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A systematic review of intracranial pressure monitoring in adults with severe traumatic brain injury/Una revision sistematica del monitoreo de la presion intracraneana en adultos con trauma craneoencefalico severo.

Introduction

Traumatic brain injury is a global public health problem that has great importance in the socioeconomic sphere. It is estimated that 57 million people have been hospitalized around the world with some degree of craniocerebral trauma, and at least 10 million cases result in hospitalization or death each year (1). In 1991 the USA had 5.3 million people who were living with disabilities related to cranial trauma (2). In 2010 the estimated cost of head trauma to the US economy amounted to approximately $76.5 billion (3,13).

In the last 10 years there have been many changes in the management of patients with cranial trauma, relating to the introduction of neurointensive care units, which have shown a substantial reduction in the risk of post-trauma mortality. The application of monitoring methods for early detection of treatable ischemic complications and the prevention of secondary brain injury improves the outcome of these patients. These new technologies have resulted in considerable innovations over the years, but intracranial and mean arterial pressure remain crucial in monitoring neurointensive care (4-14). Does monitoring the levels of intracranial ventricular pressure and CSF drainage add to neurological examination and imaging, reducing complications (mortality, functional impairment and neuropsychological) in adults with severe craniocerebral trauma? Data from randomized controlled trials that rigorously monitor intracranial pressure in the treatment of traumatic brain injury are insufficient, and few stu-dies produce high-quality data using case-controlled trials. Historically, monitoring has been confounded by several factors including the participation of intensivists and the development of the sub-specialty of neuro critical care including; major improvements in resuscitation of trauma patients (in particular those with brain injuries); the myriad of developments in the management of traumatic brain injury during pre-hospital emergency care; urgent care and rehabilitation; and notable improvements in the techniques of control and management in the intensive care unit (ICU) (5-12-17-22).

Methods

This article reports our systematic review in accordance with the Cochrane handbook for meta-analysis and systematic review furthermore QUORUM & PRISMA declarations (24, 35).

Search strategy

It was systematically searched MED-LINE, the Central Register of Controlled Trials (CENTRAL); PubMed (until March 2013); HINARI (until July 2014); EMBASE (until June 2013); Cochrane Injuries group (until June 2013) and the reference lists of articles. Randomized controlled trials and controlled clinical trials describing the control of intracranial pressure compared with controls were selected for potential inclusion. We constructed search filters for intracranial pressure (ICP) monitoring and traumatic brain injury (TBI) using a combination of exploded Medical Subject Heading (MeSH) terms and text words, all combined with Booleans operators. The search strategy is shown in the Appendix.

Inclusion criteria

We have searched for studies that met the following inclusion criteria 1) patients were older than 12 years; 2) had a severe traumatic brain injury (Glasgow coma scale < 8); 3) that compared the use of ICP monitoring with control; 4) that presented an estimate of mortality/ disability prognosis (95% confidence interval) 6 months after injury.

Search criteria

In duplicate and independently, two peoples screened all articles using the following inclusion criteria 1) patients were older than 12 years; 2) had a severe traumatic brain injury (Glasgow coma scale < 8); 3) that compared the use of ICP monitoring with control subjects; 4) that presented an estimate of mortality/disability prognosis (95% confidence interval) 6 months after injury.

Risk of bias assessment

Risk of bias was assessed in accordance with the Cochrane handbook for meta-analysis and systematic review (Charter 10).

Data extraction

In duplicate and independently the four peoples extracted the following data: mortality, duration of stay in critical care unit and the outcome at 6 months (Glasgow outcome score). The authors of the published research were contacted to obtain any missing data.

Results

Searching the electronic databases identified 1,450 potential citations. However, 1,310 were discarded due to duplications and subject matter being out of field, leaving 140. These were screened where a further 120 were discarded. From the 20 potentially eligible publications a further 8 were discarded. The remaining 12 randomized controlled trials (RTC) were evaluated and the numbers reduced further until only two were selected for the qualitative and quantitative analysis (meta-analy-sis) (Figure 1). Study characteristics, outcome, and clinical variables are lis-ted in Table 1.

