See the corresponding editorial in this issue, pp 12461247.

J Neurosurg 119:12481254, 2013

AANS, 2013

Intracranial pressure monitoring in severe head injury:

compliance with Brain Trauma Foundation guidelines
and effect on outcomes: a prospective study

Clinical article
Peep Talving, M.D., Ph.D., Efstathios Karamanos, M.D., Pedro G. Teixeira, M.D.,
Dimitra Skiada, M.D., Lydia Lam, M.D., Howard Belzberg, M.D., Kenji Inaba, M.D.,
and Demetrios Demetriades, M.D., Ph.D.

Division of Acute Care Surgery (Trauma, Emergency Surgery and Surgical Critical Care), Department of
Surgery, Keck School of Medicine, Los Angeles County + University of Southern California Medical Center,
Los Angeles, California

Object. The Brain Trauma Foundation (BTF) has established guidelines for intracranial pressure (ICP) monitor-
ing in severe traumatic brain injury (TBI). This study assessed compliance with these guidelines and the effect on
outcomes.
Methods. This is a prospective, observational study including patients with severe blunt TBI (Glasgow Coma
Scale score 8, head Abbreviated Injury Scale score 3) between January 2010 and December 2011. Demographics,
clinical characteristics, laboratory profile, head CT scans, injury severity indices, and interventions were collected.
The study population was stratified into 2 study groups: ICP monitoring and no ICP monitoring. Primary outcomes
included compliance with BTF guidelines, overall in-hospital mortality, and mortality due to brain herniation. Sec-
ondary outcomes were ICU and hospital lengths of stay. Multiple regression analyses were deployed to determine the
effect of ICP monitoring on outcomes.
Results. A total of 216 patients met the BTF guideline criteria for ICP monitoring. Compliance with BTF guide-
lines was 46.8% (101 patients). Patients with subarachnoid hemorrhage and those who underwent craniectomy/
craniotomy were significantly more likely to undergo ICP monitoring. Hypotension, coagulopathy, and increasing
age were negatively associated with the placement of ICP monitoring devices. The overall in-hospital mortality was
significantly higher in patients who did not undergo ICP monitoring (53.9% vs 32.7%, adjusted p = 0.019). Similarly,
mortality due to brain herniation was significantly higher for the group not undergoing ICP monitoring (21.7% vs
12.9%, adjusted p = 0.046). The ICU and hospital lengths of stay were significantly longer in patients subjected to
ICP monitoring.
Conclusions. Compliance with BTF ICP monitoring guidelines in our study sample was 46.8%. Patients man-
aged according to the BTF ICP guidelines experienced significantly improved survival.
(http://thejns.org/doi/abs/10.3171/2013.7.JNS122255)

Key Words intracranial pressure monitoring mortality

brain herniation Brain Trauma Foundation guidelines traumatic brain injury

T
raumatic brain injury is the major cause of mor-
tality and morbidity both in civilian and military
settings.7,14,22 The incidence and risk of intracranial
Abbreviations used in this paper: AIS = Abbreviated Injury
Scale; AOR = adjusted odds ratio; AUC = area under the curve;
BTF = Brain Trauma Foundation; CPP = cerebral perfusion pres-
sure; GCS = Glasgow Coma Scale; ICH = intracranial hemorrhage;
ICP = intracranial pressure; INR = international normalized ratio;
IPH = intraparenchymal hemorrhage; ISS = Injury Severity Score;
LOS = length of stay; NTDB = National Trauma Data Bank; PT
= prothrombin time; PTT = partial thromboplastin time; SAH =
subarachnoid hemorrhage; SBP = systolic blood pressure; SDH =
subdural hematoma; TBI = traumatic brain injury.
hypertension after severe traumatic brain injury (TBI)
have been previously documented.1113,15,18,22 Thus, ac-
cording to the Brain Trauma Foundation (BTF) guide-
lines, intracranial pressure (ICP) monitoring is consid-
ered to be the standard of care in comatose patients who
have sustained severe head injury.1 Previous studies,
however, have demonstrated inconsistent compliance
with BTF guidelines for ICP monitoring.6,20 The reason
for the marked inconsistency with BTF guidelines relates
to conflicting clinical outcomes and a lack of randomized
controlled trials.
We set out to prospectively investigate compliance
with the BTF guidelines for ICP monitoring in a large
urban trauma center. We hypothesized that compliance

