A trial of intracranial-pressure monitoring in traumatic brain injury

Neuroimaging and neuromonitoring access in Mexico, where to focus?

INTRODUCTION

Neuromonitoring plays an integral part of neurocritical care decision making in patients with acute brain injury, as it facilitates detection of physiological changes with the goal to mitigate further neurological deterioration and prevent secondary brain injury. There are increasing efforts being made to understand how the care of neurocritical patients is delivered globally, but there is little information about the use of neuroimaging and neuromonitoring in Lower Middle-Income Country. We aimed to investigate the availability of different neuromonitoring tools in intensive care units in Mexico.

METHODS

This was a prospective observational survey focused on gathering current neuroimaging and neuromonitoring practices in Mexico. We used a web-based survey using Google Forms (©2024 Google) to query practicing intensive care physicians in all states in Mexico. The questionnaire consisted of two sections with 27 questions.

RESULTS

A total of 66 responses were included in the final analysis, that represent 65% of the states in Mexico (21 out of 32 states). Most ICUs reported not having access to a neurointensivist (79%, 52/66). Computed Tomography (CT) was available around the clock in 97% of ICUs (64/66), while CT angiography (CTA) was available 24/7 in 20% of ICUs (13/66) with only daytime availability in 35% (23/66) of ICUs. The most available invasive monitor in Mexico was the jugular bulb oximetry, which was available in 62% of ICUs (41/66). One third of ICUs (34%, 29/66) reported the use of invasive ICP monitoring. Of those, ventriculostomy was the most commonly use type of catheter, followed by the intraparenchymal ICP monitor, epidural and subdural ICP monitors. Brain tissue oxygen monitor (pbtO2) was only available in less than third of ICUs, 14% (5/66). Only 62% percent (41/66) of hospitals had 24/7 access to a neurosurgeon.

CONCLUSION

The availability of neuroimaging and neuromonitoring is limited in ICUs in Mexico, despite a sizeable proportion of neurocritical care patients. This may be in part driven by resources constraints, as well as lack of neurocritical care and neurosurgical access in many centers. There is an unmet need for recruiting and training in neurocritical care and neurosurgery.

Optic Nerve Sheath Diameter on Computed Tomography Scans Reflects Elevated Intracranial Pressure in Patients with Craniosynostosis

BACKGROUND

Assessment for elevated intracranial pressure (ICP) helps guide interventional decision-making to treat craniosynostosis. However, noninvasive techniques for measuring ICP are limited. This study assessed whether optic nerve sheath diameter (ONSD) on low-dose computed tomographic (CT) scans is associated with ICP in patients with craniosynostosis.

METHODS

Pediatric patients treated between 2014 and 2023 with craniosynostosis, intraoperative ICP measurements by direct subdural catheterization, and spectral domain-optical coherent tomographic (SD-OCT) data were included. ONSD was retrospectively assessed on preoperative CT scans by a masked neuroradiologist and compared with measures and proxies of ICP.

RESULTS

Among the 132 patients included (median age, 6.9 years; interquartile range, 4.7 to 9.5 years), 41 (31.1%) had a syndromic diagnosis. Maximal ONSD was increased in patients with an ICP of 15 mmHg or greater (6.1 mm versus 5.5 mm; P < 0.01) and 20 mmHg or greater (6.3 mm versus 5.6 mm; P < 0.01). Maximal ( r = 0.32; P < 0.001), minimum ( r = 0.26; P = 0.003), and average ( r = 0.29; P < 0.001) ONSD correlated with direct ICP measurements. ONSD and SD-OCT measurements were also correlated (maximum retinal nerve fiber layer, r = 0 .21, P = 0.04; maximum retinal thickness, r = 0.24, P = 0.02). An ONSD max threshold of 5.75 mm demonstrated 65% sensitivity and 64% specificity for detecting ICP of 15 mmHg or greater on optimized receiver operating characteristic curve analysis. Multivariable logistic regression generated an algorithm incorporating ONSD max and age to detect an ICP of 20 mmHg or greater with 64% sensitivity and 80% specificity.

CONCLUSIONS

ONSD measured on low-dose CT scans detected elevated ICP with moderate accuracy. Precision increased when patient age was taken into consideration. Given the ease of accessing CT scan data, this may be a helpful ICP proxy for clinical decision-making.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, II.

Current Management and Future Challenges in the Management of Severe Traumatic Brain Injury

Background and Objectives: Severe Traumatic Brain Injury (TBI) is one of the devastating injuries occurring in all ages across the globe. Despite many advancements in the management of severe TBI, mortality and morbidities remain high. Evidence-based management in severe TBI has reduced mortality. The purpose of this review is to discuss the current management and present the future challenges in this patient cohort. Materials and Methods: A literature review was conducted to identify the current practice patterns and guidelines of severe TBI. We examined the literature regarding medical and surgical managements of the severe TBI. Results: Initial management of severe TBI includes stabilization of the primary injury and prevention of secondary insult to brain. Hemodynamic, intracranial pressure and cerebral perfusion pressure monitoring, antiseizure prophylaxis, hyperosmolar therapy, sedation, medical induced coma, and nutritional and ventilatory support are part of the medical management. Operative intervention includes craniotomy and decompressive craniectomy. Most of the current practices are recommended by the Brain Trauma Foundation (BTF). These guidelines are based on the existing literature, however, some of the recommendations by the BTF lack level one evidence. Conclusions: BTF guidelines provide recommendations in the management of severe TBI. High quality prospective randomized trials are needed to further explore the new modalities and interventions in the field of severe TBI.

Invasive and non-invasive monitoring in the ICU

Effective invasive and non-invasive monitoring, when coupled with good clinical decision making, can improve outcomes for critically ill patients. When deciding on the best monitoring technique, it is important to consider the specific information that is needed to guide critical care management, while balancing the reliability of the data obtained and the risks of invasive monitor placement. Here, we review invasive and non-invasive options for hemodynamic and neurologic monitoring in the Surgical Intensive Care Unit. Understanding how each monitoring device functions, its indications, risks, and limitations is key when deciding how to monitor bedside physiologic data that guide clinical decision making. Level of evidence: Level IV.

Optimal Cerebral Perfusion Pressure in Brain Injury: Physiological Relationships and Outcome

BACKGROUND AND OBJECTIVES

The priority for measuring and optimizing physiological metrics in brain injury care remains to be determined. Calculating and targeting optimal cerebral perfusion pressure (CPP opt ) is an emerging treatment paradigm, but its association with other parameters is uncertain. A previous analysis of 22 patients found that brain tissue oxygenation (P bt O 2 ) peaked when CPP values were near CPP opt . This study sought to validate those findings using a distinct, larger cohort. It also studied the relationship between CPP opt and physiological parameters related to intracranial dynamics and with neurological outcome.

METHODS

P bt O 2 , intracranial pressure (ICP), and arterial blood pressure data were collected during a 15-year period from 432 brain injury patients at 4 cooperating trauma centers. CPP opt was retrospectively computed.

RESULTS

The median age was 36 years ( n = 316), the median admission Glasgow coma score was 6 ( n = 323), and 75% of the patients were men ( n = 324). In aggregate data, P bt O 2 peaked at CPP values near CPP opt (+/- 2 mm Hg). Proportion of out-of-range ICP measurements (>22 mm Hg) and positive pressure reactivity index were higher in dying and unfavorable outcome groups, and increased with worsening outcome. Time spent near CPP opt was significantly lower in dying patients but not in patients with unfavorable outcome. Time near CPP opt was, however, correlated with better outcome. Proportion of out-of-range P bt O 2 (<20 mm Hg) was not associated with outcome or mortality.

CONCLUSION

The results verify CPP opt as physiologically significant and that in aggregate data achievement of CPP opt is associated with maximized P bt O 2 . Compliance with the ICP treatment threshold was, though, the only modifiable physiological variable associated with both functional outcome and mortality. Our results support optimization of ICP with highest priority. Further study is required in patients in whom CPP opt is specifically targeted.

Time-burden insults of neuromonitoring signals: practical implications for the management of acute brain injury

PURPOSE OF REVIEW

To explore recent insights into measures of time-burden insults in intracranial pressure (ICP) monitoring, and potential implications for clinical management.

RECENT FINDINGS

The ICP is an important therapeutic target in patients with traumatic brain injury (TBI) and some other brain injuries. Current clinical guidelines in TBI recommend starting treatment above a fixed ICP threshold of 22 mmHg. The concept of ICP burden was introduced recently, which takes both intensity and duration of an episode of elevated ICP into account. This burden of ICP is visualized in a colour-coded plot. In different cohorts of brain injured patients, prolonged ICP elevations, even at values below 20 or 22 mmHg, are associated with worse outcomes, and higher ICPs can only be tolerated briefly. The ICP burden plots are influenced by age, cerebral perfusion pressure, and cerebrovascular autoregulation, illustrating the complexity and dynamic aspect of secondary insults of elevated ICP events, and the need for personalization. Two clinical trials are currently investigating the impact of presenting this information at the bedside to clinicians.

SUMMARY

The implementation of information on ICP burden at the patient's bedside could assist clinicians in recognizing secondary brain injury and result in more personalized ICP management.

