The effect of ICP monitoring in severe traumatic brain injury: a propensity score–weighted and adjusted regression approach

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OBJECTIVE

The use of intracranial pressure (ICP) monitoring has been postulated to be beneficial in patients with severe traumatic brain injury (TBI), although studies investigating this hypothesis have reported conflicting results. The objective of this study was to evaluate the effect of inserting an ICP monitor on survival in patients with severe TBI.

METHODS

The Oslo University Hospital trauma registry was searched for the records of all patients admitted between January 1, 2002, and December 31, 2013, who fulfilled the Brain Trauma Foundation criteria for intracranial hypertension and who survived at least 24 hours after admission. The impact of ICP monitoring was investigated using both a logistic regression model and a multiple imputed, propensity score–weighted logistic regression analysis.

RESULTS

The study involved 1327 patients, in which 757 patients had an ICP monitor implanted. The use of ICP monitors significantly increased in the study period (p < 0.01). The 30-day overall mortality was 24.3% (322 patients), divided into 35.1% (200 patients, 95% confidence interval [CI] 31.3%–39.1%) in the group without an ICP monitor and 16.1% (122 patients, 95% CI 13.6%–18.9%) in the group with an ICP monitor. The impact of ICP monitors on 30-day mortality was found to be beneficial both in the complete case analysis logistic regression model (odds ratio [OR] 0.23, 95% CI 0.16–0.33) and in the adjusted, aggregated, propensity score–weighted imputed data sets (OR 0.22, 95% CI 0.15–0.35; both p < 0.001). The sensitivity analysis indicated that the findings are robust to unmeasured confounders.

CONCLUSIONS

The authors found that the use of an ICP monitor is significantly associated with improved survival in patients with severe head injury.

ABBREVIATIONS AIS = Abbreviated Injury Scale; ASA = American Society of Anesthesiologists Physical Status Classification; BEST-TRIP = Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure; BTF = Brain Trauma Foundation; CI = confidence interval; CPP = cerebral perfusion pressure; EVD = external ventricular drain; GB = generalized boosting; GCS = Glasgow Coma Scale; ICP = intracranial pressure; ISS = Injury Severity Score; OR = odds ratio; OUH-U = Oslo University Hospital, Ullevål; TBI = traumatic brain injury.

Article Information

Correspondence Pål Rønning: Oslo University Hospital, Oslo, Norway. palronning@gmail.com.

INCLUDE WHEN CITING Published online December 21, 2018; DOI: 10.3171/2018.7.JNS18270.

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.

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Figures

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    The left panel demonstrates the effect of weighting the propensity score obtained from the GB model on standardized differences between the ICP-monitored and -nonmonitored groups. The different points indicate the different results from the 10 imputed data sets. The right panel indicates the relative influence of the variable on the final multivariate model from the GB model. BP = blood pressure; fx = fracture.

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    A weighted Kaplan-Meier curve (using the aggregated, propensity score, multiple-imputed data set) demonstrating improved survival in the ICP-monitored cohort.

  • View in gallery

    Coefficient plot. The unadjusted and adjusted b-coefficients and their associated 95% CIs from the complete case data set using logistic regression are contrasted with the b-coefficients from the imputed, propensity score–weighted logistic regression analysis. The effect of ICP monitor insertion is significant for the adjusted analyses in both data sets (OR 0.23, 95% CI 0.16–0.33, and OR 0.22, 95% CI 0.15–0.35; both p < 0.001).

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