1248 J Neurosurg / Volume 119 / November 2013

Intracranial pressure monitoring in severe blunt TBI
with BTF ICP monitoring guidelines is associated with
improved outcomes.
Methods
After obtaining approval from the institutional re-
view board, we conducted a prospective observational
study of trauma patients with severe blunt TBI (Glasgow
Coma Scale [GCS] score 8 and head Abbreviated Injury
Scale [AIS] score 3) who met the BTF inclusion crite-
ria for ICP monitoring and were admitted to the surgical
ICU at Los Angeles County and University of Southern
California Medical Center between January 01, 2010, and
December 30, 2011. The decision to place an ICP moni-
toring device was at the neurosurgeons discretion. Exclu-
sion criteria included the pediatric population (age < 18
years), patients who were moribund, and those who were
not expected to improve prior to the decision of whether
an ICP monitoring device would be placed. Placement of
ICP monitoring devices occurred in all instances in the
first 24 hours after admission.
Demographic and clinical data collected included
age, sex, blood pressure on admission, GCS score on ad-
mission, Injury Severity Score (ISS), AIS for each body
region (head, chest, abdomen, and extremity), type of in-
tracranial injury, ICP values in patients undergoing in-
tervention, intracranial hemorrhage (ICH) treatment mo-
dalities, and neurosurgical documentation for omission of
ICP monitoring. A standardized data collection sheet was
used, allowing the treating physicians to choose from a
variety of standardized and clinically pertinent choices
as to why an ICP monitoring device was not placed. In
case the predetermined choices were not sufficient, the
physician could write down the reason for not placing an
ICP monitoring device.
The study population was stratified into 2 study arms:
patients subjected to ICP monitoring and those not under-
going ICP monitoring. All subsequent analyses were per-
formed comparing these groups. Elevated ICP was defined
as higher than 20 mm Hg for more than 15 minutes based
on the BTF guidelines.
Primary outcomes included compliance with BTF
guidelines, overall in-hospital mortality, and mortality
due to brain herniation. Secondary outcomes were ICU
and hospital lengths of stay (LOSs).
Statistical Analysis
Continuous variables were dichotomized using clini-
cally relevant cut points: age ( 55 years vs > 55 years),
systolic blood pressure (SBP) on admission (< 90 mm Hg
vs 90 mm Hg), international normalized ratio (INR, <
1.3 vs 1.3), ISS ( 15, 1624, 25), AIS score ( 3 vs < the BTF guidelines for ICP monitoring. The epidemio-
3), and heart rate on admission (> 120 bpm vs 120 bpm).
The 2 groups were compared for differences in categori-
cal variables using the Fisher exact or Pearson chi-square
tests as appropriate. The Shapiro-Wilk Test for normal-
ity was deployed for continuous variables; normally dis-
tributed variables were compared using the Student t-test
while nonnormally distributed variables were compared
using the Mann-Whitney U-test.
To identify independent predictors of ICP monitor-
J Neurosurg / Volume 119 / November 2013
ing, a forward stepwise logistic regression was deployed
using variables at a p < 0.2 level after univariate analysis.
Only the statistically significant variables are reported.
Subsequent univariate analyses for in-hospital mortality
and mortality due to brain herniation were performed.
Independent predictors of in-hospital mortality and mor-
tality due to brain herniation were derived from forward
stepwise regression models using variables from each
univariate model that were different at p < 0.2. A variance
inflation factor 5 for each variable entered in the models
was considered as evidence of multicolinearity.
To correct for the differences between the groups
(ICP monitoring vs no ICP monitoring), logistic regres-
sion was performed using as independent variables the
placement of the ICP monitoring device, adjusting for dif-
ferences between the groups at p < 0.05. The regression
calculated the predicted probability (propensity score) of
being subjected to ICP monitoring using variables that
independently predicted the placement of an ICP moni-
toring device. Propensity score matching is a technique
that tries to estimate the effect of a treatment by account-
ing for the covariates that predict receiving the treatment.
It was performed in an effort to reduce the bias due to
confounding factors that might be involved in compar-
ing outcomes among patients who received the treatment
with outcomes of those who did not. The overall in-hos-
pital mortality and mortality due to brain herniation were
assessed for each study group using logistic regression to
adjust for factors that were significant at p < 0.05. The
propensity score was also inserted in the regression as
a covariate. Adjusted odds ratios (AORs) with 95% CIs
were derived from the logistic regression. An AOR < 1.00
(95% CI) implies that the factor decreases significantly
the odds of developing the outcome, whereas an AOR >
1.00 (95% CI) increases significantly the odds of develop-
ing the outcome. A confidence interval that crosses 1.00
implies that the factor does not predict the outcome. The
hospital and ICU LOSs and ventilator days were com-
pared using an independent t-test or Mann-Whitney U-
test and subsequently linear regressions adjusting for dif-
ferences that were significant at p < 0.05. To correct for
mortality bias, the same tests were deployed after exclu-
sion of deaths.
Values are reported as the mean SEM for continu-
ous variables and as percentages for categorical variables.
All analyses were performed using SPSS for Windows
(version 12.0, SPSS, Inc.).
Results
Overall, 216 patients who sustained a severe TBI met
logical and clinical characteristics of the study population
are shown in Table 1. Hypotension was present in 5.6% of
the patients while 29.2% were tachycardic on admission.
Almost half of the patients (43.5%) had a GCS score of 3
on admission and 44.4% had a head AIS score of 5.
A total of 46.8% of patients who met the BTF criteria
underwent ICP monitoring (n = 101). A Becker ventricu-
lostomy EMDS II (Medtronic Corp.) was placed in 60 pa-
tients (59%), and a transducer-tipped pressure/temperature
1249
 P. Talving et al.
TABLE 1: Univariate analysis of the clinical characteristics of patients meeting the BTF guidelines*