Timely delivery of care in neurological emergencies: can standardized management protocols help?

PURPOSE OF REVIEW

To review the evidence that supports the implementation of goal-directed care bundle protocols to improve outcomes from neurocritical conditions, and of the possible advantage of specific over generalized protocols.

RECENT FINDINGS

Articles from January 1, 2023 to July 31, 2024 were searched to evaluate the effectiveness of standardized management in neurological emergencies. The use of care bundles and standardized protocols with time- and target-related metrics has shown benefit in patients with acute stroke and traumatic brain injury.

SUMMARY

A goal-directed care protocol to guide standard management implemented by a multidisciplinary team can improve outcomes from neurological emergencies. However, implementation challenges need to be addressed before wide adoption of protocolized care for maximum benefit to populations.

Timing of neurosurgical interventions for intracranial hypertension: the intensivists' and neurosurgeons' view

PURPOSE OF REVIEW

The aim of this study was to highlight clinical considerations regarding medical versus surgical management of elevated intracranial pressure (ICP), describe limitations of medical management, and summarize evidence regarding timing of neurosurgical interventions.

RECENT FINDINGS

The optimal ICP management strategy remains elusive, and substantial practice variations exist. Common risks of medical treatments include hypotension/shock, cardiac arrhythmias and heart failure, acute renal failure, volume overload, hypoxemia, and prolonged mechanical ventilation.In traumatic brain injury (TBI), recent randomized controlled trials (RCT) did not demonstrate outcome benefits for early, prophylactic decompressive craniectomy, but indicate a role for secondary decompressive craniectomy in patients with refractory elevated ICP. A recent meta-analysis suggested that when an extraventricular drain is required, insertion 24 h or less post-TBI may result in better outcomes.In large ischemic middle cerebral artery strokes, pooled analyses of three RCTs showed functional outcome benefits in patients less than 60 years who underwent prophylactic DC within less than 48 h. In intracranial hemorrhage, a recent RCT suggested outcome benefits for minimally invasive hematoma evacuation within less than 24 h.

SUMMARY

More data are needed to guide ICP targets, treatment modalities, predictors of herniation, and surgical triggers; clinical decisions should consider individual patient characteristics, and account for risks of medical and surgical treatments.

Unlocking the potential of high-resolution multimodality neuromonitoring for traumatic brain injury management: lessons and insights from cases, events, and patterns

Multimodality neuromonitoring represents a crucial cornerstone for patient management after acute brain injury. Despite the potential of multimodality neuromonitoring (particularly high-resolution neuromonitoring data) to transform care, its full benefits are not yet universally realized. There remains a critical need to integrate the interpretation of complex patterns and indices into the real-time clinical decision-making processes. This requires a multidisciplinary approach, to evaluate and discuss the implications of observed patterns in a timely manner, ideally in close temporal proximity to their occurrence. Such a collaborative effort could enable clinicians to harness the full potential of multimodal data. In this educational case-based scoping review, we aim to provide clinicians, researchers, and healthcare professionals with detailed, compelling examples of potential applications of multimodality neuromonitoring, focused on high-resolution modalities within the field of traumatic brain injury. This case series showcases how neuromonitoring modalities such as intracranial pressure, brain tissue oxygenation, near-infrared spectroscopy, and transcranial Doppler can be integrated with cerebral microdialysis, neuroimaging and systemic physiology monitoring. The aim is to demonstrate the value of a multimodal approach based on high-resolution data and derived indices integrated in one monitoring tool, allowing for the improvement of diagnosis, monitoring, and treatment of patients with traumatic brain injury. For this purpose, key concepts are covered, and various cases have been described to illustrate how to make the most of this advanced monitoring technology.

Intracranial pressure monitoring in patients with geriatric trauma may not improve outcome but is associated with increases in resource utilization

Background

Intracranial pressure (ICP) monitoring (ICPM) is currently recommended for severe traumatic brain injury (TBI). The hypothesis was that ICPM does not change mortality in the geriatric patient population.

Methods

The Trauma Quality Improvement Program (TQIP) database (2017-2021) was queried to identify intubated geriatric patients (≥65 years of age) with isolated blunt TBI (non-Head Abbreviated Injury Scale (AIS) score <3), with admission Glasgow Coma Scale (GCS) scores of 3-8. Patients with death on arrival or with hospital length of stay <24 hours and patients who underwent craniotomy before ICPM placement were excluded. Favorable discharge disposition was defined as home with or without assistance, and rehabilitation. Propensity score matching (PSM) was performed between ICPM and non-ICPM patients and outcomes were compared. The primary outcome was defined as in-hospital mortality. Secondary outcomes were defined as discharge disposition, hospital length of stay, intensive care unit (ICU) length of stay and ventilator days.

Results

A total of 19 416 patients met criteria for analysis. ICPM was placed in only 12.1% (n=2363) patients. The Injury Severity Score, GCS and head AIS were similar between the patients with and without monitors. After PSM, we were able to match 2148 patients and there was no difference in mortality between the two groups (52.4% vs 52.1%, p=0.874); however, patients treated with ICPM had significantly longer hospital length of stay (10 (5-17) vs 7 (3-15) days, p<0.001), ICU length of stay (8 (4-14) vs 6 (3-10), p<0.001) and ventilator days (6 (3-11) vs 4 (2-7), p<0.001). Discharge disposition was trending towards unfavorable with increasing age but was similar between the ICPM and No-ICPM groups (p=0.115).

Conclusion

The usefulness of ICPM in geriatric patients has not yet been shown and would benefit from prospective clinical studies. Minimizing ICPM in geriatric patients may reduce resource burdening without affecting outcome.

Level of evidence

Level III retrospective study.

Effects of intracranial pressure monitoring in pediatric severe traumatic brain injury: a meta-analysis of cohort studies

Introduction

As Severe traumatic brain injury (TBI) is a major cause of pediatric morbidity and mortality. The clinical benefits of intracranial pressure (ICP) monitoring in pediatric TBI remain debated. This meta-analysis aims to assess the impact of ICP monitoring on outcomes in children with severe TBI.

Methods

Following PRISMA guidelines, a comprehensive search was conducted in PubMed, EMBASE, Cochrane Library, and Web of Science. Studies comparing pediatric severe TBI patients with and without ICP monitoring were included. Primary outcomes included in-hospital mortality and complications, while secondary outcomes included craniotomy/craniectomy rate, length of hospital stay and ICU stay, mechanical ventilation duration, and medical costs. Quality assessment was performed using the Methodological Index for Non-Randomized Studies (MINORS) for cohort studies. The weighted mean difference (WMD) for continuous variables and odds ratio (OR) for dichotomous variables were calculated, along with 95% confidence intervals (CIs). Meta-analysis was performed using RevMan 5.4.1 software.

Results

Eight studies (12,987 patients) were included. ICP monitoring showed no significant impact on overall in-hospital mortality (OR, 1.14; p = 0.65), though propensity score matching (PSM) studies indicated a lower mortality rate with ICP monitoring (OR, 0.62; p = 0.005). However, ICP monitoring was associated with higher risks of infection-related (OR, 7.21; p < 0.001) and respiratory complications (OR, 5.79; p < 0.001), thromboembolic events (OR, 5.37; p < 0.001), increased craniotomy/craniectomy rates (OR, 2.34; P = 0.01), longer hospital (OR, 12.00; p < 0.001) and ICU stays (OR, 7.82; p < 0.001), extended mechanical ventilation durations (OR, 5.82; p < 0.001), and higher medical costs (WMD, 10.49; p = 0.006).

Conclusion

This meta-analysis found no overall reduction in in-hospital mortality with ICP monitoring in pediatric severe TBI, potentially due to baseline severity imbalances in retrospective studies. However, PSM studies suggest a mortality benefit, indicating that ICP monitoring may be effective when confounding is minimized. Increased complication risks, longer hospital/ICU stays, prolonged ventilation, and higher costs were associated with monitoring, though these may reflect injury severity rather than monitoring itself. Given the limitations of this study, these findings should be interpreted cautiously.

High Priority Traumatic Brain Injury Science: Analysis of the National Trauma Research Action Plan

INTRODUCTION

The National Trauma Research Action Plan convened 11 topic area panels to complete consensus-driven Delphi surveys to identify high priority trauma research questions. The Neurotrauma Panel identified questions relating to interventional and comparative effectiveness trials in severe traumatic brain injury (sTBI) critical care as highest priority. This qualitative secondary analysis aims to translate results across several Delphi panels into potential studies in sTBI critical care.

METHODS

High priority consensus research questions related to sTBI in the critical phase of care (ranked >6.5 on a 1-9 Likert scale) were screened from the Neurotrauma, Critical Care, Geriatric, and Long-Term Outcomes Panels results. Using grounded theory, two reviewers inductively open-coded questions independently and then refined them for consensus. A similar approach was used to recategorize questions into codes. Each code was then characterized into research project(s) with an aim, design, exposure(s), and outcome(s).

