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. 2023 Sep 5;6(9):e2334214.
doi: 10.1001/jamanetworkopen.2023.34214.

Comparative Effectiveness of Intracranial Pressure Monitoring on 6-Month Outcomes of Critically Ill Patients With Traumatic Brain Injury

Giovanni Nattino  1 , Lorenzo Gamberini  2 , Obou Brissy  1 , Greta Carrara  1 , Randall Chesnut  3 , Valentina Chiarini  2 , Arturo Chieregato  4 , Akos Csomos  5 , Joanne M Fleming  1 , Primoz Gradisek  6   7 , Rafael Kaps  8 , Theodoros Kyprianou  9   10 , Isaac Lazar  11 , Stanley Lemeshow  12 , Malgorzata Mikaszewska-Sokolewicz  13 , Giulia Paci  14 , Carlotta Rossi  1 , Nancy Temkin  15 , Nektaria Xirouchaki  16 , Aimone Giugni  2 , Guido Bertolini  1 ; CREACTIVE Consortium
Collaborators, Affiliations

Comparative Effectiveness of Intracranial Pressure Monitoring on 6-Month Outcomes of Critically Ill Patients With Traumatic Brain Injury

Giovanni Nattino et al. JAMA Netw Open. .

Abstract

Importance: While the relationship between persistent elevations in intracranial pressure (ICP) and poorer outcomes is well established for patients with traumatic brain injury (TBI), there is no consensus on how ICP measurements should drive treatment choices, and the effectiveness of ICP monitoring remains unknown.

Objective: To evaluate the effectiveness of ICP monitoring on short- and mid-term outcomes of patients with TBI.

Design, setting, and participants: CREACTIVE was a prospective cohort study that started in March 2014 and lasted 5 years. More than 8000 patients with TBI were enrolled at 83 intensive care units (ICUs) from 7 countries who joined the CREACTIVE Consortium. Patients with TBI who met the Brain Trauma Foundation guidelines for ICP monitoring were selected for the current analyses, which were performed from January to November 2022.

Exposure: Patients who underwent ICP monitoring within 2 days of injury (exposure group) were propensity score-matched to patients who were not monitored or who underwent monitoring 2 days after the injury (control group).

Main outcome and measure: Functional disability at 6 months as indicated by Glasgow Outcome Scale-Extended (GOS-E) score.

Results: A total of 1448 patients from 43 ICUs in Italy and Hungary were eligible for analysis. Of the patients satisfying the ICP-monitoring guidelines, 503 (34.7%) underwent ICP monitoring (median [IQR] age: 45 years [29-61 years]; 392 males [77.9%], 111 females [22.1%]) and 945 were not monitored (median [IQR] age: 66 years [48-78 years]; 656 males [69.4%], 289 females [30.6%]). After matching to balance the variables, worse 6-month recovery was observed for monitored patients compared with nonmonitored patients (death/vegetative state: 39.2% vs 40.6%; severe disability: 33.2% vs 25.4%; moderate disability: 15.7% vs 14.9%; good recovery: 11.9% vs 19.1%, respectively; P = .005). Monitored patients received medical therapies significantly more frequently.

Conclusions and relevance: In this cohort study, ICP monitoring was associated with poorer recovery and more frequent medical interventions with their relevant adverse effects. Optimizing the value of ICP monitoring for TBI requires further investigation on monitoring indications, clinical interventions, and management protocols.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Chieregato reported a patent null pending outside the submitted work. Dr Xirouchaki reported other support from the University of Crete during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flowchart Describing the Patient Selection
BTF indicates Brain Trauma Foundation; CREACTIVE, Collaborative Research on Acute Traumatic Brain Injury in Intensive Care Medicine in Europe; GOS-E, Glasgow Outcome Scale–Extended score; ICP, intracranial pressure; ICU, intensive care unit; TBI, traumatic brain injury.
Figure 2.
Figure 2.. Comparison of the Weighted Distribution of 6-Month Glasgow Outcome Scale–Extended (GOS-E) Score (Grouped in 4 Status Levels) Between the Treatment Groups
P = .005 for the comparison. ICP indicates intracranial pressure.
See this image and copyright information in PMC

Comment in

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