Intracranial pressure monitoring in patients with acute brain injury in the intensive care unit (SYNAPSE-ICU): an international, prospective observational cohort study

Robba, Chiara; Graziano, Francesca; Rebora, Paola; Elli, Francesca; Giussani, Carlo; Oddo, Mauro; Meyfroidt, Geert; Helbok, Raimund; Taccone, Fabio Silvio; Prisco, Lara; Vincent, Jean‐Louis; Suárez, José I.; Stocchetti, Nino; Citerio, Giuseppe; Abdelaty, Mohamed; Maillard, Samia Abed; Ahmed, Hatim S.; Albrecht, Lea; AL-Sudani, Ali A.; Amundarain, E.D.; Anand, Saurabh; Andersen, Jens Bo; Anglada, Montserrat Pujol; Arabi, Yaseen M.; Aragão, Irene; Verdu, Maria Dolores Arias; Asehnoune, Karim; Assunção, Fernanda Boldrini; Audibert, Gérard; Badenes, Rafael; Bajracharya, Tamanna; Banco, Pierluigi; Batista, Danusa Cassiana Rigo; Bertellini, Elisabetta; Gutiérrez, Hedgar Berty; Besch, Guillaume; Biston, Patrick; Ortíz, Aaron Blandino; Blazquez, V.; Bloria, Summit Dev; Bonetti, Chiara; Bresil, Piergiorgio; Brunetti, Iole; Buldini, Virginia; Caillard, Anaïs; Calamai, Italo; Carbonara, Marco; Caricato, Anselmo; Casadio, Maria Chiara; Casanova, Matías; Cavaleiro, Pedro; Lopez, M. Celaya; Chan, Chin‐Pang; Chauhan, Rajeev; Cinotti, Raphaël; Corral, Luisa; Cortegiani, Andrea; Cotoia, Antonella; Crippa, Ilaria Alice; Davidovich, V.; Bianco, S.; Diakaki, Chrysi; Dibu, Jamil; Dimoula, Aikaterina; Domeniconi, G.; Domínguez, Ligia J.; Dovbysh, N.Yu.; Duque, Paula Andrea; Eddelien, Heidi Shil; Efthymiou, Anna; Larsen, T. Egmose; Elhadi, Muhammed; Eva, E. Favre; Fencl, M.; Forjan, P.; Freitas, Rafael Limeira de; Fuest, Kristina; Fumale, M.; Gakuba, Clément; Galarza, Laura; Garcia, Monique Ferreira; Lopez, George Α.; Gelormini, Camilla; Gempeler, Andrés; Giannopoulos, Achilleas; Gimenez, María Estrella; Giugni, Aimone; Glorieux, D.; Perez, M.I. Gonzalez; Gradišek, Primož; Grandis, Marzia; Griesdale, Donald; Грицан, А.И.; Grotheer, S.; Gupta, Deepak; Hallt, E.D.; Hawthorne, Christopher; Holm, Morten Olskjær; Iasonidou, Christina; Idowu, Olufemi Emmanuel; Ioannoni, Eleonora; Izzi, Antonio; Jibaja, Manuel; Kafle, Prakash; Kandamby, Darshana Hewa; Khan, Muhammed; Khomiakov, S. V.; Kilapong, Bram; Kletečka, Jakub; Kojder, Klaudyna; Kolias, Angelos; Kontoudaki, E.; Koukoulitsios, George; Kovač, Nataša; Kozar, S.; Krieg, Sandro M.; Kurtz, Pedro; Kyriazopoulos, G.; Lamperti, Massimo; Lavicka, P.; Lencastre, Luís; Levin, Michael; Lightfoot, Roger; Lindner, Anna; Ojeda, Patricia; Lores, A.; Lucca, Marcelo Balbinot; Luthra, Ankur; Magni, Federico; Majholm, Birgitte; Makris, Demosthènes; Maldonado, Frank; Marudi, Andrea; Maskey, Safala; Mebis, Liese; Mejía-Mantilla, Jorge Humberto; Mendoza, Ray; Milivojević, Nikola; Miroz, John Paul; Monleón, Berta; Montes, José María de las Heras; Morelli, Paola; Motta, Alessandro; Mouloudi, Eleni; Muehlschlegel, Susanne; Silva, S.A. Ñamendys; Nardai, Gábor; Nilam, K.; Olson, Dai Wai M.; Ozair, Ahmad; Pacheco, Carlos; Juan, J. Padilla; Palli, Eleni; Panda, Nidhi; Pantelas, Nikolaos; Pariente, Laura; Pearson, David; Pérez‐Araos, Rodrigo; Picetti, Edoardo; Portilla, J.; Pons, Bertrand; Pozzi, Federico; Provaznikova, Eva; Quartarone, M; Quintard, Hervé; Rajbanshi, Lalit Kumar; Reade, Michael C.; Ribarič, Samo; Rigamonti, Andrea; Rivera, Luis; Roberts, John; Roka, Yam Bahadur; Sabeļņikovs, Oļegs; Sapra, Harsh; Schaller, Stefan J.; Sekhon, Mypinder S.; Sellami, W.; Seppelt, Ian; Serrano, Aline D; Sharma, Kopal; Shrestha, Gentle S; Shum, Hoi‐Ping; Silva, S.; Simoes, Marcela; Sivakumar, Sanjeev; Siviter, Richard; Škola, Josef; Škoti, M.; Smitt, Margit; Soley, Rafael; Sonneville, Romain; Soragni, Alessandra; Soyer, Benjamin; Špatenková, Věra; Stamou, E; Stival, Eleonora; Olson, Z.; Tánczos, Krisztián; Thompson, C.; Thomsen, Jakob Edelberg; Tsikriki, S; Velde, Stijn Van de; Videtta, Walter; Villa, Federica; Vrbica, Kamil; Vrettou, Charikleia; Hoffmeyer, H; Wolf, Stefan; Wayhs, Sâmia Yasin; Zerbi, Simone Maria