RESULTS

Among 376 high-priority questions reaching consensus, 55 related to sTBI critical care. Twelve projects emerged across eight consensus thematic codes: biomarkers (1 project, average priority score/range 6.92), imaging (1, 6.84), prognostication (1, 6.77), novel neuromonitoring (3, 6.61-6.77), intracranial pressure/cerebral perfusion pressure (2, 6.67-6.76), coagulopathy (2, 6.66-6.74), early rehabilitation (1, 6.67), and pharmacologic intervention (1, 6.66).

CONCLUSIONS

This National Trauma Research Action Plan secondary analysis identified several high-priority research projects in sTBI critical care. While some questions are being addressed in ongoing trials, investigators and funding agencies should consider using these consensus-driven Delphi panel results and subsequent analyses to prioritize future research proposals.

Self-inflicted bilateral penetrating brain injury with a nail gun in an African American male: illustrative case

BACKGROUND

Nail gun injuries to the brain are rare but increasingly more common in patients with suicidal ideation and psychiatric disturbances. Utilizing a bio-psycho-socio-ecological (BPSE) prism, the authors of this article describe the treatment and outcome of a patient with a history of psychiatric episodes who presented with a self-inflicted bilateral penetrating brain injury by nail gun. The patient described in this report initially had no formal psychiatric diagnosis but was subsequently diagnosed with schizoaffective disorder following the injury.

OBSERVATIONS

A 28-year-old male presented to the emergency department after sustaining a self-inflicted nail gun injury to the right parieto-occipital and left frontoparietal region of the head. The authors review the current literature on the treatment and outcomes of nail gun injuries while providing a narrative account of the biological, psychosocial, and ecological factors that can influence and modify the patient's injury and course of care.

LESSONS

The case illustrates the importance of exploring the BPSE context of patients with TBI to guide multidisciplinary care that optimizes outcomes and to inform prevention strategies that can reduce the incidence of similar injuries. https://thejns.org/doi/10.3171/CASE24520.

Ultrasound-based radiomics and clinical factors-based nomogram for early intracranial hypertension detection in patients with decompressive craniotomy

Objective

This study aims to develop and validate a nomogram that combines traditional ultrasound radiomics features with clinical parameters to assess early intracranial hypertension (IH) following primary decompressive craniectomy (DC) in patients with severe traumatic brain injury (TBI). The study incorporates the Shapley Additive Explanations (SHAP) method to interpret the radiomics model.

Methods

This study included 199 patients with severe TBI (training cohort: n = 159; testing cohort: n = 40). Postoperative ultrasound images of the optic nerve sheath (ONS) were obtained at 6 and 18 h after DC. Based on invasive intracranial pressure (ICPi) measurements, patients were grouped according to threshold values of 15 mmHg and 20 mmHg. Radiomics features were extracted from ONS images, and feature selection methods were applied to construct predictive models using logistic regression (LR), support vector machine (SVM), random forest (RF), and K-Nearest Neighbors (KNN). Clinical-ultrasound variables were incorporated into the model through univariate and multivariate logistic regression. A combined nomogram was developed by integrating radiomics features with clinical-ultrasound variables, and its diagnostic performance was evaluated using Receiver Operating Characteristic (ROC) curve analysis and decision curve analysis (DCA). The SHAP method was adopted to explain the prediction models.

Results

Among the machine learning models, the LR model demonstrated superior predictive efficiency and robustness at threshold values of 15 mmHg and 20 mmHg. At a threshold of 20 mmHg, the AUC values for the training and testing cohorts were 0.803 and 0.735 for the clinical model, 0.908 and 0.891 for the radiomics model, and 0.918 and 0.902 for the nomogram model, respectively. Similarly, at a threshold of 15 mmHg, the AUC values were consistent across models: 0.803 and 0.735 for the clinical model, 0.908 and 0.891 for the radiomics model, and 0.918 and 0.902 for the nomogram model. Notably, the nomogram model outperformed the clinical model. Decision curve analysis (DCA) further confirmed a higher net benefit for predicting intracranial hypertension across all models.

Conclusion

The nomogram model, which integrates both clinical-semantic and radiomics features, demonstrated strong performance in predicting intracranial hypertension across different threshold values. It shows promise for enhancing non-invasive ICP monitoring and supporting individualized therapeutic strategies.

Neuroworsening in Moderate Traumatic Brain Injury

Patients with moderate traumatic brain injury (TBI) are at high risk for developing intracerebral complications and in particular neuroworsening (NW). NW can be unpredictable and may be an important risk factor for poor neurologic outcome and for increased mortality. NW is often a medical and surgical emergency, and it is, therefore, fundamental to identify patients at risk early because they require strict neuromonitoring and repeated neuroimaging. So far, there is no standardized and validated definition of NW. In this review, we aim to discuss the definition, risk factors, and management of patients with moderate TBI at high risk of NW.

Cerebral Edema Monitoring and Management Strategies: Results from an International Practice Survey

BACKGROUND

Cerebral edema is a common, potentially life-threatening complication in critically ill patients with acute brain injury. However, uncertainty remains regarding best monitoring and treatment strategies, which may result in wide practice variations.

METHODS

A 20-question digital survey on monitoring and management practices was disseminated between July 2022 and May 2023 to clinicians who manage cerebral edema. The survey was promoted through email, social media, medical conferences, and the Neurocritical Care Society Web site. We used the χ2 test, Fisher's exact test, analysis of variance, and logistic regression to report factors associated with practice variation, diagnostic monitoring methods, and therapeutic triggers based on practitioner and institutional characteristics.

RESULTS

Of 321 participants from 160 institutions in 30 countries, 65% were from university-affiliated centers, 74% were attending physicians, 38% were woman, 38% had neurology training, and 55% were US-based. Eighty-four percent observed practice variations at their institutions, with "provider preference" being cited most (87%). Factors linked to variation included gender, experience, university affiliation, and practicing outside the United States. University affiliates tended to use more tests (median 3.87 vs. 3.43, p = 0.01) to monitor cerebral edema. Regarding management practices, 20% of respondents' preferred timing for decompressive hemicraniectomy was after 48 h, and 37% stated that radiographic findings only would be sufficient to trigger surgery. Fifty percent of respondents reported initiating osmotic therapy based on radiographic indications or prophylactically. There were no significant associations between management strategies and respondent or center characteristics. Twenty-seven percent of respondents indicated that they acquired neuroimaging at intervals of 24 h or less. Within this group, attending physicians were more likely to follow this practice (65.5% vs. 34.5%, p = 0.04).

CONCLUSIONS

Cerebral edema monitoring and management strategies vary. Features associated with practice variations include both practitioner and institutional characteristics. We provide a foundation for understanding practice patterns that is crucial for informing educational initiatives, standardizing guidelines, and conducting future trials.

Is Intracranial Pressure Monitoring After Open Cranial Procedures Associated With Outcome?

INTRODUCTION

It is unclear if intracranial pressure monitoring (ICPM) after open cranial procedures (craniotomy or craniectomy) (OC) for traumatic brain injury is associated with mortality. We hypothesized that ICPM placed early after OC was associated with lower mortality compared to no ICPM or delayed ICPM placement.

METHODS

Using 2020-2021 data from the American College of Surgeons Trauma Quality Improvement Program, patients ≥16 y from level 1 and 2 trauma centers who underwent OC were divided into two groups: ICPM placed within 72 h of OC (early) and no ICPM or ICPM placed after 72 h (none/delayed). Outcome was in-hospital mortality. Logistic regression was used to elucidate predictors of mortality.

RESULTS

A total of 19,830 patients (early ICPM, 29%) were included. Early patients were more likely to be from level 1 centers (63% versus 60%, P = 0.004), younger (median age 47 versus 60, P < 0.0001), to have a lower Glasgow Coma Score (median, 6 versus 14, P < 0.0001), higher injury severity score (median, 26 versus 26, P < 0.0001), an unreactive pupil (33% versus 18%, P < 0.0001), midline shift >5 mm (69% versus 60%, P < 0.0001), received ≥2 units of blood/first 4 h (14% versus 6%, P < 0.0001) and higher mortality (31% versus 19%, P < 0.0001) compared to none/delayed patients. Controlled for significant variables, early ICPM was associated with increased mortality (odds ratio 1.35, 95% confidence interval 1.24-1.47). Analysis of subjects with isolated brain injury found a similar association (odds ratio 1.32, 95% C1 1.15-1.52).

CONCLUSIONS

ICPM placed within 72 h of OC was associated with increased mortality. Indications for ICPM after OC should be investigated further in multicenter prospective studies.

Adherence in Evidence-Based Neurotrauma Guidelines: A Worldwide Survey

BACKGROUND

Traumatic brain injury management guidelines vary across regions and there is limited research on real-world adherence to these guidelines. We conducted a global survey to assess the adherence of neurosurgeons to traumatic brain injury guidelines and evidence-based medicine (EBM).

METHODS

A 24-item survey was created using Google Forms, covering demographic information, neurotrauma training, basic knowledge of EBM, and surgical and in-hospital management.

