Impact of intracranial pressure monitoring on mortality in patients with traumatic brain injury: a systematic review and meta-analysis

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OBJECT

Some studies have demonstrated that intracranial pressure (ICP) monitoring reduces the mortality of traumatic brain injury (TBI). But other studies have shown that ICP monitoring is associated with increased mortality. Thus, the authors performed a meta-analysis of studies comparing ICP monitoring with no ICP monitoring in patients who have suffered a TBI to determine if differences exist between these strategies with respect to mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS.

METHODS

The authors systematically searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (Central) from their inception to October 2013 for relevant studies. Randomized clinical trials and prospective cohort, retrospective observational cohort, and case-control studies that compared ICP monitoring with no ICP monitoring for the treatment of TBI were included in the analysis. Studies included had to report at least one point of mortality in an ICP monitoring group and a no–ICP monitoring group. Data were extracted for study characteristics, patient demographics, baseline characteristics, treatment details, and study outcomes.

RESULTS

A total of 14 studies including 24,792 patients were analyzed. The meta-analysis provides no evidence that ICP monitoring decreased the risk of death (pooled OR 0.93 [95% CI 0.77–1.11], p = 0.40). However, 7 of the studies including 12,944 patients were published after 2012 (January 2012 to October 2013), and they revealed that ICP monitoring was significantly associated with a greater decrease in mortality than no ICP monitoring (pooled OR 0.56 [95% CI 0.41–0.78], p = 0.0006). In addition, 7 of the studies conducted in North America showed no evidence that ICP monitoring decreased the risk of death, similar to the studies conducted in other regions. ICU LOSs were significantly longer for the group subjected to ICP monitoring (mean difference [MD] 0.29 [95% CI 0.21–0.37]; p < 0.00001). In the pooled data, the hospital LOS with ICP monitoring was also significantly longer than with no ICP monitoring (MD 0.21 [95% CI 0.04–0.37]; p = 0.01).

CONCLUSIONS

In this systematic review and meta-analysis of ICP monitoring studies, the authors found that the current clinical evidence does not indicate that ICP monitoring overall is significantly superior to no ICP monitoring in terms of the mortality of TBI patients. However, studies published after 2012 indicated a lower mortality in patients who underwent ICP monitoring.

ABBREVIATIONSBTF = Brain Trauma Foundation; GCS = Glasgow Coma Scale; ICP = intracranial pressure; ICU = intensive care unit; MD = mean difference; STROBE = Strengthening the Reporting of Observational Studies in Epidemiology; TBI = traumatic brain injury.

Article Information

Drs. Qiang Yuan, Xing Wu, and Yirui Sun contributed equally to this work.

Correspondence Jin Hu, Department of Neurosurgery, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Rd., Shanghai 200040, China. email: 297260090@qq.com.

INCLUDE WHEN CITING Published online December 5, 2014; DOI: 10.3171/2014.10.JNS1460.

DISCLOSURE The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. This work was supported by the National Natural Science Foundation of China (NSFC Grants 30371454, 81271375, and 81171133), the Science and Technology Commission of Shanghai Municipality Project (10JC1402300), and Shanghai Nature Science Foundation (08411952000).

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Identification process for eligible studies. Of the 7175 studies initially identified from our electronic search, 14 met the inclusion criteria and were included in this meta-analysis.

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    Association between ICP monitoring and mortality in patients with TBI stratified by randomization or not (shown as log[Odds Ratio] with SE). IV = inverse variance. Figure is available in color online only.

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    Association between ICP monitoring and mortality in patients with TBI stratified by publication date (shown as log[Odds Ratio] with SE). Figure is available in color online only.

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    Association between ICP monitoring and mortality in patients with TBI stratified by country (shown as log[Odds Ratio] with SE). Figure is available in color online only.

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    Association between ICP monitoring and mortality in patients with severe TBI (GCS score < 9) stratified by publication date (shown as log[Odds Ratio] with SE). Figure is available in color online only.

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    Association between ICP monitoring and ICU mortality, hospital mortality, 2-week mortality, and 6-month mortality in patients with TBI (shown as log[Odds Ratio] with SE). Figure is available in color online only.

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    Association between ICP monitoring and ICU LOS (shown as mean with SD in transformed days) in patients with TBI. Figure is available in color online only.

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    Association between ICP monitoring and hospital LOS (shown as mean with SD in transformed days) in patients with TBI. Figure is available in color online only.

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    Funnel plot for all studies included in the meta-analysis. Figure is available in color online only.

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    Funnel plot for the studies including only severe TBI patients. Figure is available in color online only.

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    Funnel plot for the studies of ICU LOS. Figure is available in color online only.

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    Funnel plot for the studies of hospital LOS. Figure is available in color online only.

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