In Reply: Patients Who Benefit From Intracranial Pressure Monitoring Without Cerebrospinal Fluid Drainage After Severe Traumatic Brain Injury.

Abstract

To the Editor: This is in response to letter to editor1 for article by Lele et al.2 The fourth edition of the Brain Trauma Foundation (BTF) guidelines3 provides level IIB evidence and recommends intracranial pressure (ICP) monitoring in patients with severe traumatic rain injury (TBI) to reduce in-hospital and 2-wk postinjury mortality. The previous edition of the BTF guidelines to which the present study is in temporal relationship recommended monitoring in all salvageable patients with a severe TBI and abnormal computed tomography (CT) scan (hematomas, contusions, swelling, herniation, or compressed basal cisterns) or normal CT scan and either age over 40 yr, unilateral or bilateral motor posturing, or systolic blood pressure (BP) < 90 mm Hg.4,5 Compliance with BTF guidelines and their impact on outcomes has been described by Alali et al,6 who demonstrated that ICP monitor placement is not routine in all severe TBI patients and that there is variation between institutions in proportion of severe TBI patients who receive ICP monitoring, but seems that those who do receive monitoring seem to experience lower mortality. Our study2 reflects real-life clinical management of patients with severe TBI, outside of any protocolized study model. The variability in critical care in severe TBI is in fact individualized care based on characteristics and demands. Abnormalities on CT may be present in isolation or may co-exist in a patient; thus, individualizing ICP monitoring to particular patient depending upon clinical and radiographic abnormalities perhaps is certainly a more practical approach. We believe that an “ICP number” should not be used in isolation when making clinical decision. Neurological trajectories and CT imaging findings may be taken into consideration prior to making the decision to place ICP monitor. However, medical and or surgical decisions may not necessarily have to wait for ICP monitoring data if CT imaging demonstrates signs associated with elevated intracranial hypertension and clinical examination corroborates. In these circumstances, having an ICP monitor allows clinicians to appreciate response to medical intervention and trend ICP over time. Multimodal physiological monitoring data points such as trends in ICP values, cerebral perfusion pressure, brain tissue oxygenation/jugular oxygenation, or microdialysis may also be valuable and may be taken into consideration to appropriately escalate the level of therapeutic intensity. However, not all of these technologies are widely available worldwide, and some still used for research purposes only. Thus, care of severe TBI patient must be individualized using the best available level of evidence within the constraints of prevailing resources. We agree that future studies examining the association between ICP monitoring and clinical outcomes must use methodological rigor as was used in our study and account for the heterogeneity in clinical and radiographic abnormalities. Disclosures Funding was from NINDS 5R21NS077444-02 (M.S.V.) and Department of Biotechnology DBT N-1349 (Mahapatra/D.G.). The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.