RESULTS

Responses were collected from 233 neurosurgeons across 53 different countries. Approximately 45% of respondents reported not staying up to date with Brain Trauma Foundation guidelines, and 48% indicated a preference for relying on their own experience over EBM guidelines. Neurosurgeons from Asia and Africa were more likely to rely on personal experience, while those from Europe and North/Central and South America leaned toward EBM (P = 0.021). Additionally, 56% of respondents reported that their neurotrauma management at least sometimes diverged from recommended guidelines. Specifically, 58% never or rarely managed epidural hematoma of 30 cm³ conservatively, and 45% sometimes, often, or always treated subdural hematomas conservatively, even when EBM recommended surgery. Moreover, 24% at least sometimes managed patients conservatively despite a Glasgow Coma Scale score of less than 9 or a decrease of 2 or more points. In cerebellar hematomas, 46% sometimes opted for external ventricular drainage alone.

CONCLUSIONS

Neurosurgeons from Europe and North/Central and South America tend to follow EBM guidelines more closely, while those from Asia and Africa often favor individual decision-making approaches.

Management of severe traumatic brain injury in pediatric patients: an evidence-based approach

BACKGROUND

Traumatic brain injury (TBI) is a major cause of death and disability worldwide. The decision-making process in the management of severe TBI must be based on the best available evidence to minimize the occurrence of secondary brain injuries. However, healthcare approaches to managing TBI patients exhibit considerable variation.

METHODS

Over an 18-month period, a multidisciplinary panel consisting of medical doctors, physiotherapists, nutritional therapists, and nurses performed a comprehensive review on various subtopics concerning TBI. The panel identified primary questions to be addressed using the Population, Intervention, Control, and Outcome (PICO) format and applied the Evidence to Decision (EtD) framework criteria for evaluating interventions. Subsequently, the panel formulated recommendations for the management of severe TBI in children.

RESULTS

Fourteen evidence-based recommendations have been devised for the management of severe TBI in children, covering nine topics, including imaging studies, neuromonitoring, prophylactic anticonvulsant use, hyperosmolar therapy, sedation and analgesia, mechanical ventilation strategies, nutritional therapy, blood transfusion, and decompressive craniectomy. For each topic, the panel provided clinical recommendations and identified research priorities.

CONCLUSIONS

This review offers evidence-based strategies aimed to guide practitioners in the care of children who suffer from severe TBI.

Development and Validation of a Neuro-Intensive Care Protocol for Traumatic Brain Injury Management

Introduction Traumatic brain injury (TBI) is a global public health concern with high mortality and disability rates, particularly among younger populations. Structured treatment protocols might improve outcomes and reduce mortality. This study aims to develop and validate the Neuro-Intensive Care Protocol for TBI (NICP-TBI) using the Medical Research Council framework for designing and evaluating complex interventions. Methods The protocol was developed using a systematic literature review, expert consensus, and validation. A 15-member multidisciplinary expert consensus group used the Delphi consensus method to refine the protocol, achieving a consensus threshold of 80%. Validation involved a seven-member expert group evaluating the protocol's relevance, clarity, comprehensiveness, and appropriateness using a five-point Likert scale. The Content Validity Index (CVI) was calculated. Results The NICP-TBI incorporated interventions from clinical practice guidelines and evidence-based protocols. It established clear treatment goals and interventions for each parameter concerned such as airway, ventilation, systemic and cerebral perfusion, intracranial pressure (ICP), sedation, seizure prophylaxis, fluid management, nutrition, infection prophylaxis, temperature management, venous thromboembolism (VTE), blood glucose management, positioning, tapering treatment and family involvement in care. The protocol used a tiered structure adaptable to resource-limited settings. The Delphi process reached a 99.2% final consensus after five rounds, and the CVI was determined to be 1, confirming high validity. Conclusions The NICP-TBI provides a structured, evidence-based framework for managing moderate and severe TBI. The protocol's consensus-driven development, tiered approach in management, and expert validation ensure its applicability across diverse clinical settings, including resource-limited environments. This study highlights the importance of expert consensus and validation in developing effective critical care protocols.

Evaluating the Impact of Point-of-Care Electroencephalography on Length of Stay in the Intensive Care Unit: Subanalysis of the SAFER-EEG Trial

BACKGROUND

Electroencephalography (EEG) is needed to diagnose nonconvulsive seizures. Prolonged nonconvulsive seizures are associated with neuronal injuries and deleterious clinical outcomes. However, it is uncertain whether the rapid identification of these seizures using point-of-care EEG (POC-EEG) can have a positive impact on clinical outcomes.

METHODS

In a retrospective subanalysis of the recently completed multicenter Seizure Assessment and Forecasting with Efficient Rapid-EEG (SAFER-EEG) trial, we compared intensive care unit (ICU) length of stay (LOS), unfavorable functional outcome (modified Rankin Scale score ≥ 4), and time to EEG between adult patients receiving a US Food and Drug Administration-cleared POC-EEG (Ceribell, Inc.) and those receiving conventional EEG (conv-EEG). Patient records from January 2018 to June 2022 at three different academic centers were reviewed, focusing on EEG timing and clinical outcomes. Propensity score matching was applied using key clinical covariates to control for confounders. Medians and interquartile ranges (IQRs) were calculated for descriptive statistics. Nonparametric tests (Mann-Whitney U-test) were used for the continuous variables, and the χ2 test was used for the proportions.

RESULTS

A total of 283 ICU patients (62 conv-EEG, 221 POC-EEG) were included. The two populations were matched using demographic and clinical characteristics. We found that the ICU LOS was significantly shorter in the POC-EEG cohort compared to the conv-EEG cohort (3.9 [IQR 1.9-8.8] vs. 8.0 [IQR 3.0-16.0] days, p = 0.003). Moreover, modified Rankin Scale functional outcomes were also different between the two EEG cohorts (p = 0.047).

CONCLUSIONS

This study reveals a significant association between early POC-EEG detection of nonconvulsive seizures and decreased ICU LOS. The POC-EEG differed from conv-EEG, demonstrating better functional outcomes compared with the latter in a matched analysis. These findings corroborate previous research advocating the benefit of early diagnosis of nonconvulsive seizure. The causal relationship between the type of EEG and metrics of interest, such as ICU LOS and functional/clinical outcomes, needs to be confirmed in future prospective randomized studies.

Low-Cost Strategies for the Development of Neurocritical Care in Resource-Limited Settings

This review explores low-cost neurocritical care interventions for resource-limited settings, including economical devices, innovative care models, and disease-specific strategies. Devices like inexpensive ventilators, wearable technology, smartphone-based ultrasound, brain4care, transcranial Doppler, and smartphone pupillometry offer effective diagnostic and monitoring capabilities. Initiatives such as intermediate care units, minimally equipped stroke units, and tele-neurocritical care have demonstrated benefits by reducing hospital stays, preventing complications, and improving clinical and economic outcomes. The review emphasizes locally applicable tailored approaches for diagnosing and managing conditions such as traumatic brain injury, neuroinfections, status epilepticus, autoimmune neurological disorders, and acute stroke as viable and affordable solutions.

Post-craniotomy intracranial pressure monitoring: a novel approach combining optic nerve sheath diameter ultrasonography and cervical-cerebral arterial ultrasound

Objective

Elevated intracranial pressure (ICP), a common complication in traumatic brain injuries (TBI), can lead to optic nerve sheath diameter (ONSD) enlargement and flow spectrum changes from the internal carotid artery (ICA) to middle cerebral artery (MCA). This study will investigate the use of Cervical-Cerebral Arterial Ultrasound (CCAU) for non-invasive ICP assessment and evaluating the related indices' clinical utility in TBI patients with decompressive craniotomy (DC).

Methods

ONSD and flow spectrum changes were measured within 24 h after DC in 106 patients via ultrasonic ONSD measurement and CCAU, simultaneously. Intracranial pressures were invasively monitored, using a microsensor or ventricular catheter as the gold standard. Patients were classified into two groups, namely the normal group and the elevated group, based on distinct intracranial pressure thresholds of 15 mmHg, 20 mmHg and 22 mmHg. Subsequently, Bland Altman plot used for evaluating agreement between estimate for ICP (ICPe) and invasive ICP (ICPi). Then, the correlation between ONSD, MCAPI (pulsatility index of MCA), PI-ratio (MCAPI/ICAPI), and ICPe was examined through linear regression analysis. Finally, receiver operator characteristic curves (ROC) were also analyzed for different indexes and their combinations (using logistic model).

Results

Significant differences were observed between the normal and elevated ICP groups with respect to ONSD, PI-ratio, MCAPI and MCAFVd (diastolic flow velocity of MCA) (p < 0.05). The correlation coefficients for the relationships between ONSD, PI ratio, FVdMCA, and PI with ICPi were 0.62, 0.33, 0.32 and 0.21, respectively, each demonstrating statistical significance (p < 0.05). Analysis of the ROC curves demonstrated that the area under the curve (AUC) for predicting elevated ICPi at thresholds of 15 mmHg, 20 mmHg, and 22 mmHg via combined ultrasonographic measurements of the PI ratio and ONSD was the largest, specifically 0.74 (95% CI: 0.65-0.82), 0.77 (95% CI: 0.69-0.85), and 0.79 (95% CI: 0.70-0.86), respectively.

Conclusion

Ultrasonographic measurements of ONSD, PI-ratio, MCAPI and MCAFVd demonstrate a moderate to low weak correlation with ICPi measurements. ICPe is not considered sufficiently precise for noninvasive accurate ICP assessment. The concurrent utilization of CCAU and ONSD measurements may offer superior accuracy for elevated ICP in TBI patients with DC, especially in specificity. Further research is imperative to validate these findings within a more extensive patient population.