Characteristic ICP Monitoring (n = 101) No ICP Monitoring (n = 115) p Value

demographics
mean age in yrs 40.1 1.9 48.0 2.4 0.011
age >55 yrs 27 (26.7%) 46 (40.0%) 0.044
male 80 (79.2%) 81 (70.4%) 0.160
admission physiology
mean SBP in mm Hg 142 3 137 3 0.267
hypotension (SBP <90 mm Hg) 2 (2.0%) 10 (8.7%) 0.040
mean heart rate 104 3 105 3 0.811
tachycardia (heart rate >120 bpm) 26 (25.7%) 37 (32.2%) 0.370
mean respiratory rate 18 1 18 1 1.000
injury severity indices
mean ISS 25 1 25 1 1.000
ISS 15 13 (12.9%) 19 (16.5%) 0.565
ISS 1624 32 (31.7%) 27 (23.5%) 0.221
ISS 25 56 (55.4%) 69 (60.0%) 0.581
head AIS Score 3 42 (41.6%) 35 (30.4%) 0.153
head AIS Score 4 22 (21.8%) 21 (18.3%) 0.609
head AIS Score 5 37 (36.6%) 59 (51.3%) 0.039
median GCS score 4 (38) 4 (38) 0.762
GCS Score 3 39 (38.6%) 55 (47.8%) 0.216
chest AIS 3 38 (37.6%) 36 (31.3%) 0.389
abdomen AIS 3 11 (10.9%) 8 (7.0%) 0.343
extremity AIS 3 18 (17.8%) 9 (7.8%) 0.038
specific head injuries
brain contusion 75 (74.3%) 82 (71.3%) 0.649
SDH 55 (54.5%) 59 (51.3%) 0.683
SAH 59 (58.4%) 40 (34.8%) 0.001
IPH 37 (36.6%) 22 (19.1%) 0.006
epidural hematoma 18 (17.8%) 17 (14.8%) 0.582
midline shift 6 (5.9%) 8 (7.0%) 0.790
loss of basal cisterns 31 (30.7%) 39 (33.9%) 0.663
cerebral edema 74 (73.3%) 91 (79.1%) 0.338
loss of gray/white differential 35 (34.7%) 28 (24.3%) 0.102
fixed, dilated pupils on admission 23 (22.8%) 35 (30.4%) 0.221
admission laboratory values
mean PTT 30.4 0.7 40.3 3.7 0.010
mean PT 15.7 0.3 16.9 0.8 0.082
mean INR 1.21 0.03 1.40 0.09 0.058
INR 1.3 28 (27.7%) 41 (35.7%) 0.243
early nutrition 85 (84.2%) 66 (57.4%) <0.001
decompressive craniectomy/craniotomy in 1st 24 hrs 42 (41.6%) 18 (15.7%) <0.001
decompressive craniectomy/craniotomy in 1st 4 hrs 32 (31.7%) 17 (14.8%) 0.003
mean probability of receiving ICP monitoring 0.64 0.02 0.34 0.02 <0.001

* Mean values are presented as the mean SEM. Median values are presented as the median (range). All other nonp values
are the number of patients (%). PT = prothrombin time.

fiberoptic catheter Camino Advanced Monitor (bolt) (In- of care. However, 58% of patients subjected to ventriculos-
tegra LifeSciences Corp.) was placed in 41 patients (41%). tomy were changed subsequently to a fiberoptic monitoring
All patients subjected to fiberoptic monitor placement re- device. The most common reason for not placing an ICP
mained with the fiberoptic monitor the entire critical phase monitoring device was the treating physicians decision

1250 J Neurosurg / Volume 119 / November 2013

Intracranial pressure monitoring in severe blunt TBI
TABLE 2: Independent predictors of ICP monitoring*

