Management of Severe Traumatic Brain Injury with Multimodal Neuromonitoring

Indications for Intracranial Pressure Monitoring

The American College of Critical Care Medicine recommends invasive intracranial pressure (ICP) monitoring in comatose patients with abnormal head computed tomography (CT) scans, showing compressed basal cisterns, midline shift >5mm, or intracerebral hematoma >25mL 3
The Anaesthesia society strongly recommends post-surgical evacuation of intracranial hematoma with at least one of the following criteria: preoperative Glasgow motor score ≤5, preoperative anisocoria or bilateral midriasis, preoperative hemodynamic instability, signs of severity on neuroimaging, intraoperative cerebral edema, or new postoperative intracranial lesions 2
The Praxis Medical Insights guideline suggests that patients requiring sedation or paralysis, where neurological examination is not feasible, should undergo ICP monitoring 3

The Intensive Care Medicine society defines intracranial hypertension as ICP >20-25 mmHg, which requires treatment 3, 7
The Anaesthesia society recommends maintaining cerebral perfusion pressure (CPP) between 60-70 mmHg in the absence of advanced multimodal monitoring 2, 3
CPP <60 mmHg is associated with poor outcome, while CPP >70 mmHg is not routinely recommended due to increased risk of acute respiratory distress syndrome without benefit in neurological outcome 2

The Intensive Care Medicine society recommends continuous monitoring of cerebral autoregulation as part of multimodal neuromonitoring, using derived indices such as the pressure reactivity index (PRx) 5, 1
Approximately two-thirds of patients with severe traumatic brain injury have an optimal CPP range (CPPopt) where their autoregulatory efficiency is maximized 5, 1
Patients with preserved autoregulation may benefit from higher mean arterial pressure (MAP) and CPP as part of an integrated scheme to control ICP 5, 1

The Anaesthesia society recommends using mannitol 20% or hypertonic saline solution at a dose of 250 mOsm in a 15-20 minute infusion to treat threatening intracranial hypertension or signs of cerebral herniation after controlling secondary cerebral insults 2

The Intensive Care Medicine society recommends the use of standardized protocols for insertion and maintenance to ensure safety and reliability of the ICP monitoring procedure 5, 1, 6
Protocols should include continuous evaluation of ICP and CPP, including waveform quality 5, 1
Indications and method of ICP monitoring should be adapted to the specific diagnosis (subarachnoid hemorrhage, traumatic brain injury, encephalitis), as they have different needs and monitoring thresholds 1, 3