British Journal of Neurosurgery, October 2014; 28(5): 663–665 © 2014 The Neurosurgical Foundation ISSN: 0268-8697 print / ISSN 1360-046X online DOI: 10.3109/02688697.2014.881463
ORIGINAL ARTICLE
Attitudes to intracranial pressure monitoring of traumatic intracerebral haemorrhage Richard Francis, Barbara A. Gregson & A. David Mendelow
Br J Neurosurg Downloaded from informahealthcare.com by Chulalongkorn University on 12/30/14 For personal use only.
Neurosurgical Trials Unit, 3-4 Claremont Terrace, Newcastle University, Newcastle upon Tyne, UK
Abstract Introduction. Recent research has been equivocal regarding the usefulness of intracranial pressure (ICP) monitoring for traumatic intracerebral haemorrhage (ICH). We aimed to investigate attitudes of clinicians from as wide an international audience as possible. Materials and methods. A SurveyMonkey® questionnaire was distributed to individuals, including members of the Society of British Neurological Surgeons, the European Brain Injury Consortium, the neurotrauma committee of the Euroacademia Multidisciplinaria Neurotraumatologica and the World Federation of Neurosurgical Societies. Results. N ⴝ 98 completed the survey (surgeons n ⴝ 86) from at least 25 different countries. ICP was routinely monitored by 76% and would be monitored by 5% more if they had equipment. ICP monitoring was valued (0 ⴝ not at all important, 10 ⴝ critically important) as 10 by 21% (median ⴝ 8, Q1 ⴝ 7, Q3 ⴝ 9). Triggers to begin ICP monitoring included midline shift (n ⴝ 48), contusion (n ⴝ 47), ICH (n ⴝ 46), subdural haemorrhage (n ⴝ 42), Glasgow coma scale reduction of median 2 for eye, verbal or motor, and one reactive pupil (30%). Responders stated that intervention would begin for adults with an ICP median of 25 mmHg and for children 20 mmHg. Most favourable treatments of raised ICP included Mannitol and ventriculostomy, which were ranked as most favourable (out of 10) by n ⴝ 31 each. Responders claimed to be aware of 16 different trials that investigated the value of ICP monitoring in neurotrauma, including BEST TRIP (n ⴝ 35), Rescue ICP (n ⴝ 13) and DECRA (n ⴝ 8). Conclusion. ICP monitoring continues to be a highly valued and clinically desirable technique for managing traumatic ICH patients.
traumatic brain injury (TBI) thresholds for ICP and cerebral perfusion pressure (CPP) have been published by the Brain Trauma Foundation.4,6
Materials and methods An invitation to a SurveyMonkey® questionnaire (Supplemantary Appendix I: Survey used to be found online at http://informahealthcare.com/doi/abs/10.3109/02688697. 2014.881463) was e-mailed to members of the Society of British Neurological Surgeons, the European Brain Injury Consortium, the Euroacademia Multidisciplinaria Neurotraumatologica and the neurotrauma committee of the World Federation of Neurosurgical Societies. Invitations were also e-mailed to all international investigators (n ⫽ 419) who had registered interest in the STITCH(Trauma) trial. An open invitation and web link to the survey was also posted on the STITCH(Trauma) trial website.
Results Questionnaires were completed by 98 individuals from at least 25 different countries (n ⫽ 89 reported their country). Countries included Austria, Belgium, China, Columbia (3), Croatia, Czech Republic, Denmark (2), Egypt (2), Estonia, Germany (10), India (4), Israel, Italy (2), Lithuania, Macedonia, Malaysia (3), Netherlands (2), Pakistan, Romania, Spain (4), Switzerland (2), Taiwan, Ukraine (2) United Kingdom (35), United States of America (3). Responders described themselves as surgeon (n ⫽ 86), intensivist (n ⫽ 6), anaesthetist (n ⫽ 1), nurse (n ⫽ 1) and Director of Neurotraumatological Service (n ⫽ 1) (unreported n ⫽ 1). ICP was routinely monitored by 76% and would be monitored by 5% more if they had equipment, while 19% had equipment but did not routinely monitor (n ⫽ 95 responders, Fig. 1). CPP was routinely monitored by 70% and would be monitored by 10% more if they had equipment, while 19% had such equipment but did not routinely monitor and 2% would not routinely monitor even if they had the equipment (n ⫽ 98 responders). ICP monitoring was valued (0 ⫽ not
Keywords: cerebral perfusion pressure; intracerebral haemorrhage; intracranial pressure; trauma
Introduction Intracranial pressure (ICP) monitoring is performed for traumatic intracerebral haemorrhage (ICH), though recent research is inconclusive in determining its effect on outcome.1–5 The present paper examines international responses to a questionnaire, which sought the opinion of clinicians, regarding ICP monitoring for traumatic ICH. In
Correspondence: Dr Richard Francis, Neurosurgical Trials Unit, 3-4 Claremont Terrace, Newcastle University, Newcastle upon Tyne, NE2 4AE, UK. Tel: ⫹ 44 (0)1912225764. Fax: ⫹ 44 (0)1912225762. E-mail:
[email protected] Received for publication 13 August 2013; accepted 30 December 2013
663
Br J Neurosurg Downloaded from informahealthcare.com by Chulalongkorn University on 12/30/14 For personal use only.
