Is intraparenchymal (Intracranial Pressure) ICP monitoring indicated in traumatic brain injury without space-occupying lesions and a Glasgow Coma Scale (GCS) score of 9 at arrival?

From the Guidelines

Intraparenchymal ICP monitoring is not routinely indicated in traumatic brain injury patients with a GCS score of 9 at arrival without space-occupying lesions, but should be considered if there are concerning features such as progressive neurological deterioration or CT findings suggesting increased intracranial pressure. The management of severe traumatic brain injury, as outlined in the 2018 study published in Anaesthesia 1, emphasizes the importance of assessing the severity of traumatic brain injury using the Glasgow coma scale, specifically the motor response, as well as pupillary size and reactivity.

Key Considerations

• The Glasgow coma scale must be described according to each of the 3 components, and the motor component remains robust in sedated patients and is well correlated with the severity of head trauma 1.
• Moderate TBI patients, i.e., with a Glasgow coma score between 9 and 13, have a significant risk of secondary neurological degradation, and the rhythm of neurological examination can be planned every hour or more frequently depending on the clinical context 1.
• The occurrence of a secondary neurological deficit or a decrease of at least two points in the Glasgow coma score should lead to a second CT scan, which may indicate the need for ICP monitoring 1.

ICP Monitoring Decision

The decision to use intraparenchymal ICP monitoring in patients with moderate TBI (GCS 9-12) without space-occupying lesions should be based on individual patient factors, including the presence of concerning features such as progressive neurological deterioration, CT findings suggesting increased intracranial pressure, or the need for sedation/anesthesia for other injuries preventing reliable neurological examination.

Treatment Goals

If ICP monitoring is indicated, the goal is to maintain ICP below 22 mmHg and cerebral perfusion pressure between 60-70 mmHg, using treatments such as head elevation, sedation, analgesia, normothermia, osmotherapy, and hyperventilation as needed. ICP monitoring helps guide therapy and is associated with improved outcomes by allowing early detection and treatment of intracranial hypertension before secondary brain injury occurs.

From the Research

Intraparenchymal Brain ICP Monitoring in Traumatic Brain Injury

• The indication for intraparenchymal brain ICP monitoring in traumatic brain injury without space-occupying lesions and a Glasgow Coma Scale (GCS) score of 9 at arrival is not clearly established in the provided studies.
• However, a study published in 2022 2 suggests that ICP monitoring may be beneficial for patients with severe TBI, including those with a GCS score of 9, as it was associated with a decreased in-hospital mortality.
• Another study from 2015 3 found that ICP monitor placement was associated with a reduced risk-adjusted mortality rate in patients with severe TBI, including those with a GCS score of 8 or lower.
• A 2023 review 4 states that ICP monitoring is typically indicated for patients with severe TBI with a GCS score of 3-8, but may also be considered for moderate TBI patients with a GCS score of 9-12 who are at risk of increased ICP.
• The choice of ICP monitoring device, including intraparenchymal monitors, should be based on individual patient needs and the clinical scenario, as different devices have different advantages and disadvantages, as discussed in a 2012 study 5.
• It is essential to consider the individual patient's risk factors and the potential benefits and risks of ICP monitoring when making decisions about its use, as highlighted in a 2019 study 6 that found associations between ICP control management and neurological outcome in patients with mild TBI who required neurosurgical intervention.

Key Considerations

• The decision to use intraparenchymal brain ICP monitoring in traumatic brain injury without space-occupying lesions and a GCS score of 9 at arrival should be based on individual patient assessment and consideration of the potential benefits and risks.
• The use of ICP monitoring should be guided by clinical judgment and evidence-based guidelines, taking into account the patient's overall condition, injury severity, and other relevant factors.
• Further research is needed to fully establish the benefits and limitations of ICP monitoring in different patient populations, including those with moderate TBI and a GCS score of 9.