An Overview of Adult Acute Traumatic Neurologic Injury for the Anesthesiologist: What is Known, What is New, and Emerging Concepts

Purpose of Review

We examine what is known, what is new, and what is emerging in acute neurotrauma relevant to the anesthesiologist.

Recent Findings

Timely and goal-directed care is critical for all patients requiring urgent/emergent anesthesia care. Anesthesia care for acute neurological injury should incorporate understanding the evolution of traumatic brain injury and spinal cord injury that translates to preoperative preparation, hemodynamic resuscitation, prevention of second insults, and safe transport between care settings. Anesthesia care should support optimizing patient outcomes.

Summary

Best practices involve extrapolating data from the intensive care unit setting since there is a lack of research addressing anesthesia care for acute neurological injury. There are opportunities to generate data to support evidence-based anesthetic care.

Standardized Outcomes for Randomized Controlled Trials Targeting Early Interventions in Patients With Moderate-to-Severe Traumatic Brain Injury: Protocol for the Development of a Core Outcome Set

BACKGROUND

: With more than 60 million new cases around the world each year, traumatic brain injury (TBI) causes substantial mortality and morbidity. Managing TBI is a major human, social, and economic concern. In the last 20 years, there has been an increase in clinical trials in neurocritical care, leading mostly to negative results. The evaluation of neurological outcomes, predominantly as primary outcomes, using clinical scales (Glasgow Outcome Scale) has limitations that could explain these results. Moreover, patient-centered outcomes are seldom reported despite their recognized clinical relevance.

OBJECTIVE

: The aim of this project is to establish a core outcome set (COS) for patients with moderate-to-severe TBI in randomized control trials in neurocritical care research.

METHODS

This study will follow five distinct steps: (1) systematic review to identify outcomes that have been reported in trials; (2) semistructured interviews with patients and their families to identify their priorities after TBI and explore potential patient-centered outcomes; (3) health care stakeholder focus groups with clinicians, researchers, and policy makers to describe potential outcomes; (4) an eDelphi survey with stakeholder groups to make a list of previously identified core outcomes; and (5) a consensus workshop to establish a COS for moderate-to-severe TBI clinical trials.

RESULTS

: The systematic review was published in August 2024. Regarding Step 2, 30 semistructured interviews of patients and relatives were performed from July 2021 to December 2023, and analyses were completed in October 2024. Step 3 is currently under development, and Step 4 is planned for the end of 2025. Step 5 is expected to occur during fall/winter 2026. Conclusions: Establishing a COS, to be consistently measured and reported in TBI trials in neurocritical care will ensure rigorous reporting, avoid bias, and improve the integrity, transparency, and usability of clinical research. The French context of the study is the main limitation, but we are seeking international collaboration on the project. The results of each step of the project will be disseminated through abstracts, publications, and patient associations.

CONCLUSIONS

Establishing a COS, to be consistently measured and reported in TBI trials in neurocritical care will ensure rigorous reporting, avoid bias, and improve the integrity, transparency, and usability of clinical research. The French context of the study is the main limitation, but we are seeking international collaboration on the project. The results of each step of the project will be disseminated through abstracts, publications, and patient associations.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54525.

Optical approaches for neurocritical care: Toward non-invasive recording of cerebral physiology in acute brain injury

Acute brain injury (ABI) is a complex disease process that begins with an initial insult followed by secondary injury resulting from disturbances in cerebral physiology. In the metabolically active brain, early recognition of physiologic derangements is critical in enabling clinicians with the insight to adjust therapeutic interventions and reduce risk of ischemia and permanent injury. Current established approaches for monitoring cerebral physiology include the neurologic physical examination, traditional brain imaging such as computed tomography (CT) and magnetic resonance imaging (MRI), electroencephalography (EEG), and bedside modalities such as invasive parenchymal probes and transcranial doppler ultrasound. Diffuse optical spectroscopy (DOS), diffuse correlation spectroscopy (DCS), and optical coherence tomography (OCT) are non-invasive optical techniques that have shown promise in measuring clinically relevant changes in cerebral physiology. These new modalities may offer clinicians significant benefits as they are safe, can be utilized at the point-of-care, and provide continuous measurements. This paper reviews major causes of primary and secondary ABI encountered in neurocritical care units, conventional measures of cerebral physiology during ABI, and emerging non-invasive optical techniques that have significant potential for translation to the bedside.

Evolving concepts in intracranial pressure monitoring - from traditional monitoring to precision medicine

A wide range of acute brain injuries, including both traumatic and non-traumatic causes, can result in elevated intracranial pressure (ICP), which in turn can cause further secondary injury to the brain, initiating a vicious cascade of propagating injury. Elevated ICP is therefore a neurological injury that requires intensive monitoring and time-sensitive interventions. Patients at high risk for developing elevated ICP undergo placement of invasive ICP monitors including external ventricular drains, intraparenchymal ICP monitors, and lumbar drains. These monitors all generate an ICP waveform, but each has its own unique caveats in monitoring and accuracy. Current ICP monitoring and management clinical guidelines focus on the mean ICP derived from the ICP waveform, with standard thresholds of treating ICP greater than 20 ​mmHg or 22 ​mmHg applied broadly to a wide range of patients. However, this one-size fits all approach has been criticized and there is a need to develop personalized, evidence-based and possibly multi-factorial precision-medicine based approaches to the problem. This paper provides historical and physiological context to the problem of elevated ICP, provides an overview of the challenges of the current paradigm of ICP management strategies, and discusses advances in ICP waveform analysis, emerging non-invasive ICP monitoring techniques, and applications of machine learning to create predictive algorithms.

The Brussels consensus for non-invasive ICP monitoring when invasive systems are not available in the care of TBI patients (the B-ICONIC consensus, recommendations, and management algorithm)

BACKGROUND

Invasive systems are commonly used for monitoring intracranial pressure (ICP) in traumatic brain injury (TBI) and are considered the gold standard. The availability of invasive ICP monitoring is heterogeneous, and in low- and middle-income settings, these systems are not routinely employed due to high cost or limited accessibility. The aim of this consensus was to develop recommendations to guide monitoring and ICP-driven therapies in TBI using non-invasive ICP (nICP) systems.

METHODS

A panel of 41 experts, that regularly use nICP systems for guiding TBI care, was established. Three scoping and four systematic reviews with meta-analysis were performed summarizing the current global-literature evidence. A modified Delphi method was applied for the development of recommendations. An in-person meeting with group discussions and voting was conducted. Strong recommendations were defined for an agreement of at least 85%. Weak recommendations were defined for an agreement of 75-85%.

RESULTS

A total of 34 recommendations were provided (32 Strong, 2 Weak) divided into three domains: general consideration for nICP use, management of ICP using nICP methods and thresholds of nICP tools for escalating/de-escalating treatment. We developed four clinical algorithms for escalating treatment and heatmaps for de-escalating treatment.

CONCLUSIONS

Using a mixed-method approach involving literature review and an in-person consensus by experts, a set of recommendations designed to assist clinicians managing TBI patients using nICP systems plus clinical assessment, in the presence or absence of brain imaging, were built. Further clinical studies are required to validate the potential use of these recommendations in the daily clinical practice.

Current Challenges in Neurocritical Care: A Narrative Review

Neurocritical care as a field aims to treat patients who are neurologically critically ill due to a variety of pathologies. As a recently developed subspecialty, the field faces challenges, several of which are outlined in this review. The authors discuss aneurysmal subarachnoid hemorrhage, status epilepticus, and traumatic brain injury as specific disease processes with opportunities for growth in diagnosis, management, and treatment, as well as disorders of consciousness that can arise as a result of many neurological injuries. They also address logistical challenges, such as the need for specialized resources needed to successfully run a neurosciences intensive care unit (neuro-ICU), the variations in training of those who staff neuro-ICUs, and different interdisciplinary team structures. Although an immense amount of data is collected in the neuro-ICU, leveraging the data for clinical research is an area with room for further innovation. Additionally, developing accurate basic science models for these disease processes is an ongoing area of exploration. Finally, the authors explore psychosocial challenges present in the care of neurologically critically ill patients, including limitations in prognostication and religious and cultural perceptions of brain death.

From intensive care monitors to cloud environments: a structured data pipeline for advanced clinical decision support

BACKGROUND

Clinical decision-making is increasingly shifting towards data-driven approaches and requires large databases to develop state-of-the-art algorithms for diagnosing, detecting and predicting diseases. The intensive care unit (ICU), a data-rich setting, faces challenges with high-frequency, unstructured monitor data. Here, we showcase a successful example of a data pipeline to efficiently move patient data to the cloud environment for structured storage. This supports individual patient analysis, enables largescale retrospective research, and the development of data-driven algorithms.

METHODS

Since June 2021, ICU data of the Amsterdam UMC have been collected and stored in a third-party cloud environment which is hosted on large virtual servers. The feasibility of the pipeline will be demonstrated with the available data through research and clinical use cases. Furthermore, privacy, safety, data quality, and environmental impact are carefully considered in the cloud storage transition.