Step of Forward Logistic

Regression Analysis Variable Cumulative R 2 AOR (95% CI) Adjusted p Value
1 decompressive craniectomy 4 hrs 0.113 3.85 (1.828.14) <0.001
2 extremity AIS score 3 0.171 3.01 (1.098.32) 0.033
3 increasing age 0.213 0.97 (0.960.99) 0.001
4 increasing PTT on admission 0.256 0.96 (0.920.99) 0.021
5 best GCS score w/in 24 hrs of admission 0.298 0.81 (0.710.93) 0.002
6 hypotension on admission 0.329 0.13 (0.020.86) 0.034
7 SAH 0.353 2.07 (1.098.32) 0.033

* Other variables entered in the model were sex, presence of IPH on CT, loss of gray and white differential on CT, presence of reactive
pupils during the first physical examination, PT and INR values on admission, initiation of nutrition in the first 7 days, head AIS score
of 3, head AIS score of 5, and evacuation of a mass lesion within the first 24 hours. AUC 0.807 (95% CI 0.7460.867), p < 0.001.

(89.6%), followed by decompressive surgery (13.9%) and
expectation of a rapid improvement (4.3%). Patients who
sustained a subarachnoid hemorrhage (SAH) or an intrapa-
renchymal hemorrhage (IPH) were more likely to receive
an ICP monitoring device. Patients with SAH who did not
receive ICP monitoring accounted for 34.8% of the study
population, whereas patients with SAH who received ICP
monitoring accounted for 58.4% (p = 0.001). Patients with
an IPH who did not receive ICP monitoring accounted for
19.1% of the population, whereas patients with an IPH who
received ICP monitoring accounted for 36.6% of the entire
study sample (p = 0.006). No other differences in the inci-
dence of type of intracranial lesions were noted between
the groups (Table 1).
The independent predictors for ICP monitoring de-
vice placement are summarized in Table 2. Patients un-
dergoing decompressive craniectomy or patients with an
extremity AIS score 3 were more likely to be subjected
to ICP monitoring (AOR 3.85 [95% CI 1.828.14] adjust-
ed p < 0.001 and AOR 3.01 [95% CI 1.098.32] adjusted p
= 0.033, respectively). Patients who were older (AOR 0.97
[95% CI 0.960.99], adjusted p = 0.001), those with an in-
creased partial thromboplastin time (PTT) on admission
(AOR 0.96 [95% CI 0.920.99], adjusted p = 0.021), those
with a higher GCS score within first 24 hours of admis-
sion (AOR 0.81 [95% CI 0.710.93], adjusted p = 0.002),
or those who were hypotensive on admission (AOR 0.13
[95% CI 0.020.86], adjusted p = 0.034) were significant-
ly less likely to undergo ICP monitoring. We noted no dif-
ference in mortality for the ICP monitoring group when
the 2 devices were compared (Table 3).
For the patients subjected to ICP monitoring, the
highest mean ICP noted in the study sample was 33.4
2.3 mm Hg ( SEM, range 9118 mm Hg) and the lowest
TABLE 3: Impact of type of ICP monitoring on outcomes for patients receiving an ICP monitoring device (n = 101)
ICP was 5.9 1.1 mm Hg (range 099 mm Hg). Patients
undergoing ICP monitoring who experienced episodes of
sustained elevated ICP were treated in all instances (n =
64). Elevation of the head of the bed was used in 90.6%
of the cases, sedation in 89.1%, furosemide injection in
73.4%, pentobarbital coma in 23.4%, hypertonic saline
infusion in 62.5%, mannitol bolus in 54.7%, hyperven-
tilation in 51.6%, decompressive craniectomy in 15.6%,
hypothermia in 14.1%, and paralysis in 3.1% of cases.
Intracranial pressure monitoring was noted to be an
independent predictor of overall in-hospital mortality
(AOR 0.13 [95% CI 0.020.81], adjusted p = 0.029), along
with a head AIS score of 5 (AOR 79.81 [95% CI 12.95
91.75]), early initiation of nutrition (AOR 0.27 [95% CI
0.010.43]), older age, best GCS score within the first 24
hours, and presence of SDH on CT. Intracranial pressure
monitoring was also found to be an independent predic-
tor of mortality due to brain herniation with an AOR of
0.31 (95% CI 0.100.93, adjusted p = 0.037), along with
a head AIS score of 5 (AOR 35.54 [95% CI 8.2253.75],
adjusted p < 0.001), loss of basal cisterns on CT (AOR
5.01 [95% CI 1.8213.82]), best GCS score within the first
24 hours, and presence of IPH. The R2 and the area under
the curve (AUC) for the model were 0.881 and 0.989 for
overall mortality and 0.474 and 0.887 for mortality due to
brain herniation, respectively (Table 4).
The overall complication rate throughout hospitaliza-
tion was 5%. The incidence of pneumonia, acute kidney
injury, and deep venous thrombosis/pulmonary embolism
was 3.7% (8 of 216), 0.9% (2 of 216), and 0.9% (2 of 216),
respectively; all of these complications occurred in the
ICP study group. No incidents of acute respiratory dis-
tress syndrome and/or septic shock were noted.
The overall in-hospital mortality was significantly