664
R. Francis et al.
Fig. 3. CT factors that would prompt survey responders to begin ICP monitoring.
at all important, 10 ⫽ critically important) as 10 by 21% (median ⫽ 8, Q1 ⫽ 7, Q3 ⫽ 9) (n ⫽ 97 responders, Fig. 2). Responders mainly began ICP monitoring in response to CT factors such as midline shift (n ⫽ 48), contusion (n ⫽ 47), ICH (n ⫽ 46) and subdural haemorrhage (SDH) (n ⫽ 42) (multiple selections were permitted, Fig. 3). ICP monitoring was also triggered in response to clinical factors such as a reduction of eye Glasgow Coma Scale (GCS) median ⫽ 2 (of n ⫽ 60 responders), verbal GCS median ⫽ 2 (of n ⫽ 57 responders), motor GCS median ⫽ 2 (of n ⫽ 70 responders). Furthermore, ICP monitoring would be prompted in response to mild paralysis (32%), complete paralysis (9%), no paralysis (12%) (of n ⫽ 41 responders) and both reactive pupils (23%), one reactive pupil (30%), no reactive pupil (5%) (of n ⫽ 45 responders). Another 29% of responders emphasised that they would undertake ICP monitor depending on the clinical state, in particular when GCS was 8 or below, or if clinical evaluation was not possible (e.g. unconscious or sedated). Responders were also asked to identify the total GCS reduction that would
make them decide to begin ICP monitoring following trauma; however there may have been inconsistencies in the way that this question was interpreted. Responses to this were largely bimodal, focused around those that responded with 2 (n ⫽ 15) and with 8 (n ⫽ 24) (of n ⫽ 81 responders). Responders stated that intervention would begin for adults with an ICP median of 25 mmHg (Q1 ⫽ 20, Q3 ⫽ 25, Fig. 4), CPP median of 60 mmHg (Q1 ⫽ 60, Q3 ⫽ 65) and for children with ICP median of 20 mmHg (Q1 ⫽ 19, Q3 ⫽ 20), CPP median of 55 mmHg (Q1 ⫽ 50, Q3 ⫽ 60). The most favourable treatment options for raised ICP included Mannitol and ventriculostomy, which were respectively ranked as most favourable (1 ⫽ most favourable, 10 ⫽ least favourable) by n ⫽ 31 (of 90 responders) and n ⫽ 31 (of 89 responders). Furthermore hypertonic saline was also reported to be 1st or 2nd most favourable by n ⫽ 47 (of 87 responders). Responders claimed to be aware of 16 different trials that investigated the value of ICP monitoring in neurotrauma. These included BEST TRIP (n ⫽ 35), Rescue ICP (n ⫽ 13) and DECRA (n ⫽ 8). Some investigators stated more than one study, however many responders either stated “none”, or did not answer this question (n ⫽ 42).
Fig. 2. Survey responders’ values of ICP monitoring for traumatic ICH treatment.
Fig. 4. ICP threshold to begin intervention in adults from survey responders.
Fig. 1. ICP monitoring by survey responders.
ICP monitoring for TICH
Br J Neurosurg Downloaded from informahealthcare.com by Chulalongkorn University on 12/30/14 For personal use only.
