Intracranial pressure monitoring in patients with severe head injury

The study objective is to evaluate the effectiveness of intracranial pressure (ICP) monitoring in patients with severe head injury in a multispecialty hospital.

Materials and methods. A retrospective study included 2343 patients who underwent surgical treatment at the N. V. Sklifosovsky Research Institute of Emergency Medicine between 2012 and 2018. Patients admitted in atonic coma, who died in the space of 48 hours after hospitalization, with intracranial hematoma volume >200 cm3, and older than 65 years were excluded. Additionally, results of conservative therapy in 69 patients with severe cerebral contusion were included. ICP monitoring was performed in 249 patients (22.5 % of all patients who underwent surgery with indications for monitoring and no counterindications). A binary logistic regression model included age, sex, type of intracranial injury, depression of consciousness severity at admittance as variables. For treatment outcomes, odds ratio (OR) with 95 % confidence interval and p <0.05 were calculated.

Results. Postoperative mortality among patients without ICP monitoring was 64.6 %, among patients with ICP monitoring — 51.2 %. Probability of death in the patient group without ICP was somewhat higher than among patients who underwent ICP (odds ratio (OR) 1.74; 95 % confidence interval (CI) 1.31—2.34). No significant differences were observed in outcomes between patients with or without ICP monitoring for level of consciousness of 4—6 points per the Glasgow Coma Scale (OR 1.01; 95 % CI 0.43—2.37). Among patients with 7—8 points per the Glasgow Coma Scale, outcomes were significantly better among patients who underwent ICP monitoring (OR 1.65; 95 % CI 1.23—2.20). In patients with acute epidural hematomas (AEH), time to death was significantly different: in patients with 7—8points per the Glasgow Scale it was 15 days, with ICP monitoring 52 days; for patients with 4—6points it was 7 and 39 days, respectively. Among patients with multiple hematomas who underwent surgery in moderate coma, outcomes of surgical treatment were a little better with ICP monitoring (OR 1.82; 95 % CI 1.09—3.41). Time to death was significantly different: in patients without ICP monitoring it was 16 days, in patients with ICP monitoring it was 29 days. In patients with microfocal cerebral contusions, probability of death with ICP monitoring was 40 % lower than among patients without ICP monitoring (OR 1.43; 95 % CI 1.01—3.12). Per our data, invasive ICP monitoring is an independent predictor of infectious complications in the postoperative period (OR 1.39; 95 % CI 1.17—3.19). On day 1 after intracranial hemorrhage, hyperosmotic solutions were used in 35 % of patients who underwent ICP monitoring, and in 19 % of patients without ICP measurement (p < 0.05).

Conclusion. ICP monitoring does not decrease postoperative mortality and does not improve outcomes in patients with epidural and subdural hematomas. In these patients, ICP control significantly increases time to death. ICP monitoring significantly decreases postoperative mortality in patients with intracranial hematomas and cerebral contusions. ICP monitoring is effective in patients with consciousness levels of moderate coma and above. ICP control allows to accurately diagnose intracranial hypertension and perform targeted therapy. In the absence of ICP monitoring, hyperosmotic solutions are used empirically or for increased negative neurological symptoms.

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