Ventriculostomy Fiberoptic Monitor Adjusted

Parameter (n = 60) (n = 41) OR (95% CI) p Value AOR (95% CI)* p Value*
overall in-hospital mortality 22 (36.7%) 11 (26.8%) 1.58 (0.663.76) 0.388 0.65 (0.104.32) 0.651
mortality due to brain herniation 8 (13.3%) 5 (12.2%) 1.11 (0.343.66) 1.000 0.74 (0.173.24) 0.693

* Controlled for age, sex, IPH, SAH, PTT on admission, and presence of reactive pupils on admission.

J Neurosurg / Volume 119 / November 2013 1251

 P. Talving et al.
TABLE 4: Independent predictors of overall in-hospital mortality and mortality due to brain herniation*

Step of Forward Logistic

Regression Analysis Variable Cumulative R 2 AOR (95% CI) Adjusted p Value
overall in-hospital mortality
1 head AIS Score 5 0.788 79.81 (12.9591.75) <0.001
2 early nutrition 0.819 0.27 (0.010.43) 0.005
3 increasing age 0.842 1.07 (1.021.12) 0.005
4 best GCS score w/in 24 hrs of admission 0.86 0.51 (0.310.85) 0.009
5 SDH 0.871 10.70 (1.6967.81) 0.012
6 ICP monitoring 0.881 0.13 (0.020.81) 0.029
mortality due to brain herniation
1 head AIS Score 5 0.284 35.54 (8.2253.75) <0.001
2 loss of basal cisterns 0.376 5.01 (1.8213.82) 0.002
3 best GCS score w/in 24 hrs of admission 0.423 0.73 (0.550.96) 0.023
4 presence of IPH 0.441 5.16 (1.7015.65) 0.004
5 ICP monitoring 0.474 0.31 (0.100.93) 0.037

* Other variables entered in the models were age; sex; hypotension on admission; tachycardia on admission; extremity AIS score
3; chest AIS score 3; ISS; other intracranial lesions on CT; admission PT, PTT and INR values; alcohol intoxication; head AIS
score of 3; head AIS score of 4; GCS on admission of 3; and fixed dilated pupils on admission.
Overall mortality: AUC 0.989 (95% CI 0.9781.000), p < 0.001.
Mortality due to brain herniation: AUC 0.887 (95% CI 0.8410.933), p < 0.001.

higher in patients not subjected to ICP monitoring after ad-
justing for relevant confounders between the groups (age,
presence of hypotension on admission, head AIS score of
5, extremity AIS score 3, presence of IPH or SAH on CT,
PTT on admission, early nutrition, decompressive craniec-
tomy/craniotomy in 4 hours, decompressive craniectomy/
craniotomy in 24 hours, and probability of receiving ICP
monitoring; 53.9% vs 32.7%, adjusted p = 0.019). Simi-
larly, mortality due to brain herniation was significantly
higher in patients not subjected to ICP monitoring (21.7%
vs 12.9% (adjusted p = 0.046 [adjusting for the cofounders
mentioned above]). Early deaths (< 48 hours) were equally
distributed among the study groups.
The hospital and ICU LOSs were significantly longer
for the group subjected to ICP monitoring before and af-
ter exclusion of deaths (Table 5).
Discussion
The BTF guidelines support ICP monitoring in all
salvageable patients with severe TBI (GCS score of 38
after resuscitation) with an abnormal CT scan depicting
ICH, brain edema, herniation, or compressed basal cis-
terns (Level II evidence). In addition, patients with a GCS
score of 38 with no CT-identified lesion featuring 2 of 3
variables (unilateral/bilateral posturing, patient age 40
years, and presence of hypotension) are also candidates
for ICP monitoring (Level III evidence1). In brain injuries
that are likely to require aggressive ICP management, a
ventriculostomy is placed, which can also provide CSF
drainage. Patients not likely to require CSF drainage are
subjected to placement of a fiberoptic ICP monitoring de-
vice, allowing continuous ICP monitoring.
The BTF guidelines are based on retrospective and
limited prospective observational data; thus, the ICP com-
pliance varies widely in neurocritical care, and the out-
comes related to the intervention are conflicting.24,8,10,20,21
The BTF provides guidelines for physicians with regard
to the type of patients who should receive ICP monitor-
ing. It is worth noting, however, that these guidelines do
not constitute a universal protocol and thus treating physi-
cians commonly use their own experience and judgment to
decide which patient will be subjected to ICP monitoring.
Previous surveys of ICP monitoring in Europe and North
America have noted utilization of ICP monitoring in 50%
75% of patients with severe head injury in institutions pro-
viding neurocritical care.6,9,17,19,20,23
Cremer et al.4 performed a retrospective cohort study
with prospective follow-up ( 12 months) in 2 trauma
centers providing supportive therapy only compared with
ICP/CPP-targeted management in the severe head injury
population. The ICP/CPP-guided therapy did not improve
in-hospital survival, and the follow-up Glasgow Outcome
Scale score was similar in both study groups. At the cen-
ter relying on ICP/CPP-targeted therapy, the prevalence
of ICP monitoring was 67%.4 Shafi et al. performed a Na-
tional Trauma Data Bank (NTDB) analysis and noted that
ICP monitoring was applied in 43% of patients who met
BTF criteria.20 Likewise, we observed the prevalence of
ICP monitoring in patients meeting BTF guideline cri-
teria at 46.8%. In our prospective study we documented
reasons for omission of ICP monitoring, which included
neurosurgeons discretion, decompressive craniotomy/
craniectomy precluding the need for an ICP device, and
expectation of rapid neurological recovery. The indepen-
dent predictors of ICP monitoring included SAH, early
decompressive craniectomy, and severe extremity injury
with AORs of 2.07, 3.85, and 3.01, respectively (Table 2).
Patients with increasing age, those experiencing coagu-
lopathy, those with an elevated GCS score, or those pre-

