Predictive value of initial intracranial pressure for refractory intracranial hypertension in persons with traumatic brain injury: A prospective observational study

Abstract

Objective: To prospectively investigate the predictive value of initial intracranial pressure (ICP) for refractory intracranial hypertension and outcomes in persons with diffuse traumatic brain injury (TBI).Methods: A prospective observational study was conducted in 107 adult persons with diffuse TBI (Marshall CT Class II–IV). Initial ICP was defined as the first ICP recorded in the operating room. Refractory intracranial hypertension was defined as ICP increases to more than 30 mmHg and/or reduces in cerebral perfusion pressure to less than 60 mmHg for a period longer than 15 minutes and failure to respond to the maximum medical treatment. Baseline demographics and injury-specific data were recorded. Multiple logistic regression models were used to determine independent risk factors for refractory intracranial hypertension and unfavourable outcomes. A receiver-operating characteristic (ROC) curve was then drawn.Results: The initial ICP allowed for a better refractory intracranial hypertension prediction (ROC area = 0.868; 95% CI = 0.799–0.937) than the Marshall Classification (ROC area = 0.670; 95% CI = 0.569–0.772) or Rotterdam Classification scores (ROC area = 0.679; 95% CI = 0.577–0.780). An initial ICP value higher than 20 mmHg had 83% sensitivity and 83% specificity, whereas an initial ICP value higher than 25 mmHg had 64% sensitivity and 92% specificity for refractory intracranial hypertension. A multivariable logistic regression model showed that any 5 mmHg pressure increase in a patient with initial ICP led to 2.884-times higher odds of refractory intracranial hypertension (95% CI = 1.893–4.395; p < 0.001). Head Abbreviated Injury Scale score, initial Glasgow Coma Scale (GCS) and initial GCS motor scores were not predictive of refractory intracranial hypertension (p > 0.05).Conclusion: For persons with diffuse TBI, the initial ICP provides great prognostic discrimination and is an independent predictor of refractory intracranial hypertension.