FINDINGS

Over two years, data from over 9000 patients have been stored in the cloud. The availability, agility, computational power, high uptime, and streaming data pipelines allow for large retrospective analyses as well as the opportunity to implement real-time prediction of critical events with machine learning algorithms. Critical events can be accessed by applying keyword search in the natural language data, annotated by the treating team. Besides, the cloud environment offers storage of institutional data enabling evaluation of healthcare.

INTERPRETATION

The combined data and features of cloud environments offer support for predictive algorithm development and implementation, healthcare evaluation, and improved individual patient care.

FUNDING

University of Amsterdam Research Priority Agenda Program AI for Heath Decision-Making.

Cerebral compliance assessment from intracranial pressure waveform analysis: Is a positional shift-related increase in intracranial pressure predictable?

Real-time monitoring of intracranial pressure (ICP) is a routine part of neurocritical care in the management of brain injury. While mainly used to detect episodes of intracranial hypertension, the ICP signal is also indicative of the volume-pressure relationship within the cerebrospinal system, often referred to as intracranial compliance (ICC). Several ICP signal descriptors have been proposed in the literature as surrogates of ICC, but the possibilities of combining these are still unexplored. In the present study, a rapid ICC assessment consisting of a 30-degree postural shift was performed on a cohort of 54 brain-injured patients. 73 ICP signal features were calculated over the 20 minutes prior to the ICC test. After a selection step, different combinations of these features were provided as inputs to classification models. The goal was to predict the level of induced ICP elevation, which was categorized into three classes: less than 7 mmHg ("good ICC"), between 7 and 10 mmHg ("medium ICC"), and more than 10 mmHg ("poor ICC"). A logistic regression model fed with a combination of 5 ICP signal features discriminated the "poor ICC" class with an area under the receiving operator curve (AUROC) of 0.80 (95%-CI: [0.73-0.87]). The overall one-versus-one classification task was achieved with an averaged AUROC of 0.72 (95%-CI: [0.61-0.83]). Adding more features to the input set and/or using nonlinear machine learning algorithms did not significantly improve classification performance. This study highlights the potential value of analyzing the ICP signal independently to extract information about ICC status. At the patient's bedside, such univariate signal analysis could be implemented without dependence on a specific setup.

Unravelling Secondary Brain Injury: Insights from a Human-Sized Porcine Model of Acute Subdural Haematoma

Traumatic brain injury (TBI) remains one of the leading causes of death. Because of the individual nature of the trauma (brain, circumstances and forces), humans experience individual TBIs. This makes it difficult to generalise therapies. Clinical management issues such as whether intracranial pressure (ICP), cerebral perfusion pressure (CPP) or decompressive craniectomy improve patient outcome remain partly unanswered. Experimental drug approaches for the treatment of secondary brain injury (SBI) have not found clinical application. The complex, cellular and molecular pathways of SBI remain incompletely understood, and there are insufficient experimental (animal) models that reflect the pathophysiology of human TBI to develop translational therapeutic approaches. Therefore, we investigated different injury patterns after acute subdural hematoma (ASDH) as TBI in a post-hoc approach to assess the impact on SBI in a long-term, human-sized porcine TBI animal model. Post-mortem brain tissue analysis, after ASDH, bilateral ICP, CPP, cerebral oxygenation and temperature monitoring, and biomarker analysis were performed. Extracerebral, intraparenchymal-extraventricular and intraventricular blood, combined with brainstem and basal ganglia injury, influenced the experiment and its outcome. Basal ganglia injury affects the duration of the experiment. Recognition of these different injury patterns is important for translational interpretation of results in this animal model of SBI after TBI.

Managing Intracranial Pressure Crisis

PURPOSE OF REVIEW

The objective of this review is to provide a comprehensive management protocol for the treatment of intracranial pressure (ICP) crises based on the latest evidence.

RECENT FINDINGS

The review discusses updated information on various aspects of critical care management in patients experiencing ICP crises, including mechanical ventilation, fluid therapy, hemoglobin targets, and hypertonic saline infusion, the advantages of ICP monitoring, the critical ICP threshold, and bedside neuromonitoring. All aspects of critical care treatment, including hemodynamic and respiratory support and adjustment of ICP reduction therapy, may impact patient outcomes. ICP monitoring allows ICP values, trends, waveforms, and CPP calculation, which are helpful to guide patient care. Advanced neuromonitoring devices are available at the bedside to diagnose impaired intracranial compliance and intracranial hypertension, assess brain function, and optimize cerebral perfusion. Future research should focus on developing appropriate intervention protocols for both invasive and noninvasive neuromonitoring in managing ICP crisis patients.

Brain health: A concern for anaesthesiologists and intensivists

Damage to the brain can have disastrous and long-lasting consequences. The European Society of Anaesthesiology and Intensive Care (ESAIC) is aware of the importance of taking good care of the brain, both of patients and of anaesthesia and intensive care unit (ICU) caregivers, and has organised a complete learning track on brain health to bring this concern to the attention of practitioners. This learning track included an online Focus Meeting on Brain Health (November 25, 2023). We here provide readers with a digest of the information that was delivered during that meeting in an opinion paper driven by the authors' own reading of the literature. It is divided according to the meeting's sessions, including how to improve the health of an injured brain, how to keep a young or old brain healthy, how to keep a healthy adult brain unimpaired, how monitoring can impact brain health in the operating room and in the intensive care unit, and how to keep the anaesthesia and ICU caregivers' brain healthy. Each part is a brief and focused summary. The main delivered messages are that the management of injured brain patients involves an adequate choice of sedation, adequate brain monitoring, and focused attention to specific points depending on the underlying pathology; that several measures can be undertaken to protect the brain of the very young needing anaesthesia; that it is possible to detect older patients at risk of postoperative neurocognitive disorders, and that dedicated perioperative management by a multidisciplinary expert team may improve their outcomes; that apparently healthy adult brains may suffer during anaesthesia; that the electroencephalogram may track peri-operative brain dysfunction, and that female patients should be given special care in this respect; that multimodal brain monitoring helps to detect pathological processes and to maintain brain homeostasis; and that burnout in anaesthesiologists can be effectively fought using personal, organisational, managerial and legal approaches.

Impact of early follow-up CT in the conservative management of traumatic brain injury on surgical decision making: A retrospective, single-center analysis with special respect to coagulopathy

INTRODUCTION

Initial management of traumatic brain injury (TBI) without immediate need for surgical therapy varies across centers. The additional value of routine repeat cranial computerized tomography (CT) to neurological monitoring is controversial. This retrospective study investigates the impact of routine follow-up CT after 6 h (CT6h) in initially conservatively managed TBI on surgical decision making. Furthermore, the impact of coagulopathy on lesion size and progression was examined.

METHODS

We reviewed charts of patients admitted to our clinic in the time between 1st January 2020 and 30th June 2022 for the ICD10 diagnosis S06.3 (traumatic brain contusion), S06.4 (epidural hematoma), S06.5 (subdural hematoma), and S06.6 (traumatic subarachnoid hemorrhage). Baseline characteristics as well as timing, reason, and consequences of first and second cranial CT, clinical course, lesion size at first and second CT as well as presence and type of coagulopathy (standard laboratory testing and prior medical history) were noted among others. Significance testing was carried out using Student's t-test. The significance level was set to p < 0.005.

RESULTS

A total of 213 patients were included, 78 were operated after first CT, 123 underwent clinical and imaging surveillance, and 12 patients were not treated. CT6h did not anticipate imminent neurological deterioration. Early secondary deteriorating patients (9/123, 7.3%) did so before 6 h after admission clustering between 3 and 4 h (6/9, 66.7%). CT6h changed surgical decision making in one case (1/114, < 1%). Nine out of 106 (8.5%) patients managed conservatively after CT6h showed a late secondary clinical deterioration or failure of conservative treatment, eight out of which had stable size of hemorrhage in CT6h. There was no significant difference in lesion size at first CT related to the presence of coagulopathy, antiplatelet agents, or anticoagulant drugs for SDH or contusions. In patients with radiological progression of SDH in combined brain injury (CBI), coagulopathy was associated with a higher increase of lesion size (diameter increase > 6 mm: 11.1% with vs. 2.8% without coagulopathy). This effect was not observed for contusions in CBI (volume increase > 6 ml: 17.4% with vs. 22.7% without coagulopathy).

CONCLUSION

Early routine follow-up CT does neither anticipate imminent neurological deterioration nor impact surgical decision making. A substantial number of patients with initially stable follow-up imaging need delayed surgery due to conservative treatment failure. If patients can be monitored clinically, surgical decision making depends on clinical status. Patients with coagulopathy do not present with larger lesions, but show a higher ratio of drastic increase in SDH in contrast to contusions.

