Impact of ICP instability and hypotension on outcome in patients with severe head trauma

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  • 1 Division of Neurosurgery and Department of Biostatistics, Medical College of Virginia, Richmond, Virginia
  • 2 Division of Neurosurgery, University of Texas Medical Branch, Galveston, Texas
  • 3 Biometry and Field Studies Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
  • 4 Division of Neurological Surgery, University of California, San Diego, California
  • 5 Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, Virginia
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✓ This study describes the relationship between raised intracranial pressure (ICP), hypotension, and outcome from severe head injury. The study is based on information derived from the Traumatic Coma Data Bank where ICP records from a relatively large number of patients were available to help delineate the major factors influencing outcome. From the total data base of 1030 patients, 428 met minimum monitoring duration criteria for inclusion in the present analysis. Outcome was classified according to the Glasgow Outcome Scale score determined at 6 months postinjury. Arrays of comparably defined summary measures describing the patient's course were considered for ICP, blood pressure (BP), central perfusion pressure, and therapy intensity level. For instance, the array of ICP summary descriptors included the proportion of ICP readings greater than x, for x = 0 to 80 mm Hg by increments of 5 mm Hg. A total of 187 candidate summary descriptors were considered. A stepwise ordinal logistic regression was used to select the subset of candidate summary descriptors that best explained the 6-month outcome.

As established previously, age, admission motor score, and abnormal pupils were each highly significant in explaining outcome. Beyond these factors, the proportion of hourly ICP readings greater than 20 mm Hg was next selected and was also highly significant in explaining outcome (p < 0.0001). In addition to the ICP factor, the cutoff point of 20 mm Hg was selected by the procedure as most indicative of outcome. With these four factors modeled, the next selected factor was the proportion of hourly BP readings less than 80 mm Hg. Again, the BP factor was highly significant in explaining outcome (p < 0.0001). As with the ICP factor, the BP cutoff point of 80 mm Hg was objectively selected as most indicative of outcome. In summary, the incidence of mortality and morbidity resulting from severe head trauma is strongly related to raised ICP and hypotension measured during the course of ICP management. Moreover, these ICP and BP factors provide a better indication of outcome than the similarly defined factors of central perfusion pressure or therapy intensity level.

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Contributor Notes

Address reprint requests to: Anthony Marmarou, Ph.D., Medical College of Virginia, P.O. Box 508, MCV Station, Richmond, Virginia 23298–0001.
  • 1.

    Alberico AM, , Ward JD, & Choi SC, et al: Outcome after severe head injury. Relationship to mass lesions, diffuse injury, and ICP course in pediatric and adult patients. J Neurosurg 67:648656, 1987 Alberico AM, Ward JD, Choi SC, et al: Outcome after severe head injury. Relationship to mass lesions, diffuse injury, and ICP course in pediatric and adult patients. J Neurosurg 67:648–656, 1987

    • Search Google Scholar
    • Export Citation
  • 2.

    Bartolucci AA, & Fraser MD: Comparative step-up and composite tests and selecting prognostic indicators associated with survival. Biomedical J 19:437448, 1977 Bartolucci AA, Fraser MD: Comparative step-up and composite tests and selecting prognostic indicators associated with survival. Biomedical J 19:437–448, 1977

    • Search Google Scholar
    • Export Citation
  • 3.

    Becker DP, , Miller JD, & Ward JD, et al: The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg 47:491502, 1977 Becker DP, Miller JD, Ward JD, et al: The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg 47:491–502, 1977

    • Search Google Scholar
    • Export Citation
  • 4.

    Chestnut RM, & Marshall LF: Analysis of the role of secondary brain injury in determining outcome from severe head injury. J Neurosurg 72:360A, 1990 (Abstract) Chestnut RM, Marshall LF: Analysis of the role of secondary brain injury in determining outcome from severe head injury. J Neurosurg 72:360A, 1990 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 5.

    Choi SC, , Narayan RK, & Anderson RL, et al: Enhanced specificity of prognosis in severe head injury. J Neurosurg 69:381385, 1988 Choi SC, Narayan RK, Anderson RL, et al: Enhanced specificity of prognosis in severe head injury. J Neurosurg 69:381–385, 1988

    • Search Google Scholar
    • Export Citation
  • 6.

    Choi SC, , Ward JD, & Becker DP: Chart for outcome prediction in severe head injury. J Neurosurg 59:294297, 1983 Choi SC, Ward JD, Becker DP: Chart for outcome prediction in severe head injury. J Neurosurg 59:294–297, 1983

    • Search Google Scholar
    • Export Citation
  • 7.

    Eisenberg HM, , Cayard C, & Papanicolaou A, et al: The effects of three potentially preventable complications on outcome after severe closed head injury, in Ishii S, , Nagai H, & Brock M (eds): Intracranial Pressure V. Berlin: Springer-Verlag, 1983, pp 549553 Eisenberg HM, Cayard C, Papanicolaou A, et al: The effects of three potentially preventable complications on outcome after severe closed head injury, in Ishii S, Nagai H, Brock M (eds): Intracranial Pressure V. Berlin: Springer-Verlag, 1983, pp 549–553

    • Search Google Scholar
    • Export Citation
  • 8.

