What are the advantages and disadvantages of Intracranial Pressure (ICP) monitoring in Acute Brain Injury?

From the Guidelines

Intracranial pressure (ICP) monitoring in acute brain injury is recommended for patients with severe traumatic brain injury (GCS ≤8) with abnormal CT findings or those at high risk for developing intracranial hypertension, despite carrying significant risks such as hemorrhage and infection. The primary advantage of ICP monitoring is that it provides real-time data on intracranial pressure, allowing clinicians to detect dangerous elevations early and guide therapeutic interventions before secondary brain injury occurs, as noted in the guidelines for the management of spontaneous intracerebral hemorrhage 1. This monitoring helps optimize cerebral perfusion pressure, evaluate treatment effectiveness, and allows for individualized management rather than empiric therapies. Additionally, it can reduce unnecessary treatments in patients with normal ICP values. However, ICP monitoring has several disadvantages including the invasive nature of placement which carries risks of hemorrhage (1-2%), infection (approximately 5-10%), and malfunction, as reported in a series of 108 intraparenchymal devices 1. The external ventricular drain (EVD) approach, while allowing CSF drainage as a treatment, has higher infection rates compared to parenchymal monitors. Some key points to consider when deciding to use ICP monitoring include:

• The patient's coagulation status should be evaluated before insertion of a monitoring device, and prior use of antiplatelet agents may justify platelet transfusion before the procedure 1.
• The decision to use a VC or a parenchymal catheter device should be based on whether there is a need to drain CSF to treat hydrocephalus or elevated ICP 1.
• ICP treatment is important and is best guided by ICP monitoring, clinical imaging, and clinical evaluation used in combination and in the context of a structured protocol, as emphasized by the international multidisciplinary consensus conference on multimodality monitoring in neurocritical care 1. It is essential to weigh the benefits and risks of ICP monitoring and to consider the individual patient's needs and circumstances when making a decision, as the absence of published studies showing that management of elevated ICP has an effect on ICH outcome makes the decision whether to monitor and treat elevated ICP unclear in patients with ICH 1.

From the Research

Advantages of ICP Monitoring in Acute Brain Injury

• ICP monitoring can help detect intracranial mass lesions early and guide therapeutic interventions 2
• It can assess prognosis and is recommended by consensus guidelines for head injury management 2
• ICP monitoring is associated with lower 6-month mortality in patients with severe traumatic brain injury 3, 4
• It can help identify patients with increased intracranial pressure and guide treatment to reduce mortality 5, 3
• ICP monitoring can provide additional information from identification and analysis of pathologic ICP wave forms 2

Disadvantages of ICP Monitoring in Acute Brain Injury

• There is considerable variability in the use of ICP monitoring and treatment modalities among head injury centers 2
• The evidence suggesting benefit of ICP monitoring is limited, and there is a need for a prospective, randomized, controlled trial to identify its value 2, 4
• ICP monitoring is not suitable for all patients, and its use should be considered on a case-by-case basis 5, 6
• The prevalence of ICP monitoring in moderate traumatic brain injury is low, and the prevalence of intracranial hypertension is high among patients undergoing ICP monitoring 6
• ICP monitoring may not be associated with improved outcomes in all patients, and its use should be guided by clinical judgment and evidence-based guidelines 3, 4

Factors Associated with ICP Monitoring

• Glasgow Coma Scale (GCS) score: patients with lower GCS scores may be more likely to undergo ICP monitoring 6
• Severity of traumatic brain injury: patients with severe TBI may be more likely to undergo ICP monitoring 3, 4
• Institutional practices: hospitals with higher rates of ICP monitoring use may be associated with lower mortality 4