1252 J Neurosurg / Volume 119 / November 2013

Intracranial pressure monitoring in severe blunt TBI
TABLE 5: Outcome measures
ICP Monitoring No ICP Monitoring
Variable (n = 101) (n = 115)
overall in-hospital mortality 33 (32.7%) 62 (53.9%)
mortality due to brain herniation 13 (12.9%) 25 (21.7%)
ICP Monitoring No ICP Monitoring
Variable (n = 101) (n = 115)
mean ICU LOS in days 16.8 1.3 8.2 1.0
mean hospital LOS in days 19.4 1.6 10.1 1.2
after exclusion of deaths
mean ICU LOS in days 21.7 1.5 13.0 1.8
mean hospital LOS in days 25.8 1.8 18.2 2.1
* Controlled for age, presence of hypotension on admission, head AIS of 5, extremity AIS 3, presence of IPH or SAH on CT, PTT on admission, early
nutrition, decompressive craniectomy/craniotomy in 4 hours and decompressive craniectomy/craniotomy in 24 hours, and probability of receiving
ICP monitoring.
senting with hypotension on admission were less likely
to be subjected to ICP monitoring (AOR 0.97, 0.96, 0.81,
and 0.13, respectively). The univariate analysis compar-
ing the patients who received ICP monitoring with those
who did not revealed some differences in their basic
characteristics, which, however, did not impact outcomes.
Even though patients with hypotension were significantly
more likely not to receive an ICP monitoring device, the
mean SBP did not differ between the groups (142 3 mm
Hg vs 137 3 mm Hg, p = 0.267). In addition, injury
severity indices were not statistically different between
the groups. Likewise, the severity of head injury based on
head AIS and GCS score was equally distributed between
the groups. When specific injury patterns of TBI were
analyzed, again, there was no difference except in the in-
cidence of SAH and IPH. Finally, patients with admission
coagulopathy were less likely to undergo ICP monitor-
ing placement, not because of the severity of injury but
to avoid potential bleeding due to the intervention. The
main reason for not receiving an ICP monitoring device
was at the discretion of the neurosurgical attending. Pa-
tients who were moribund or were assessed to have poor
outcome on admission were excluded from the study per
study design. In addition, a small percentage of patients
who did not receive ICP monitoring were expected by the
neurosurgeon to improve rapidly. That contrasts with the
idea that ICP monitoring was not used in sicker patients
and emphasizes the fact that BTF guidelines are not uni-
versally applied and each patient is treated based on phy-
sician preference. In 41% of all ICP devices a fiberoptic
ICP monitoring device, that is, a fiberoptic monitor, was
placed with no difference in overall mortality and mortal-
ity due to brain herniation when compared with ventricu-
lostomy (Table 3).
We performed a regression analysis to elucidate inde-
pendent predictors for both overall and head injuryrelated
outcomes. The deployed model noted multiple significant
independent predictors for overall in-hospital mor tality
including devastating head injury (head AIS score of 5)
and subdural hematoma (SDH) with AORs for poor out-
J Neurosurg / Volume 119 / November 2013
Adjusted p
OR (95% CI) p Value AOR (95% CI)* Value*
0.42 (0.24 to 0.72) 0.002 0.15 (0.03 to 0.74) 0.019
0.53 (0.26 to 1.11) 0.107 0.34 (0.10 to 0.87) 0.046
Mean Difference Adjusted Mean Difference Adjusted p
(95% CI) p Value (95% CI)* Value*
8.62 (11.83 to 5.41) <0.001 6.04 (9.46 to 1.69) <0.001
9.26 (13.10 to 5.42) <0.001 7.14 (11.14 to 2.08) 0.001
8.74 (13.36 to 4.13) <0.001 2.78 (11.58 to 2.78) 0.007
7.61 (13.13 to 2.09) <0.001 2.34 (9.56 to 2.34) 0.022
come of 79.81 and 10.70, respectively (Table 4). We noted
that patients subjected to ICP monitoring experienced a
significant overall mortality reduction effect of 69% after
adjustment for most clinically relevant confounders includ-
ing head injury severity (Table 5). Similar to our findings,
previous examinations have observed survival advantage
in ICP-targeted therapy, but with less marked survival ef-
fect.3,5,15,16 However, a recent NTDB-based investigation by
Shafi et al. observed a significantly worsened survival in
patients subjected to ICP monitoring.20 These authors in-
terpreted the BTF guidelines to be inadequate to identify
patients who benefit from ICP monitoring. Furthermore,
these investigators suggested that the interventions in pa-
tients subjected to ICP monitoring may be associated with
worsened outcomes. Such interventions include ICP moni-
toring device insertion in a coagulopathic state, utilization
of vasoactive medication, osmotic diuresis with mannitol,
furosemide utilization, hyperventilation, and use of para-
lytics. We documented all of the above interventions in our
study group subjected to ICP monitoring; nevertheless, de-
spite all these potentially harmful interventions, these pa-
tients experienced significantly improved outcomes.
We noted extended ICU and hospital LOSs when ICP
monitoring was instituted before and after exclusion of
deaths. This finding may relate to improved survival in
patients subjected to the intervention.
Our study has multiple limitations including the lack
of randomization, long-term follow-up of outcome, and
functional impairment measures. First, we attempted to
compensate for the lack of randomization with multiple
regression models adjusting for an extensive number of
clinically relevant confounders introducing propensity
score into our analysis. Second, the patients were selected
for all interventions at the discretion of the attending neu-
rosurgeon without any strict protocol. Finally, it is likely
that some of those patients in the group not receiving ICP
monitoring were being treated differentlyand perhaps
less intensivelythan those in the ICP monitoring group.
Nevertheless, our data were collected prospectively and
our study is, to the best of our knowledge, the first to
1253

