical decision rule improved with higher ICP cutoffs up to a sensitivity of 100% when intracranial hypertension was defined as ICP > 30 mm Hg. Similar results were found in the North American cohort.


A simple clinical decision rule based on a combination of clinical and imaging findings was found to be highly sensitive in distinguishing patients with severe TBI who would suffer intracranial hypertension. It could be used to identify patients who require ICP monitoring in high-resource settings or start ICP-lowering treatment in environments where resource limitations preclude invasive monitoring.

Clinical trial registration no.: NCT02059941 (clinicaltrials.gov).

ABBREVIATIONS AUC = area under the curve; BEST TRIP = Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure; CI = confidence interval; COBRIT = Citicoline Brain Injury Treatment Trial; DI = diffuse injury; GCS = Glasgow Coma Scale; ICP = intracranial pressure; TBI = traumatic brain injury.

Article Information

Correspondence Aziz S. Alali: University of Washington, Seattle, WA. aalali@uw.edu.

INCLUDE WHEN CITING Published online September 28, 2018; DOI: 10.3171/2018.4.JNS173166.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.




Bratton SLChestnut RMGhajar JMcConnell Hammond FFHarris OAHartl R: Guidelines for the management of severe traumatic brain injury. VI. Indications for intracranial pressure monitoring. J Neurotrauma 24 (Suppl 1):S37S442007


Carney NLujan SDikmen STemkin NPetroni GPridgeon J: Intracranial pressure monitoring in severe traumatic brain injury in Latin America: process and methods for a multi-center randomized controlled trial. J Neurotrauma 29:202220292012


Carney NTotten AMO’Reilly CUllman JSHawryluk GWBell MJ: Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 80:6152017


Chesnut RMBleck TPCiterio GClassen JCooper DJCoplin WM: A consensus-based interpretation of the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure trial. J Neurotrauma 32:172217242015


Chesnut RMTemkin NCarney NDikmen SRondina CVidetta W: A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med 367:247124812012


Chun KAManley GTStiver SIAiken AHPhan NWang V: Interobserver variability in the assessment of CT imaging features of traumatic brain injury. J Neurotrauma 27:3253302010


Eisenberg HMFrankowski RFContant CFMarshall LFWalker MD: High-dose barbiturate control of elevated intracranial pressure in patients with severe head injury. J Neurosurg 69:15231988


Feigin VLTheadom ABarker-Collo SStarkey NJMcPherson KKahan M: Incidence of traumatic brain injury in New Zealand: a population-based study. Lancet Neurol 12:53642013


Finkelstein EACPMiller TR: The Incidence and Economic Burden of Injuries in the United States. New York: Oxford University Press2006


Hendrickson PPridgeon JTemkin NRVidetta WPetroni GLujan S: Development of a severe traumatic brain injury consensus-based treatment protocol conference in Latin America. World Neurosurg 110:e952e9572018


Hyder AAWunderlich CAPuvanachandra PGururaj GKobusingye OC: The impact of traumatic brain injuries: a global perspective. NeuroRehabilitation 22:3413532007


LittleRJA: Regression with missing X’s: a review. J Am Stat Assoc 87:122712371992


Marshall LFMarshall SBKlauber MRClark MvBEisenberg HMJane JA: A new classification of head injury based on computerized tomography. J Neurosurg 75:S14S201991


Miller JDBecker DPWard JDSullivan HGAdams WERosner MJ: Significance of intracranial hypertension in severe head injury. J Neurosurg 47:5035161977


Narayan RKKishore PRBecker DPWard JDEnas GGGreenberg RP: Intracranial pressure: to monitor or not to monitor? A review of our experience with severe head injury. J Neurosurg 56:6506591982


Oyetunji TACrompton JGEhanire IDStevens KAEfron DTHaut ER: Multiple imputation in trauma disparity research. J Surg Res 165:e37e412011


Park EBell JDBaker AJ: Traumatic brain injury: can the consequences be stopped? CMAJ 178:116311702008


Rubiano AMCarney NChesnut RPuyana JC: Global neurotrauma research challenges and opportunities. Nature 527:S193S1972015


Sahuquillo JArikan F: Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury. Cochrane Database Syst Rev (1):CD0039832006


Zafonte RDBagiella EAnsel BMNovack TAFriedewald WTHesdorffer DC: Effect of citicoline on functional and cognitive status among patients with traumatic brain injury: Citicoline Brain Injury Treatment Trial (COBRIT). JAMA 308:1993–20002012


Zygun DALaupland KBHader WJKortbeek JBFindlay CDoig CJ: Severe traumatic brain injury in a large Canadian health region. Can J Neurol Sci 32:87922005




All Time Past Year Past 30 Days
Abstract Views 7625 7625 2186
Full Text Views 5722 5722 30
PDF Downloads 433 433 23
EPUB Downloads 0 0 0


Google Scholar