Relationship of “dose” of intracranial hypertension to outcome in severe traumatic brain injury

Clinical article

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  • 1 Departments of Neurosurgery,
  • 2 Physical Medicine and Rehabilitation, and
  • 3 Anaesthesia and Acute Medicine, St. Olav University Hospital;
  • 4 Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway; and
  • 5 Department of Neurosurgery and University of California San Francisco Brain and Spinal Injury Center, University of California, San Francisco
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Object

It has recently been suggested that the degree of intracranial pressure (ICP) above the treatment goal can be estimated by the area under the curve (AUC) of ICP versus time in patients with severe traumatic brain injury (TBI). The objective of this study was to determine whether the calculated “ICP dose”—the ICP AUC—is related to mortality rate, outcome, and Marshall CT classification.

Methods

Of 135 patients (age range 1–82 years) with severe TBI treated during a 5-year period at the authors' institution, 113 patients underwent ICP monitoring (84%). Ninety-three patients with a monitoring time > 24 hours were included for analysis of ICP AUC calculated using the trapezoidal method. Computed tomography scans were assessed according to the Marshall TBI classification. Patients with Glasgow Outcome Scale scores at 6 months and > 3 years were separated into 2 groups based on outcome.

Results

Sixty patients (65%) had ICP values > 20 mm Hg, and 12 (13%) developed severe intracranial hypertension and died secondary to herniation. A multiple regression analysis adjusting for Glasgow Coma Scale score, age, pupillary abnormalities and Injury Severity Scale score demonstrated that the ICP AUC was a significant predictor of poor outcome at 6 months (p = 0.034) and of death (p = 0.035). However, it did not predict long-term outcome (p = 0.157). The ICP AUC was significantly higher in patients with Marshall head injury Categories 3 and 4 (24 patients) than in those with Category 2 (23 patients, p = 0.025) and Category 5 (46 patients, p = 0.021) TBIs using the worst CT scan obtained.

Conclusions

The authors found a significant relationship between the dose of ICP, the worst Marshall CT score, and patient outcome, suggesting that the AUC method may be useful in refining and improving the treatment of ICP in patients with TBI.

Abbreviations used in this paper: AUC = area under the curve; CPP = cerebral perfusion pressure; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; ISS = Injury Severity Scale; TBI = traumatic brain injury.

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Contributor Notes

Address correspondence to: Anne Vik, M.D., Ph.D., Department of Neurosurgery, St. Olav University Hospital and Department of Neuroscience, Norwegian University of Science and Technology, 7489 Trondheim, Norway. email: anne.vik@ntnu.no.
  • 1

    Balestreri M, , Czosnyka M, , Hutchinson P, , Steiner LA, , Hiler M, & Smielewski P, : Impact of intracranial pressure and cerebral perfusion pressure on severe disability and mortality after head injury. Neurocrit Care 4:813, 2006

    • Search Google Scholar
    • Export Citation
  • 2

    Barton CW, , Hemphill JC, , Morabito D, & Manley G: A novel method of evaluating the impact of secondary brain insults on functional outcomes in traumatic brain-injured patients. Acad Emerg Med 12:16, 2005

    • Search Google Scholar
    • Export Citation
  • 3

    Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons AANS/CNS, Joint Section on Neurotrauma and Critical Care: Guidelines for the management of severe traumatic brain injury. VIII. Intracranial pressure thresholds. J Neurotrauma 24:Suppl S55S58, 2007

    • Search Google Scholar
    • Export Citation
  • 4

    Elf K, , Nilsson P, , Ronne-Engström E, , Howells T, & Enblad P: Cerebral perfusion pressure between 50 and 60 mm Hg may be beneficial in head-injured patients: a computerized secondary insult monitoring study. Neurosurgery 56:962 971, 2005

    • Search Google Scholar
    • Export Citation
  • 5

    Firsching R, , Woischneck D, , Klein S, , Reissberg S, , Dohring W, & Peters B: Classification of severe head injury based on magnetic resonance imaging. Acta Neurochir (Wien) 143:263271, 2001

    • Search Google Scholar
    • Export Citation
  • 6

    Hemphill JC III, , Barton CW, , Morabito D, & Manley GT: Influence of data resolution and interpolation method on assessment of secondary brain insults in neurocritical care. Physiol Meas 26:373386, 2005