    Foulkes MA, , Eisenberg HM, & Jane JA, et al: The Traumatic Coma Data Bank: design, methods, and baseline characteristics. J Neurosurg 75 (Suppl):S8S13, 1991 Foulkes MA, Eisenberg HM, Jane JA, et al: The Traumatic Coma Data Bank: design, methods, and baseline characteristics. J Neurosurg 75 (Suppl):S8–S13, 1991

    • Search Google Scholar
    • Export Citation
  • 9.

    Gaab MR, & Haubitz I: Intracranial pressure, primary/secondary brain stem injury and prognosis in cerebral trauma, in Ishii S, , Nagai H, & Brock M (eds): Intracranial Pressure V. Berlin: Springer-Verlag, 1983, pp 501531 Gaab MR, Haubitz I: Intracranial pressure, primary/secondary brain stem injury and prognosis in cerebral trauma, in Ishii S, Nagai H, Brock M (eds): Intracranial Pressure V. Berlin: Springer-Verlag, 1983, pp 501–531

    • Search Google Scholar
    • Export Citation
  • 10.

    Harrell FE, & Lee KL: The practical value of logistic regression. Proceedings of the Tenth Annual SAS Users Group International Conference. Cary, NC: SAS Institute, 1985, pp 10311036 Harrell FE, Lee KL: The practical value of logistic regression. Proceedings of the Tenth Annual SAS Users Group International Conference. Cary, NC: SAS Institute, 1985, pp 1031–1036

    • Search Google Scholar
    • Export Citation
  • 11.

    Harrell FE, , Lee KL, & Califf RM, et al: Regression modelling strategies for improved prognostic prediction. Stat Med 3:143152, 1984 Harrell FE, Lee KL, Califf RM, et al: Regression modelling strategies for improved prognostic prediction. Stat Med 3:143–152, 1984

    • Search Google Scholar
    • Export Citation
  • 12.

    Janny P, , Jouan JP, & Gourgand M, et al: A statistical approach to long-term monitoring of intracranial pressure, in Brock M, & Dietz H (eds): Intracranial Pressure. Berlin: Springer-Verlag, 1972, pp 5964 Janny P, Jouan JP, Gourgand M, et al: A statistical approach to long-term monitoring of intracranial pressure, in Brock M, Dietz H (eds): Intracranial Pressure. Berlin: Springer-Verlag, 1972, pp 59–64

    • Search Google Scholar
    • Export Citation
  • 13.

    Jennett B, & Bond M: Assessment of outcome after severe damage. A practical scale. Lancet 1:480484, 1975 Jennett B, Bond M: Assessment of outcome after severe damage. A practical scale. Lancet 1:480–484, 1975

    • Search Google Scholar
    • Export Citation
  • 14.

    Marmarou A, , Anderson RL, & Ward JD, et al: NINDS Traumatic Coma Data Bank: intracranial pressure monitoring methodology. J Neurosurg 75 (Suppl):S21S27, 1991 Marmarou A, Anderson RL, Ward JD, et al: NINDS Traumatic Coma Data Bank: intracranial pressure monitoring methodology. J Neurosurg 75 (Suppl):S21–S27, 1991

    • Search Google Scholar
    • Export Citation
  • 15.

    Marshall LF, , Smith RW, & Shapiro HM: The outcome with aggressive treatment in severe head injuries. Part I: The significance of intracranial pressure monitoring. J Neurosurg 50:2025, 1979 Marshall LF, Smith RW, Shapiro HM: The outcome with aggressive treatment in severe head injuries. Part I: The significance of intracranial pressure monitoring. J Neurosurg 50:20–25, 1979

    • Search Google Scholar
    • Export Citation
  • 16.

    Maset AL, , Marmarou A, & Ward JD, et al: Pressure-volume index in head injury. J Neurosurg 67:832840, 1987 Maset AL, Marmarou A, Ward JD, et al: Pressure-volume index in head injury. J Neurosurg 67:832–840, 1987

    • Search Google Scholar
    • Export Citation
  • 17.

    McGraw CP, , Howard G, & O'Connor C: Outcome associated with management based on ICP monitoring, in Ishii S, , Nagai H, & Brock M (eds): Intracranial Pressure V. Berlin: Springer-Verlag, 1983, pp 558561 McGraw CP, Howard G, O'Connor C: Outcome associated with management based on ICP monitoring, in Ishii S, Nagai H, Brock M (eds): Intracranial Pressure V. Berlin: Springer-Verlag, 1983, pp 558–561

    • Search Google Scholar
    • Export Citation
  • 18.

    Miller JD, , Becker DP, & Ward JD, et al: Significance of intracranial hypertension in severe head injury. J Neurosurg 47:503516, 1977 Miller JD, Becker DP, Ward JD, et al: Significance of intracranial hypertension in severe head injury. J Neurosurg 47:503–516, 1977

    • Search Google Scholar
    • Export Citation
  • 19.