Discussion Despite inconsistencies in the literature, concerning ICP monitoring for traumatic ICH, the vast majority of our responders continue to routinely monitor ICP for these patients and highly value this facility. Interestingly, 43% of responders to the present survey did not state awareness of any randomised controlled trial that investigated the value of ICP monitoring in neurotrauma. Furthermore, only 36% of responders indicated an awareness of the recent randomised controlled trial by Chesnut et al. (BEST TRIP).3 This study was a multicentre controlled trial involving 324 severe TBI patients and concluded that care focused on maintaining monitored ICP at 20 mmHg or less was not shown to be superior to care based on imaging and clinical examination. Published comments have been made concerning this study and indeed responded to by the authors (New England Journal of Medicine 2013;368(18):1748–1751). One limitation of the study was that prehospital resuscitation may have been less developed in study countries (Bolivia and Ecuador) compared with higher income countries. Therefore, study patients may have died before hospital admission, resulting in a less severely injured study population than in higher income countries. This would reduce the generalizability of study findings to other patient populations. However it is noted that Chesnut et al. reported that early outcome curves in the study were consistent with those expected from similar patients from wealthier countries. In our study, when only those who were aware of the BEST TRIP trial were considered, n ⫽ 29/34 reported that they routinely monitor ICP for traumatic ICH patients. It was noted that responders were prompted to begin ICP monitoring if computed tomography (CT) detected midline shift, contusion, ICH and SDH. ICP monitoring would also be prompted by a reduction of eye, verbal or motor GCS by 2 points (median). While some responders reported that ICP may also be prompted by factors such as reduction in the individual GCS components, degree of focal deficit or pupil reactivity, it should be noted that high numbers of responders did not answer questions related to these factors. The ICP threshold for intervention in adults was median 25 mmHg and preferred treatments included mannitol, ventriculostomy and hypertonic saline. Responders (29%) indicated that they would monitor ICP when GCS was below 8, or if clinical evaluation was not possible (e.g. unconscious or sedated). Responders would then intervene depending on ICP. This suggests that such patients may be more likely to present surgical equipoise in centres which do not monitor ICP. Indeed, in the surgical trial in traumatic intracerebral haemorrhage (STITCH(Trauma)) we set out to evaluate the role of surgery for traumatic ICH patients who presented surgical equipoise.7 ICP monitoring was not a requirement for entry into the trial, but data was collected on the frequency of monitoring in this patient group. We noted differences in the frequency of ICP monitoring in different parts of the world and that centres in our top
Supplementary material available online Supplementary Appendix I: Survey used.
665
recruiting country (India) monitored ICP in very few patients recruited to the trial (4%), compared with centres in Europe (26%), China (21%) and others (19%). The following limitations should be considered regarding the present survey: 1) It is apparent that there were inconsistencies in responses to being asked what reduction in GCS would encourage ICP monitoring to begin (Question 4). Some investigators appear to have responded with a GCS threshold, while others with a GCS reduction. This limits the value of our findings regarding the impact of GCS reduction, on motivating ICP monitoring. This is something that future similar surveys may wish to consider. 2) It is unclear how many different individuals received information about the survey and so it was not possible to calculate a rate of response. This is because surveys were openly accessible via the STITCH(Trauma) website and also because various academic groups distributed the survey to their members internally (rather than giving us the confidential details of their members, for us to contact directly). Furthermore, even if these separate numbers were known, it is likely that many people would have been aware of the survey from more than one source. Despite this, it is expected that substantially more individuals would have been aware of the survey, than the 98 who responded (considering the method that we employed to make people aware of it). As it is therefore unclear what the views of non-responders to the survey are, this may be viewed as a potential source of bias.
Conclusion ICP monitoring continues to be a highly valued and clinically desirable technique for managing traumatic ICH patients. Declaration of interest: Richard Francis and Barbara Gregson have no conflicting interests to declare. David Mendelow is a Director of Newcastle Neurosurgical Foundation and Consultant for Stryker.
References 1. Barmparas G, Singer M, Ley E, et al. Decreased intracranial pressure monitor use at level II trauma centers is associated with increased mortality. Am Surg 2012;78:1166–71. 2. Badri S, Chen J, Barber J, et al. Mortality and long-term functional outcome associated with intracranial pressure after traumatic brain injury. Intensive Care Med 2012;38:1800–9. 3. Chesnut RM, Temkin N, Carney N, et al. A trial of intracranialpressure monitoring in traumatic brain injury. N Engl J Med 2012;367:2471–81. 4. Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the management of severe traumatic brain injury. VIII. Intracranial pressure thresholds. J Neurotrauma 2007;24: S55–8. 5. Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the management of severe traumatic brain injury. IX. Cerebral perfusion thresholds. J Neurotrauma 2007;24: S59–64. 6. Mendelson AA , Gillis C, Henderson WR, et al. Intracranial pressure monitors in traumatic brain injury: a systematic review. Can J Neurol Sci 2012;39:571–6. 7. Gregson BA , Rowan EN, Mitchell PM, et al. Surgical trial in traumatic intracerebral hemorrhage (STITCH(Trauma)): study protocol for a randomized controlled trial. Trials 2012;13:193.