    • Search Google Scholar
    • Export Citation
  • 7

    Hiler M, , Czosnyka M, , Hutchinson P, , Balestreri M, , Smielewski P, & Matta B, : Predictive value of initial computerized tomography scan, intracranial pressure, and state of autoregulation in patients with traumatic brain injury. J Neurosurg 104:731737, 2006

    • Search Google Scholar
    • Export Citation
  • 8

    Jones PA, , Andrews PJ, , Midgley S, , Anderson SI, , Piper IR, & Tocher JL, : Measuring the burden of secondary insults in head injured patients during intensive care. J Neurosurg Anesthesiol 6:414, 1994

    • Search Google Scholar
    • Export Citation
  • 9

    Juul N, , Morris GF, , Marshall SB, & Marshall LF: Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury. The Executive Committee of the International Selfotel Trial. J Neurosurg 92:16, 2000

    • Search Google Scholar
    • Export Citation
  • 10

    Lee TT, , Galarza M, & Villanueva PA: Diffuse axonal injury (DAI) is not associated with elevated intracranial pressure (ICP). Acta Neurochir (Wien) 140:4146, 1998

    • Search Google Scholar
    • Export Citation
  • 11

    Maas AI, , Dearden M, , Teasdale GM, , Braakman R, , Cohadon F, & Iannotti F, : EBIC-guidelines for management of severe head injury in adults. European Brain Injury Consortium. Acta Neurochir (Wien) 139:286294, 1997

    • Search Google Scholar
    • Export Citation
  • 12

    Marmarou A, , Anderson RL, , Ward JD, , Choi SC, , Young HF, & Eisenberg HM, : Impact of ICP instability and hypotension on outcome in patients with severe head trauma. J Neurosurg 75:Suppl S59S66, 1991

    • Search Google Scholar
    • Export Citation
  • 13

    Marshall LF, , Marshall SB, , Klauber MR, , van Berkum Clark M, , Eisenberg HE, & Jane JA, : A new classification of head injury based on computerized tomography. J Neurosurg 75:Suppl S14S20, 1991

    • Search Google Scholar
    • Export Citation
  • 14

    Miller KJ, , Schwab KA, & Warden DL: Predictive value of an early Glasgow Outcome Scale score: 15-month score changes. J Neurosurg 103:239245, 2005

    • Search Google Scholar
    • Export Citation
  • 15

    Narayan RK, , Kishore PR, , Becker DP, , Ward JD, , Enas GG, & Greenberg RP, : Intracranial pressure: to monitor or not to monitor? A review of our experience with severe head injury. J Neurosurg 56:650659, 1982

    • Search Google Scholar
    • Export Citation
  • 16

    Poca MA, , Sahuquillo J, , Báguena M, , Pedraza S, , Gracia RM, & Rubio E: Incidence of intracranial hypertension after severe head injury: a prospective study using the Traumatic Coma Data Bank classification. Acta Neurochir Suppl 71 2730, 1998

    • Search Google Scholar
    • Export Citation
  • 17

    Resnick DK, , Marion DW, & Carlier P: Outcome analysis of patients with severe head injuries and prolonged intracranial hypertension. J Trauma 42:11081111, 1997

    • Search Google Scholar
    • Export Citation
  • 18

    Servadei F, , Murray GD, , Penny K, , Teasdale GM, , Dearden M, & Iannotti F, : The value of the “worst” computed tomographic scan in clinical studies of moderate and severe head injury. European Brain Injury Consortium. Neurosurgery 46:7075, 2000

    • Search Google Scholar
    • Export Citation
  • 19

    Stocchetti N, , Rossi S, , Buzzi F, , Mattioli C, , Paparella A, & Colombo A: Intracranial hypertension in head injury: management and results. Intensive Care Med 25:371376, 1999

    • Search Google Scholar
    • Export Citation
  • 20

    Taylor A, , Butt W, , Rosenfeld J, , Shann F, , Ditchfield M, & Lewis E, : A randomised trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension. Childs Nerv Syst 17:154162, 2001

    • Search Google Scholar
    • Export Citation
  • 21

    Unterberg A, , Kiening K, , Schmiedek P, & Lanksch W: Longterm observations of intracranial pressure after severe head injury. The phenomenon of secondary rise of intracranial pressure. Neurosurgery 32:1724, 1993

    • Search Google Scholar
    • Export Citation

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