document reasons for omission of ICP monitoring with
respective outcomes. Our findings support the need for
prospective randomized trials to settle the debate.
Conclusions
Compliance with the BTF ICP monitoring guidelines
in our study sample was 46.8%. Compliance with these
guidelines was associated with improved survival.
Disclosure
The authors report no conflict of interest concerning the mate-
rials or methods used in this study or the findings specified in this
paper.
Author contributions to the study and manuscript preparation
include the following. Conception and design: Talving, Demetriades.
Acquisition of data: Karamanos, Skiada. Analysis and interpretation
of data: Karamanos, Inaba. Drafting the article: Talving, Karamanos,
Lam. Critically revising the article: all authors. Reviewed submitted
version of manuscript: all authors. Approved the final version of the
manuscript on behalf of all authors: Talving. Statistical analysis:
Karamanos, Teixeira. Study supervision: Talving, Demetriades.
References
1.Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond
FF, Harris OA, Hartl R, et al: Guidelines for the management
of severe traumatic brain injury. VIII. Intracranial pressure
thresholds. J Neurotrauma 24 (Suppl 1):S55S58, 2007 (Er-
ratum in J Neurotrauma 25:276278, 2008)
2. Bulger EM, Nathens AB, Rivara FP, Moore M, MacKenzie
EJ, Jurkovich GJ: Management of severe head injury: insti-
tutional variations in care and effect on outcome. Crit Care
Med 30:18701876, 2002
3. Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C,
Videtta W, et al: A trial of intracranial-pressure monitoring in
traumatic brain injury. N Engl J Med 367:24712481, 2012
4.Cremer OL, van Dijk GW, van Wensen E, Brekelmans GJ,
Moons KG, Leenen LP, et al: Effect of intracranial pressure
monitoring and targeted intensive care on functional outcome
after severe head injury. Crit Care Med 33:22072213, 2005
5. Fakhry SM, Trask AL, Waller MA, Watts DD: Management
of brain-injured patients by an evidence-based medicine pro-
tocol improves outcomes and decreases hospital charges. J
Trauma 56:492500, 2004
6. Hesdorffer DC, Ghajar J, Iacono L: Predictors of compliance
with the evidence-based guidelines for traumatic brain injury
care: a survey of United States trauma centers. J Trauma 52:
12021209, 2002
7.Hukkelhoven CW, Steyerberg EW, Rampen AJ, Farace E,
Habbema JD, Marshall LF, et al: Patient age and outcome
following severe traumatic brain injury: an analysis of 5600
patients. J Neurosurg 99:666673, 2003
8. Idris Z, Ghani RI, Musa KI, Ibrahim MI, Abdullah M, Nyi
NN, et al: Prognostic study of using different monitoring
modalities in treating severe traumatic brain injury. Asian J
Surg 30:200208, 2007
9. Jeevaratnam DR, Menon DK: Survey of intensive care of se-
verely head injured patients in the United Kingdom. BMJ
312:944947, 1996
1254
P. Talving et al.
10. Lane PL, Skoretz TG, Doig G, Girotti MJ: Intracranial pressure
monitoring and outcomes after traumatic brain injury. Can J
Surg 43:442448, 2000
