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Table of Contents    
COMMENTARY
Year : 2016  |  Volume : 64  |  Issue : 5  |  Page : 962-964

Is intracranial pressure monitoring useful in children with severe traumatic brain injury?


Department of Neurosurgery, All India institute of Medical Sciences, New Delhi, India

Date of Web Publication12-Sep-2016

Correspondence Address:
Deepak Gupta
Department of Neurosurgery, All India institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.190287

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How to cite this article:
Gupta D, Dash C. Is intracranial pressure monitoring useful in children with severe traumatic brain injury?. Neurol India 2016;64:962-4

How to cite this URL:
Gupta D, Dash C. Is intracranial pressure monitoring useful in children with severe traumatic brain injury?. Neurol India [serial online] 2016 [cited 2019 Nov 15];64:962-4. Available from: http://www.neurologyindia.com/text.asp?2016/64/5/962/190287




We read with keen interest the article by Kumar et al., regarding the benefits of intracranial pressure (ICP) monitoring in pediatric patients with severe traumatic brain injury [TBI] (Is intracranial pressure monitoring useful in children with severe traumatic brain injury?). The authors enrolled 50 pediatric patients with severe TBI in their series and concluded that ICP monitoring was beneficial in severe TBI in children (<16 years age group). However, they were cautious in interpreting the results as more number of patients who did not undergo ICP monitoring went on to require surgery, thereby suggesting that they probably had more severe TBI. Twenty-one out of 30 children in the “ICP monitored” group had a favorable outcome compared to only 9 out of 20 subjects in the “no ICP monitored” group.[1]

The authors have solely used ventricular catheters to monitor ICP. Although considered the gold standard for ICP monitoring, it may be difficult to place these catheters in the decompressed and displaced ventricles in patients with TBI. A useful technique has been described by Mathew Joseph in this regard.[2] The entry site for the catheter placement, described in this study, is on the medial canthal parasagittal line immediately in front of the coronal suture with the catheter being directed perpendicularly in the sagittal plane, being slightly tilted in the coronal plane, with the maximum permissible length of catheter that may be inserted being 7 cm from the entry site.

The authors have not mentioned as separate figures, the number of patients who actually died within the two groups, as death is an independent marker of outcome measurement. The authors have used only the Glasgow outcome score, assessed at a single point of time, to evaluate outcomes; however, it is advisable to grade the participants' recovery by periodic assessments (GOS Extended) at 3 and 6 months and carry out a detailed assessment, including a neuropsychological assessment, at 12 months after injury. Assessment tests should measure the child's behavior, attention, and general thinking instead of the Glasgow outcome scoring at a single time point. The authors have described that ICP monitoring was removed early in patients who improved in consciousness to the extent of obeying commands or when the ICP remained within the normal range for 48 hours. The authors mention that more aggressive therapies in the “ICP monitored” group were given leading to a better outcome; however, none of the patients in the “ICP monitored group” had more decongestant therapies being administered or had a prolonged intensive care unit (ICU) stay.

The control group of 20 subjects in this study did not really act as a control group for comparison with the “ICP monitored” group due to reasons stated above, lack of randomization, and also unclear logistical reasons of not instituting ICP monitoring in this group. The authors' conclusions that better outcomes in the ICP monitored group result from the usefulness of external ventricular drainage (controlled/intermittent/continuous) in severely injured TBI cases, therefore, are not convincing. The authors also do not give the time interval at the end of which they considered patients with persistently elevated ICP to be refractory to medical management and, therefore, were appropriate candidates for surgery. They do mention that if the ICP did not decrease even after three doses of the hyperosmolar agent, it was considered refractory to therapy and a third tier treatment was initiated. However, they do not describe the time interval between each dose of osmotherapy, which actually needs to be accounted, for deciding unequivocally, the time scale for the development of refractoriness to medical management. Although the authors do mention one death due to ventriculitis in the “ICP monitored” group, they do not mention whether there were any other complications in rest of the patients. Some of these unmentioned complications could have been the cause of longer ICU stay and longer duration of ventilator support required in patients in whom the ICP was monitored.

The authors have not mentioned the logistical reasons that prevented them from inserting catheters in the control group. One common reason that may be speculated could have been the inability to place the catheter in ventricles in an edematous brain.[3],[4],[5],[6] In such a scenario, other modalities of ICP monitoring, such as, an intraparenchymal monitoring may be considered, which is probably less technically demanding. Another reason for non-usage of an ICP monitoring device in various centers in the developing nations is the high cost of the fibreoptic/strain gauze technology based monitoring devices. However, the authors have not specified the kind of catheters and monitoring systems used in their study. The costs may be decreased to one-fourth of its original value by resterilising the catheters by the ethylene oxide sterlization technique.[7] In a study published on the cost effectiveness as well as safety and efficacy of resterilized intra-parenchymal catheters utilized for ICP monitoring in the developing world, we concluded that the usage of resterilized intra-parenchymal ICP catheters is feasible, safe, efficacious, and cost effective and brings down the cost of monitoring significantly. A total of 100 consecutive cases of severe TBI, receiving ICP monitoring at a level 1 trauma center of a developing nation, were prospectively studied (34 cases had fresh catheters, and 66 had resterilized [using ethylene oxide sterlization] catheters. The use of reused and resterilized catheters was not associated with an increased incidence of meningitis or fever. Also, there was concordance between the pressure recording of the reused catheters and the operative findings as well as the subsequent computed tomography scans. These catheters after sterilization could be reused 2–4 times and reliably recorded the ICP (with insignificant drift) with no increase in the incidence of meningitis.[7]