    Miller JD, , Butterworth JF, & Gudeman SK, et al: Further experience in the management of severe head injury. J Neurosurg 54:289299, 1981 Miller JD, Butterworth JF, Gudeman SK, et al: Further experience in the management of severe head injury. J Neurosurg 54:289–299, 1981

    • Search Google Scholar
    • Export Citation
  • 20.

    Miller JD, , Sweet RC, & Narayan R, et al: Early insults to the injured brain. JAMA 240:439442, 1978 Miller JD, Sweet RC, Narayan R, et al: Early insults to the injured brain. JAMA 240:439–442, 1978

    • Search Google Scholar
    • Export Citation
  • 21.

    Narayan RK, , Greenberg RP, & Miller JD, et al: Improved confidence of outcome prediction in severe head injury. A comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning, and intracranial pressure. J Neurosurg 54:751762, 1981 Narayan RK, Greenberg RP, Miller JD, et al: Improved confidence of outcome prediction in severe head injury. A comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning, and intracranial pressure. J Neurosurg 54:751–762, 1981

    • Search Google Scholar
    • Export Citation
  • 22.

    Nordby HK, & Gunnerød N: Epidural monitoring of the intracranial pressure in severe head injury characterized by non-localizing motor response. Acta Neurochir 74:2126, 1985 Nordby HK, Gunnerød N: Epidural monitoring of the intracranial pressure in severe head injury characterized by non-localizing motor response. Acta Neurochir 74:21–26, 1985

    • Search Google Scholar
    • Export Citation
  • 23.

    Pitts LH, , Kaktis JV, & Juster R, et al: ICP and outcome in patients with severe head injury, in Shulman K, , Marmarou A, & Miller JD, et al (eds): Intracranial Pressure IV. Berlin: Springer-Verlag, 1980, pp 59 Pitts LH, Kaktis JV, Juster R, et al: ICP and outcome in patients with severe head injury, in Shulman K, Marmarou A, Miller JD, et al (eds): Intracranial Pressure IV. Berlin: Springer-Verlag, 1980, pp 5–9

    • Search Google Scholar
    • Export Citation
  • 24.

    Price JE, & Murray A: The influence of hypoxia and hypotension on recovery from head injury. Br J Accid Surg 3:218224, 1972 Price JE, Murray A: The influence of hypoxia and hypotension on recovery from head injury. Br J Accid Surg 3:218–224, 1972

    • Search Google Scholar
    • Export Citation
  • 25.

    Rosner MJ, & Daughton S: Cerebral perfusion pressure management in head injury. J Trauma 30:933941, 1990 Rosner MJ, Daughton S: Cerebral perfusion pressure management in head injury. J Trauma 30:933–941, 1990

    • Search Google Scholar
    • Export Citation
  • 26.

    Saul TG, & Ducker TB: Effect of intracranial pressure monitoring and aggressive treatment on mortality in severe head injury. J Neurosurg 56:498503, 1982 Saul TG, Ducker TB: Effect of intracranial pressure monitoring and aggressive treatment on mortality in severe head injury. J Neurosurg 56:498–503, 1982

    • Search Google Scholar
    • Export Citation
  • 27.

    Smith HP, , Kelly DL Jr, & McWhorter JM, et al: Comparison of mannitol regimens in patients with severe head injury undergoing intracranial monitoring. J Neurosurg 65:820824, 1986 Smith HP, Kelly DL Jr, McWhorter JM, et al: Comparison of mannitol regimens in patients with severe head injury undergoing intracranial monitoring. J Neurosurg 65:820–824, 1986

    • Search Google Scholar
    • Export Citation
  • 28.

    Stuart GG, , Merry GS, & Smith JA, et al: Severe head injury managed without intracranial pressure monitoring. J Neurosurg 59:601605, 1983 Stuart GG, Merry GS, Smith JA, et al: Severe head injury managed without intracranial pressure monitoring. J Neurosurg 59:601–605, 1983

    • Search Google Scholar
    • Export Citation
  • 29.

    Teasdale G, & Jennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:8184, 1974 Teasdale G, Jennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81–84, 1974

    • Search Google Scholar
    • Export Citation
  • 30.

    Tsutsumi H, , Ide K, & Mizutani T, et al: The relationship between intracranial pressure, cerebral perfusion pressure and outcome in head injured patients: the critical level of cerebral perfusion pressure, in Miller JD, , Teasdale GM, & Rowan JO, et al (eds): Intracranial Pressure VI. Berlin: Springer-Verlag, 1986, pp 661666 Tsutsumi H, Ide K, Mizutani T, et al: The relationship between intracranial pressure, cerebral perfusion pressure and outcome in head injured patients: the critical level of cerebral perfusion pressure, in Miller JD, Teasdale GM, Rowan JO, et al (eds): Intracranial Pressure VI. Berlin: Springer-Verlag, 1986, pp 661–666

    • Search Google Scholar
    • Export Citation

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