11. Lee TT, Galarza M, Villanueva PA: Diffuse axonal injury (DAI)
is not associated with elevated intracranial pressure (ICP). Acta
Neurochir (Wien) 140:4146, 1998
12. Lobato RD, Sarabia R, Rivas JJ, Cordobes F, Castro S, Muoz
MJ, et al: Normal computerized tomography scans in severe
head injury. Prognostic and clinical management implica-
tions. J Neurosurg 65:784789, 1986
13. Miller MT, Pasquale M, Kurek S, White J, Martin P, Bannon
K, et al: Initial head computed tomographic scan characteris-
tics have a linear relationship with initial intracranial pressure
after trauma. J Trauma 56:967973, 2004
14. Myburgh JA, Cooper DJ, Finfer SR, Venkatesh B, Jones D,
Higgins A, et al: Epidemiology and 12-month outcomes from
traumatic brain injury in Australia and New Zealand. J Trau-
ma 64:854862, 2008
15.Narayan RK, Kishore PR, Becker DP, Ward JD, Enas GG,
Greenberg RP, et al: Intracranial pressure: to monitor or not to
monitor? A review of our experience with severe head injury.
J Neurosurg 56:650659, 1982
16. Palmer S, Bader MK, Qureshi A, Palmer J, Shaver T, Borzatta
M, et al: The impact on outcomes in a community hospital
setting of using the AANS traumatic brain injury guidelines.
J Trauma 50:657664, 2001
17.Patel HC, Menon DK, Tebbs S, Hawker R, Hutchinson PJ,
Kirkpatrick PJ: Specialist neurocritical care and outcome
from head injury. Intensive Care Med 28:547553, 2002
18. Poca MA, Sahuquillo J, Bguena M, Pedraza S, Gracia RM,
Rubio E: Incidence of intracranial hypertension after severe
head injury: a prospective study using the Traumatic Coma
Data Bank classification. Acta Neurochir Suppl 71:2730,
1998
19. Sahjpaul R, Girotti M: Intracranial pressure monitoring in se
vere traumatic brain injuryresults of a Canadian survey. Can
J Neurol Sci 27:143147, 2000
20. Shafi S, Diaz-Arrastia R, Madden C, Gentilello L: Intracra-
nial pressure monitoring in brain-injured patients is associ-
ated with worsening of survival. J Trauma 64:335340, 2008
21. Stocchetti N, Penny KI, Dearden M, Braakman R, Cohadon F,
Iannotti F, et al: Intensive care management of head-injured
patients in Europe: a survey from the European Brain Injury
Consortium. Intensive Care Med 27:400406, 2001
22. Thurman DJ, Alverson C, Dunn KA, Guerrero J, Sniezek JE:
Traumatic brain injury in the United States: a public health
perspective. J Head Trauma Rehabil 14:602615, 1999
23. Wilkins IA, Menon DK, Matta BF: Management of comatose
head-injured patients: are we getting any better? Anaesthesia
56:350352, 2001
Manuscript submitted December 20, 2012.
Accepted July 22, 2013.
Please include this information when citing this paper: pub-
lished online August 23, 2013; DOI: 10.3171/2013.7.JNS122255.
Address correspondence to: Peep Talving, M.D., Ph.D., Depart-
ment of Surgery, Division of Acute Care Surgery, (Trauma, Emer-
gency Surgery and Surgical Critical Care), Keck School of Medicine,
LAC + USC Medical Center, 2051 Marengo St., Rm. IPT-C5L100,
Los Angeles, CA 90033. email: peep.talving@surgery.usc.edu.
J Neurosurg / Volume 119 / November 2013