The decision on whether or not to perform ICP monitoring in children suffering from severe TBI remains controversial with unclear guidelines. Advances in care can come from adopting a variety of scientific approaches and not just from randomized control trials. For pediatric TBI, evidenced-based guidelines were first published in 2003 and have recently been revised.[3],[6] The new guidelines shed light on our inadequate knowledge of the modalities of treatments available for pediatric TBI. Specifically, there was insufficient evidence to support a Level I recommendation for any of the topics. The existing literature cannot recommend that a clinician “must perform” any of the 15 therapies or maneuvers identified by the pediatric neurotrauma community. As an example, the guidelines can only recommend that ICP monitoring “may be considered” and can only suggest that a threshold of an ICP >20 mm Hg “may be considered” for therapeutic intervention. Many of the recommendations for ICP control, available in literature, are based on providing treatment following the detection of intracranial hypertension – which would not be diagnosed without the ICP monitor providing the necessary data and the clinician deciding on an appropriate threshold for ICP.

The basic questions regarding therapies that are widely believed to improve outcome that must be answered by any clinician caring for a child with severe TBI include the following: Will a cerebrospinal fluid diversion procedure lead to an improved outcome?; and, are all hyperosmolar therapies equally effective? The lack of evidence regarding these questions hampers evidenced-based clinical decision-making for all children with TBI and introduces uncontrollable variability into the research protocols that attempt to standardize practices at multiple centers for a prospective evidence-based strategy. Thus, we are confronted with a methodological conundrum that includes the following issues: (i) High-quality, multi-centric randomized control trials are needed to generate guidelines that are compelling enough to change clinical practice and improve outcomes; (ii) there is lack of sufficient understanding of the fundamental aspects of TBI care that are directly associated with the outcomes and on which the experts in the field have a consensus; (iii) as a result of the two factors mentioned above, standardized clinical protocols for multi-center randomized clinical trials, that limit variability of these practices, are difficult to be adopted; (iv) this ultimately leads to failure of randomized control trials in establishing novel treatment options leading to lack of advancement in TBI care. The Approaches and Decisions for Acute Pediatric TBI (ADAPT) study is an observational study of 1000 children to evaluate the effectiveness of 6 therapies encompassing 3 specific aims – therapies that control intracranial hypertension, prevent secondary insults and normalize metabolism. The inclusion criteria for this study includes all children with severe TBI (GCS ≤8 after resuscitation), who have an ICP monitor placed as a part of their routine care. This ongoing study that is recruiting a large and homogenous population of children affected by TBI is likely to address some of the unanswered questions on the usefulness and efficacy of ICP monitoring in children with severe TBI.

Roumeliotis et al.,[3] analyzed the causes for not monitoring ICP in pediatric patients with head injury and concluded that a moribund status as well as a rapid improvement in the neurological status were the main reasons for not monitoring ICP in such patients. It is possible that ICP monitoring was done in those patients in whom a favorable outcome was anticipated and could be a very important cause of bias in the present study.[1] There is a statistically significant difference in the Marshall computed tomographic score (P = 0.027) with the patients in whom ICP monitoring was done having a lower score.

The results and the conclusions of the study should be interpreted with caution considering the small number of patients and the above mentioned limitations. We once again commend the authors for this study and for their efforts to evaluate the role of ICP monitoring in pediatric TBI, which still is not being done worldwide in all eligible pediatric patients with severe TBI, despite the established guidelines.[3],[6] The ongoing ADAPT study (Approaches and Decisions in Pediatric Traumatic Brain Injuries) on pediatric patients suffering from severe TBI might be able to answer some of the questions related to ICP monitoring in children in the future.

 
  References Top

1.
Arunkumar S, Indira Devi B, Shukla D, Reddy M. Is intracranial pressure monitoring useful in children with severe traumatic brain injury? Neurol India 2016;64:958-61.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Joseph M. Intracranial pressure monitoring in a resource-constrained environment: A technical note. Neurol India 2003;51:333-5.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Roumeliotis N, Pettersen G, Crevier L, Émeriaud G. ICP monitoring in children: Why are we not adhering to guidelines? Childs Nerv Syst 2015;31:2011-4.  Back to cited text no. 3
    
4.
Sinha S, Raheja A, Satyarthee G, Singh P, Tandon V, Pandey R, et al. Decompressive craniectomy in traumatic brain injury: A single-center, multivariate analysis of 1,236 patients at a tertiary care hospital in India. Neurol India 2015;63:175.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.
Bekar A, Doğan S, Abaş F, Caner B, Korfali G, Kocaeli H, et al. Risk factors and complications of intracranial pressure monitoring with a fiberoptic device. J Clin Neurosci Off J Neurosurg Soc Australas 2009;16:236-40.  Back to cited text no. 5
    
6.
Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, Bratton S, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents-second edition. Pediatr Crit Care 2012;13 Suppl 1:S1-82.  Back to cited text no. 6
    
7.
Gupta DK, Bisht A, Batra P, Mathur P, Kumar A, Mahapatra AK. A cost effectiveness based safety and efficacy study of resterilized intra-parenchymal catheter based intracranial pressure monitoring in developing world. Asian J Neurosurg 2016. DOI 10.4103/1793-5482.165785.  Back to cited text no. 7
    




 

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