Intracranial Pressure Monitoring and Management

Every 15 seconds someone suffers a traumatic brain injury (TBI) in the United States. TBI causes more deaths in males <35 years old than all other diseases combined, and it is estimated that 2% of the U.S. population lives with TBI-associated disability. Despite extensive research and success in animal studies, successful drug therapies have proved elusive in clinical trials. Instead, TBI care focuses on the early identification and removal of mass lesions and on the detection, prevention, and management of secondary brain insults that adversely affect outcome (e.g., hypotension, hypoxia, seizures, elevated intracranial pressure). TBI is a heterogeneous disease in cause, pathology, severity, and prognosis. Consequently, TBI care depends in large part on careful and repeated assessment of clinical and laboratory findings, imaging studies, and bedside physiological data.

A variety of physiological processes can be monitored at the bedside. Traditionally, monitoring and treating intracranial pressure (ICP) that is also used to quantify cerebral perfusion pressure (CPP) has been the cornerstone of severe TBI (sTBI) management, in large part because ICP is considered an indicator of injury severity. In this chapter, the indications, technique, and safety for ICP monitoring will be discussed. In addition, we will examine the relationship between ICP and outcome, treatment thresholds, ICP management, and how ICP management influences outcome. Finally, though ICP and CPP are important, emerging evidence suggests ICP is better viewed as an indicator of an underlying pathophysiological process that needs treatment rather than an independent target. The chapter will finish with a brief discussion on how a multimodal approach may supplement the information obtained from ICP monitoring to better target and individualize care. The focus of this chapter is on adults with TBI and may not apply to pediatric TBI.