The normalization of increased intracranial pressure (ICP) in patients with severe traumatic brain injury (TBI) is assumed to limit secondary brain injury and improve outcome. Despite evidence-based recommendations for monitoring and treatment of elevated ICP, there are few studies that show an association between response to ICP-directed therapeutic regimens and adjusted mortality rate. This study utilizes a large prospective database to examine the effect of response to ICP-lowering therapy on risk of death within the first 2 weeks of injury in patients who sustained TBI and are older than 16 years.
The current study is based on 1426 patients with severe TBI (Glasgow Coma Scale [GCS] score < 9) of whom 388 were treated for elevated ICP (> 25 mm Hg) between 2000 and 2008 at 22 trauma centers enrolled in a New York State quality improvement program. This prospectively collected database also contains information including age, admission GCS score, pupillary status, CT scanning parameters, and hypotension, which are all known early prognostic indicators of death. Treatment of elevated ICP consisted of administration of mannitol, hypertonic saline, barbiturates, and/or drainage of CSF or decompressive craniectomy. The factors predicting ICP response to treatment and predicting death at 2 weeks were evaluated using logistic regression analyses.
Increasing age and fewer hours of elevated ICP on Day 1 were found to be significant predictors (p = 0.001 and 0.0003, respectively) of a positive response to treatment. Response to ICP-lowering therapy (p = 0.03), younger age (p < 0.0001), fewer hours of elevated ICP (p < 0.0001), and absence of arterial hypotension on Day 1 (p = 0.001) significantly predicted reduced risk of death.
Patients who responded to ICP-lowering treatment had a 64% lower risk of death at 2 weeks than those who did not respond after adjusting for factors that independently predict risk of death.
Abbreviations used in this paper: GCS = Glasgow Coma Scale; ICP = intracranial pressure; TBI = traumatic brain injury.
Address correspondence to: Jamshid Ghajar, M.D., Ph.D., Department of Neurological Surgery, Weill Cornell Medical College, Starr Building, Room 651, 525 East 68th Street, Box 99, New York, New York 10021. email: email@example.com.
Please include this information when citing this paper: published online January 7, 2011; DOI: 10.3171/2010.11.JNS101116.
The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Resuscitation of blood pressure and oxygenation. J Neurotrauma17:471–4782000
BrattonSLChestnutRMGhajarJMcConnell HammondFFHarrisOAHartlR: Guidelines for the management of severe traumatic brain injury. VI. Indications for intracranial pressure monitoring. J Neurotrauma24:Suppl 1S37–S442007
FaulMWaldMMRutland-BrownWSulliventEESattinRW: Using a cost-benefit analysis to estimate outcomes of a clinical treatment guideline: testing the Brain Trauma Foundation guidelines for the treatment of severe traumatic brain injury. J Trauma63:1271–12782007
KerwinAJSchincoMATepasJJIIIRenfroWHVitarboEAMuehlbergerM: The use of 23.4% hypertonic saline for the management of elevated intracranial pressure in patients with severe traumatic brain injury: a pilot study. J Trauma67:277–2822009
MarshallLFSmithRWShapiroHM: The outcome with aggressive treatment in severe head injuries. Part II: acute and chronic barbiturate administration in the management of head injury. J Neurosurg50:26–301979
RobertsIYatesDSandercockPFarrellBWasserbergJLomasG: Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet364:1321–13282004