A Comprehensive Perspective on Intracranial Pressure Monitoring and Individualized Management in Neurocritical Care: Results of a Survey with Global Experts

BACKGROUND

Numerous trials have addressed intracranial pressure (ICP) management in neurocritical care. However, identifying its harmful thresholds and controlling ICP remain challenging in terms of improving outcomes. Evidence suggests that an individualized approach is necessary for establishing tolerance limits for ICP, incorporating factors such as ICP waveform (ICPW) or pulse morphology along with additional data provided by other invasive (e.g., brain oximetry) and noninvasive monitoring (NIM) methods (e.g., transcranial Doppler, optic nerve sheath diameter ultrasound, and pupillometry). This study aims to assess current ICP monitoring practices among experienced clinicians and explore whether guidelines should incorporate ancillary parameters from NIM and ICPW in future updates.

METHODS

We conducted a survey among experienced professionals involved in researching and managing patients with severe injury across low-middle-income countries (LMICs) and high-income countries (HICs). We sought their insights on ICP monitoring, particularly focusing on the impact of NIM and ICPW in various clinical scenarios.

RESULTS

From October to December 2023, 109 professionals from the Americas and Europe participated in the survey, evenly distributed between LMIC and HIC. When ICP ranged from 22 to 25 mm Hg, 62.3% of respondents were open to considering additional information, such as ICPW and other monitoring techniques, before adjusting therapy intensity levels. Moreover, 77% of respondents were inclined to reassess patients with ICP in the 18-22 mm Hg range, potentially escalating therapy intensity levels with the support of ICPW and NIM. Differences emerged between LMIC and HIC participants, with more LMIC respondents preferring arterial blood pressure transducer leveling at the heart and endorsing the use of NIM techniques and ICPW as ancillary information.

CONCLUSIONS

Experienced clinicians tend to personalize ICP management, emphasizing the importance of considering various monitoring techniques. ICPW and noninvasive techniques, particularly in LMIC settings, warrant further exploration and could potentially enhance individualized patient care. The study suggests updating guidelines to include these additional components for a more personalized approach to ICP management.

Intraoperative Intracranial Pressure Monitoring as an Intraoperative Guide During Operations for Relieving Elevated Intracranial Pressure

BACKGROUND

Intracranial pressure (ICP) is a well-established measure in managing not only traumatic brain injury but also nontraumatic intracranial bleeding or edema. When ICP increases despite nursing or medical management, ICP may be reduced via surgical measures. Deciding whether to perform a craniotomy vs. craniectomy (whether the bone flap is replaced or not, respectively) is commonly made intraoperatively following preoperative planning. While ICP monitoring (ICPm) is standard pre- and postoperatively, its intraoperative utility remains understudied.

METHODS

We conducted a study utilizing prospectively gathered and retrospectively analyzed data from 25 traumatic brain injury surgical decompression cases at a single center. All cases had intraoperative ICPm throughout surgery.

RESULTS

Our findings indicate that ICPm significantly influenced real-time intraoperative decision-making, diverging from preoperative.

CONCLUSIONS

These results bring forward the potential pivotal role of intraoperative ICPm in guiding surgical strategies for elevated ICP, suggesting a novel data-driven approach to intraoperative management of decompression surgery.

Marital Stability During the Year After Traumatic Brain Injury in an Ecuadorian Sample: A Repeated-Measures Study

Background: Traumatic brain injury (TBI) is a major cause of death and disability worldwide and often leads to long-lasting emotional, physical, and cognitive changes and results in reduced functioning across multiple domains. These changes often lead to strain in marital relationships as the uninjured spouse grapples with adapting to the changes in their partner. Aims: The purpose of this study was to examine the probability of marital stability after TBI at 6 and 12 months following injury (i.e., probability trajectory across those two time points), as well as predictors of that probability trajectory. Methods: The study design was repeated-measures and observational. Patient recruitment and follow-up took place from January 2018 to March 2020 in Quito, Ecuador. Ninety-seven TBI survivors were recruited while hospitalized in the neurosurgery unit of Hospital Eugenio Espejo, a tertiary care center. Patients were assessed at 6 and 12 months after their injury. Hierarchical linear modeling (HLM) was used to examine baseline predictors of linear marital probability trajectories across 6 and 12 months after injury. A final set of HLMs included each of the previously significant predictors from the first model, time, and the interaction terms between time and the previously significant predictor. Results: The first HLM found that marital probability remained stable between 6 and 12 months after TBI. Individuals who were employed at baseline had higher marital probability trajectories than those who had been unemployed. Older individuals had higher marital probability trajectories than younger individuals, and women had higher marital probability trajectories than men. Conclusions: This is the first study to examine marital probability trajectories for an Ecuadorian adult population with TBI, and the data are of great value to understanding post-TBI outcomes in the region. These results can inform interventions and support systems to bolster marital resilience in the aftermath of TBI. Further research is warranted to explore the nuances of these relationships and to validate these findings in diverse populations.

The impact of age and intensity of treatment on the outcome of traumatic brain injury

Background

Approximately one-third of trauma-related deaths are due to traumatic brain injury (TBI), particularly among young adults and elderly patients. Management strategies may vary across different age groups, potentially influencing short-term neurological outcomes. This study aims to investigate age-related disparities in treatment approaches and 3-month neurological outcomes among TBI patients.

Methods

We conducted a retrospective study on TBI patients requiring Intensive Care Unit (ICU) admission from January 1, 2015, to January 1, 2024, in a tertiary University hospital. Patient demographics, major comorbidities, ICU admission parameters, interventions and ICU complications were collected. An unfavorable neurological outcome at 3 months (UO) was defined as a Glasgow Outcome Scale (GOS) score of 1-3. A high therapy intensity level (TIL) was defined as a TIL basic of 3-4. A multivariable logistic regression model and a Cox proportional Hazard Regression model were used to assess the association of age and TIL with neurological outcome and mortality. A sensitivity analysis on low TIL (0-2) and high TIL subgroups was also conducted.

Results

We enrolled 604 TBI patients, of which 240 (40%) had UO. The highest prevalence of UO was found in patients aged ≥80 years (53/94, 56%), followed by patients aged 50-79 years (104/255, 41%). The age group 35-49 years had the lowest rate of UO (38/127, 30%). Older patients (age ≥ 80 years) received less frequently high TIL than others (p = 0.03). In the multivariable analysis, age ≥ 80 years [OR: 3.42 (95% CI 1.72-6.81)] was independently associated with UO, while age ≥ 80 years [HR 5.42 (95% CI 3.00-9.79)] and age 50-79 years [HR 2.03, (95% CI 1.19-3.48)] were independently associated with mortality. Although there was no interaction between age groups and TIL on outcome, an exploratory analysis showed that in the high TIL subgroup of patients, age had no independent impact on the outcome, whereas, in the low TIL group, age ≥ 80 years was independently associated with UO [OR: 3.65 (95% CI: 1.64-8.14)].

Conclusion

Older age, especially in the setting of low intensity treatment, may impact short-term neurological outcome of traumatic brain-injured patients.

Initial experience with a state-of-the-art mobile head CT scanner for use in neurointensive care units

OBJECTIVE

Mobile head computed tomography (CT) scanners can reduce transport-related complications in neurointensive care unit (NICU) patients and decrease the burden on NICU staff; however, the initial investment cost and reduced image quality of early mobile scanners have prevented their widespread clinical use. Here, we report our initial experience with a novel 32-row mobile CT scanner for use in NICUs.

METHODS

Over a 2-year period, 107 patients received a mobile head CT scan. The technical characteristics of the scanner and the organizational procedures are described in detail. Patient characteristics were retrospectively collected and image quality was subjectively evaluated on a Likert scale ranging from 0 to 5 and compared with a stationary CT scanner.

RESULTS

Mobile head CT was used for follow-up of intracranial hemorrhage in 51%, routine postoperative imaging in 28%, evaluation of neurological deterioration in 14%, bedside monitoring after external ventricular drain placement in 4%, and follow-up of ischemic stroke in 3% of cases. Diagnostic imaging quality was achieved in all cases, eliminating the need for stationary CT scanning. The overall image quality of mobile CT (median 4 points) was inferior to that of conventional stationary CT (median 5 points, p < 0.01), but was rated with 4 or 5 points in the majority of cases.

CONCLUSIONS

State-of-the-art mobile CT was found to be easy to use and maneuver and has the potential to expedite the diagnosis of NICU patients and reduce staff workload. Image quality was adequate for common NICU issues.

Traumatic brain injury in companion animals: Pathophysiology and treatment

Traumatic brain injuries (TBI) are common in dogs and cats that have sustained head trauma from a variety of causes. In moderate to severe TBI, damage from both the primary and secondary injuries can be life-threatening. TBI management may be further complicated by concurrent injuries in polytrauma patients. Thorough initial and serial examinations are key in detecting neurologic changes quickly and guiding treatment. Intensive treatments such as nursing care, fluid therapy, hyperosmolar agents, analgesia, sedation, anticonvulsants, oxygen supplementation, surgery, and rehabilitation may be employed in TBI management. Prognostication resources for an individual patient are limited and a perceived poor prognosis may worsen clinical outcomes. In this paper, we review the pathophysiology of TBI, identification, injury stratification and prognosis of patients with TBI as well as propose treatment and monitoring recommendations for companion animals based on severity of TBI.