doi:10.1016/s1474-4422(21)00138-1

Cited by 165 publications

(94 citation statements)

References 31 publications

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“…Surgery for mass lesion removal or decompressive craniectomy (DC) changes brain architecture and dynamics [14], which makes ICP thresholds also change. In this environment, multimodal monitoring becomes essential to guide therapeutic interventions [6,15,16]. Although neurosurgical procedures are effective for ICP control, morbidity remains high, which might be explained by the persistence of low ICC (despite ICP under acceptable standards).…”

Section: Figurementioning

confidence: 99%

“…Nevertheless, the ICP threshold value for intervention is still uncertain. The continuous assessment and monitoring of ICP, including waveform quality, is also strongly recommended [6]. In addition, the committee indicated that further research into the relationship between ICP and clinical outcomes will benefit from automated, high-resolution monitoring and alternate forms of analysis [5].…”

Section: Introductionmentioning

confidence: 99%

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Intracranial Compliance Assessed by Intracranial Pressure Pulse Waveform

et al. 2021

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Background: Morphological alterations in intracranial pressure (ICP) pulse waveform (ICPW) secondary to intracranial hypertension (ICP >20 mmHg) and a reduction in intracranial compliance (ICC) are well known indicators of neurological severity. The exclusive exploration of modifications in ICPW after either the loss of skull integrity or surgical procedures for intracranial hypertension resolution is not a common approach studied. The present study aimed to assess the morphological alterations in ICPW among neurocritical care patients with skull defects and decompressive craniectomy (DC) by comparing the variations in ICPW features according to elevations in mean ICP values. Methods: Patients requiring ICP monitoring because of acute brain injury were included. A continuous record of 10 min-length for the beat-by-beat analysis of ICPW was performed, with ICP elevation produced by means of ultrasound-guided manual internal jugular vein compression at the end of the record. ICPW features (peak amplitude ratio (P2/P1), time interval to pulse peak (TTP) and pulse amplitude) were counterweighed between baseline and compression periods. Results were distributed for three groups: intact skull (exclusive burr hole for ICP monitoring), craniotomy/large fractures (group 2) or DC (group 3). Results: 57 patients were analyzed. A total of 21 (36%) presented no skull defects, 21 (36%) belonged to group 2, whereas 15 (26%) had DC. ICP was not significantly different between groups: ±15.11 for intact, 15.33 for group 2 and ±20.81 mmHg for group 3, with ICP-induced elevation also similar between groups (p = 0.56). Significant elevation was observed for the P2/P1 ratio for groups 1 and 2, whereas a reduction was observed in group 3 (elevation of ±0.09 for groups 1 and 2, but a reduction of 0.03 for group 3, p = 0.01), and no significant results were obtained for TTP and pulse amplitudes. Conclusion: In the present study, intracranial pressure pulse waveform analysis indicated that intracranial compliance was significantly more impaired among decompressive craniectomy patients, although ICPW indicated DC to be protective for further influences of ICP elevations over the brain. The analysis of ICPW seems to be an alternative to real-time ICC assessment.