Assessment of traumatic brain injury treatment guided by continuous monitoring of intracranial pressure and brain tissue oxygen partial pressure: A single-center pilot study

Severe traumatic brain injury (TBI) is a leading cause of death and disability. Monitoring intracranial pressure (ICP) is recommended, but the data on the outcomes are conflicting. Adding continuous brain tissue oxygen partial pressure (PbtO2) monitoring may have some benefit but the OXY-TC suggested it did not improve 6-month neurological outcomes. This single-center pilot randomized controlled study aimed to evaluate whether adding PbtO2 monitoring was feasible and could improve the prognosis of severe TBI. The participants were randomized into either an ICP alone or an ICP + PbtO2 group for 7 days, with treatment protocols based on existing guidelines. Clinical parameters were collected hourly. The primary outcome was the feasibility of using PbtO2 monitoring. The secondary outcomes were 6-month survival, analyzed by the log-rank test, the 3- and 6-month Glasgow Outcome Scale (GOS) scores, compared between groups by chi-squared test. Seventy patients were included (36 ICP, 34 ICP + PbtO2). The ICP + PbtO2 group had lower mean daily ICP (13.4 vs. 18.2 mmHg, P = 0.0024) and higher mean daily cerebral perfusion pressure (82.1 vs. 74.5 mmHg, P = 0.0055). The ICP + PbtO2 group had higher 6-month survival (79.4 % vs. 55.6 %, P = 0.0337) and more favorable outcomes at 3 months (67.6 % vs. 38.9 %, P = 0.0160) and 6 months (70.6 % vs. 41.7 %, P = 0.0149). Adding PbtO2 monitoring to ICP monitoring is feasible in patients with severe TBI and could maybe improve the intermediate-term outcomes. The results will serve to design larger trials.

Intracranial pressure monitoring and treatment practices in severe traumatic brain injury between low-and middle-income countries and high-income countries: Data or dogma?

Background

Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. Intracranial pressure (ICP) monitoring forms the cornerstone of most severe TBI (sTBI) management guidelines, yet treatment practices vary between high income countries (HIC) and low/middle-income countries (LMICs). We sought to find the reasons for variation in ICP monitoring and treatment practices between neurosurgeons in low- and high-income countries.

Methods

We developed a 34-item anonymous survey questionnaire on ICP monitoring and treatments, which was emailed to neurosurgeons of various neurosurgical societies (Africa, Asia, Europe, and North America) who manage TBI.

Results

One hundred and six respondents from 23 countries completed the questionnaire. Sixty-nine were from Africa, 16 were from North America, 12 were from Western Europe, and 8 were from Asia. About 48.72% of respondents from LMICs versus 96.43% from HICs have had training on ICP use. Among practitioners who monitor ICP invasively in <50% of patients that need it, 41.6% and 37.5% from LMIC cited availability and cost as the major constraints, versus 3.3% and 6.67%, respectively, in HIC. Only 7 (8.97%) from LMIC follow Brain Trauma Foundation guidelines all the time compared to 17.86% from HIC. When asked about their knowledge of randomized controlled trial(RCT), 78.57% of respondents from HIC versus 11.54% from LMIC knew about RCTs that tested the role of ICP monitoring in sTBI.

Conclusion

Significant differences exist in ICP monitoring and treatment in patients with sTBI between high and LMICs. Cost and availability are the main determinants of ICP monitor usage. Practice pattern among the respondents was not completely supported by evidence.

Impact of Intracranial Pressure and Invasive Cerebral Oxygenation Monitoring in Patients with Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Intracranial pressure (ICP) monitoring and monitoring of brain tissue oxygen (Pbto2) in addition to ICP have been used in the management of traumatic brain injury (TBI). However, the optimal monitoring method is inconclusive. We searched 4 databases with no language restrictions through January 2024 for peer-reviewed randomized controlled trials (RCTs) comparing ICP monitoring with combined Pbto2 and ICP monitoring in patients with traumatic brain injury. A favorable neurologic outcome was the primary outcome, and the secondary outcome was survival. Two reviewers screened manuscripts, extracted data, and assessed the risk of bias. We then performed a meta-analysis to assess efficacy using the Grading of Recommendations, Assessment, Development, and Evaluation working group approach. We included 5 trials comprising 512 patients. There was no difference in favorable neurologic outcome (risk ratio: 1.21; 95% confidence interval: 0.93, 1.58; I2: 45%; 5 RCTs: 512 patients; moderate certainty) and survival (risk ratio: 1.10; 95% confidence interval: 0.99, 1.21; I2: 13%; 5 RCTs: 512 patients; moderate certainty). We found no evidence that the combination of Pbto2 and ICP is more useful than ICP. The included RCTs are few and small, and further study is needed to draw conclusions.

How to Define and Meet Blood Pressure Targets After Traumatic Brain Injury: A Narrative Review

BACKGROUND

Traumatic brain injury (TBI) poses a significant challenge to healthcare providers, necessitating meticulous management of hemodynamic parameters to optimize patient outcomes. This article delves into the critical task of defining and meeting continuous arterial blood pressure (ABP) and cerebral perfusion pressure (CPP) targets in the context of severe TBI in neurocritical care settings.

METHODS

We narratively reviewed existing literature, clinical guidelines, and emerging technologies to propose a comprehensive approach that integrates real-time monitoring, individualized cerebral perfusion target setting, and dynamic interventions.

RESULTS

Our findings emphasize the need for personalized hemodynamic management, considering the heterogeneity of patients with TBI and the evolving nature of their condition. We describe the latest advancements in monitoring technologies, such as autoregulation-guided ABP/CPP treatment, which enable a more nuanced understanding of cerebral perfusion dynamics. By incorporating these tools into a proactive monitoring strategy, clinicians can tailor interventions to optimize ABP/CPP and mitigate secondary brain injury.

DISCUSSION

Challenges in this field include the lack of standardized protocols for interpreting multimodal neuromonitoring data, potential variability in clinical decision-making, understanding the role of cardiac output, and the need for specialized expertise and customized software to have individualized ABP/CPP targets regularly available. The patient outcome benefit of monitoring-guided ABP/CPP target definitions still needs to be proven in patients with TBI.

CONCLUSIONS

We recommend that the TBI community take proactive steps to translate the potential benefits of personalized ABP/CPP targets, which have been implemented in certain centers, into a standardized and clinically validated reality through randomized controlled trials.

Clinical Capacity Building Through Partnerships: Boots on the Ground in Global Neurosurgery

Global neurosurgery seeks to provide quality neurosurgical health care worldwide and faces challenges because of historical, socioeconomic, and political factors. To address the shortfall of essential neurosurgical procedures worldwide, dyads between established neurosurgical and developing centers have been established. Concerns have been raised about their effectiveness and ability to sustain capacity development. Successful partnerships involve multiple stakeholders, extended timelines, and twinning programs. This article outlines current initiatives and challenges within the neurosurgical community. This narrative review aims to provide a practical tool for colleagues embarking on clinical partnerships, the Engagements and assets, Capacity, Operative autonomy, Sustainability, and scalability (ECOSystem) of care. To create the ECOSystem of care in global neurosurgery, the authors had multiple online discussions regarding important points in the practical tool. All developed tiers were expanded based on logistics, clinical, and educational aspects. An online search was performed from August to November 2023 to highlight global neurosurgery partnerships and link them to tiers of the ECOSystem. The ECOSystem of care involves 5 tiers: Tiers 0 (foundation), 1 (essential), 2 (complexity), 3 (autonomy), and 4 (final). A nonexhaustive list of 16 neurosurgical partnerships was created and serves as a reference for using the ECOSystem. Personal experiences from the authors through their partnerships were also captured. We propose a tiered approach for capacity building that provides structured guidance for establishing neurosurgical partnerships with the ECOSystem of care. Clinical partnerships in global neurosurgery aim to build autonomy, enabling independent provision of quality healthcare services.

NK1 tachykinin receptor antagonist treatment reduces cerebral edema and intracranial pressure in an ovine model of ischemic stroke

Following ischemic stroke, substance P (SP)-mediated neurogenic inflammation is associated with profound blood-brain barrier (BBB) dysfunction, cerebral edema, and elevated intracranial pressure (ICP). SP elicits its effects by binding the neurokinin 1 tachykinin receptor (NK1-R), with administration of an NK1-R antagonist shown to ameliorate BBB dysfunction and cerebral edema in rodent and permanent ovine stroke models. Given the importance of reperfusion in clinical stroke, this study examined the efficacy of NK1-R antagonist treatment in reducing cerebral edema and ICP in an ovine model of transient middle cerebral artery occlusion (tMCAo). Anesthetized sheep (n = 24) were subject to 2-hours tMCAo and randomized (n = 6/group) to receive early NK1-R treatment (days 1-3 post-stroke), delayed NK1-R treatment (day 5 post-stroke), or saline vehicle. At 6-days post-stroke animals were re-anaesthetized and ICP measured, followed by MRI to evaluate infarction, edema and BBB dysfunction. Following both early and delayed NK1-R antagonist administration, ICP was significantly reduced on day 6 compared to vehicle animals (p < 0.05), accompanied by a reduction in cerebral edema, midline shift and BBB dysfunction (p < 0.05). This study demonstrates that NK1-R antagonist treatment is an effective novel therapy for cerebral edema and elevated ICP following stroke in an ovine model, warranting future clinical evaluation.