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Section: Figurementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Intracranial Compliance Assessed by Intracranial Pressure Pulse Waveform

et al. 2021

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“…In several conditions, such as liver failure, preeclampsia, encephalitis, meningitis and stroke, the role of invasive ICP monitoring is not well established or the risk–benefit ratio remains unclear [ 5 – 9 ]. Moreover, invasive insertion of intracranial transducers can result in important complications, including infection and hemorrhage [ 10 , 11 ]. For these reasons, the presence of intracranial hypertension is often estimated based on noninvasive screening methods, including neurological examination, brain imaging or cerebral ultrasonography (i.e., optic nerve sheath diameter and transcranial Doppler, TCD) [ 12 ].…”

Section: Introductionmentioning

confidence: 99%

Transcranial Doppler as a screening test to exclude intracranial hypertension in brain-injured patients: the IMPRESSIT-2 prospective multicenter international study

et al. 2022

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Background Alternative noninvasive methods capable of excluding intracranial hypertension through use of transcranial Doppler (ICPtcd) in situations where invasive methods cannot be used or are not available would be useful during the management of acutely brain-injured patients. The objective of this study was to determine whether ICPtcd can be considered a reliable screening test compared to the reference standard method, invasive ICP monitoring (ICPi), in excluding the presence of intracranial hypertension. Methods This was a prospective, international, multicenter, unblinded, diagnostic accuracy study comparing the index test (ICPtcd) with a reference standard (ICPi), defined as the best available method for establishing the presence or absence of the condition of interest (i.e., intracranial hypertension). Acute brain-injured patients pertaining to one of four categories: traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) or ischemic stroke (IS) requiring ICPi monitoring, were enrolled in 16 international intensive care units. ICPi measurements (reference test) were compared to simultaneous ICPtcd measurements (index test) at three different timepoints: before, immediately after and 2 to 3 h following ICPi catheter insertion. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated at three different ICPi thresholds (> 20, > 22 and > 25 mmHg) to assess ICPtcd as a bedside real-practice screening method. A receiver operating characteristic (ROC) curve analysis with the area under the curve (AUC) was used to evaluate the discriminative accuracy and predictive capability of ICPtcd. Results Two hundred and sixty-two patients were recruited for final analysis. Intracranial hypertension (> 22 mmHg) occurred in 87 patients (33.2%). The total number of paired comparisons between ICPtcd and ICPi was 687. The NPV was elevated (ICP > 20 mmHg = 91.3%, > 22 mmHg = 95.6%, > 25 mmHg = 98.6%), indicating high discriminant accuracy of ICPtcd in excluding intracranial hypertension. Concordance correlation between ICPtcd and ICPi was 33.3% (95% CI 25.6–40.5%), and Bland–Altman showed a mean bias of -3.3 mmHg. The optimal ICPtcd threshold for ruling out intracranial hypertension was 20.5 mmHg, corresponding to a sensitivity of 70% (95% CI 40.7–92.6%) and a specificity of 72% (95% CI 51.9–94.0%) with an AUC of 76% (95% CI 65.6–85.5%). Conclusions and relevance ICPtcd has a high NPV in ruling out intracranial hypertension and may be useful to clinicians in situations where invasive methods cannot be used or not available. Trial registration: NCT02322970.

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“…These episodes should be considered in terms of intensity and duration; invasive ICP monitoring is potentially useful for their timely estimation and management, and should be considered according to the BTF guidelines “to reduce in-hospital and 2-week post-injury mortality” (level 2B) [ 23 , 72 , 73 , 76 , 77 , 78 ]. A recent prospective multicenter study showed that the use of ICP monitoring might be associated with a more intensive therapeutic approach and with a lower six-month mortality in more severe cases [ 79 ]. Regarding indications for ICP monitoring, two consensus conferences recommend ICP to be monitored in all salvageable comatose patients with radiological signs of intracranial hypertension, and not to be monitored in patients with minimal intracranial pathology (i.e., diffuse axonal injury and small petechiae) [ 80 , 81 ].…”

Section: Perioperative Brain Protectionmentioning

confidence: 99%

Perioperative Management of Polytrauma Patients with Severe Traumatic Brain Injury Undergoing Emergency Extracranial Surgery: A Narrative Review

Picetti

Rosenstein

Balogh

et al. 2021

JCM

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Managing the acute phase after a severe traumatic brain injury (TBI) with polytrauma represents a challenging situation for every trauma team member. A worldwide variability in the management of these complex patients has been reported in recent studies. Moreover, limited evidence regarding this topic is available, mainly due to the lack of well-designed studies. Anesthesiologists, as trauma team members, should be familiar with all the issues related to the management of these patients. In this narrative review, we summarize the available evidence in this setting, focusing on perioperative brain protection, cardiorespiratory optimization, and preservation of the coagulative function. An overview on simultaneous multisystem surgery (SMS) is also presented.

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Intracranial pressure monitoring in patients with acute brain injury in the intensive care unit (SYNAPSE-ICU): an international, prospective observational cohort study

Cited by 165 publications

References 31 publications

Intracranial Compliance Assessed by Intracranial Pressure Pulse Waveform

Intracranial Compliance Assessed by Intracranial Pressure Pulse Waveform

Transcranial Doppler as a screening test to exclude intracranial hypertension in brain-injured patients: the IMPRESSIT-2 prospective multicenter international study

Perioperative Management of Polytrauma Patients with Severe Traumatic Brain Injury Undergoing Emergency Extracranial Surgery: A Narrative Review

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