Assessment of methodological quality and risk bias

The two publications selected were Chesnut (2012) and Kostic (2011). The work by Chesnut (2012) is categorized as "low risk" in all elements. The work of Kostic (2011) is categorized as "not a clear risk" in random sequence generation and allocation concealment, selective reporting and other bias, but "low risk" in all other items (Figure 2).

ICP monitoring and mortality

There was no significant reduction in mortality (RR 0.85, 95% CI 0.67 to 1.07) and no heterogeneity between the trials (I 2 = 0%, P = 0.42 [Chi.sup.2] P = 0.17) when comparing ICP monitoring with the controls (Figure 3).

ICP monitoring and neuropsychological prognosis

There were no differences in the prognosis of neuropsychological function (RR 1.01, 95% CI 0.87 to 1.18) when comparing ICP monitoring with the controls (Figures 4 and 5).

Stay in ICU

ICP monitoring shows greater efficacy compared to no monitoring, reducing the duration of stay in ICU (RR 3, 95% CI: 2-4), which reached statistical significance (P [less than or equal to] 0.001). The duration of stay in ICU with specific medical support for brain injuries was also reduced compared to the control group (P = 0.0001, 95% CI -1.4 -2,3 RR -0.43) (Figures 6 and 7).

Discussion

Although conflicting results were found regarding the effect of the protocol for trauma-based ICP monitoring and clinical and imaging by reviewing the global scientific literature, overall the reports recommend the use of these procedures. The descriptive cohort studies showed a positive effect on the implementation of a strict monitoring of ICP compared to imaging and clinical monitoring alone. Balestreri et al. (2006), reported that strict monitoring of ICP or by clinical monitoring of cerebral perfusion pressure (pupils, reflections stem, fundus, mean arterial pressure led to a substantial reduction in mortality. They considered the two methods to be complementary and recommend applying both procedures. However, these studies fail to demonstrate whether these methods are preventive as the evidence is of poor quality and strength.

In two double-blind randomized clinical trials published by Kostic et al. (2011) and Chesnut et al. 2012, it was evident that ICP monitoring did not improve the prognosis of the neuropsychological function (RR 1.01; 95% CI: 0.87 1.18), but it did lead to improved efficiency compared to any other surveillance method and reduced the length of stay in the ICU (RR 3, 95% CI: 2-4), reaching statistical significance (P [less than or equal to] 0.001). Also, the duration of stay in the ICU with specific medical support for brain injury was reduced compared to the control group (P = 0.0001; RR 1.4 95 -2.3 -0.43%). Relating to complications, there were no significant differences in either group, nor were there differences in the requirement for neurosurgery (RR 0.93, 95% CI 0.81 to 1.07, P = 0.33). The group who developed intracranial hypertension had a high mortality with poor prognosis. The average value of ICP was 17.25 mmHg.

A systematic review by Shao Hua et al. (2014), was conducted in patients that had suffered severe head injuries. However, the evidence presented in their study did not include the duration of stay in the ICU, the brain specific treatment, the need for neurosurgery, the need for specific treatment or the value of the ICP (36).

Conclusions

The monitoring of intracranial pressure no had an impact in terms of mortality. It also showed benefits in reducing polypharmacy and the number of interventions. We recommend maintaining the intracranial pressure below 16 mm Hg, but there is a lack of quality studies that provide better evidence. Further research should involve analysis of other diagnostic methods such as ultrasound or the measurement of cerebral perfusion.

Recibido: 01 de agosto de 2016

Aceptado: 09 de agosto de 2016
Appendix. Search strategy

PUBMED

#1Craniocerebral Trauma [mh] OR Brain Edema [mh] OR Glasgow Coma
Scale [mh] OR Glasgow Outcome Scale [mh] OR Unconsciousness [mh] OR
Cerebrovascular Trauma [mh] OR ((head or cranial or cerebral or
brain* or intra-cranial or inter-cranial) AND (haematoma * or
hematoma * or haemorrhag * or hemorrhage * or bleed * or pressure))
OR (Glasgow AND scale) OR ("diffuse axonal injury" OR "diffuse
axonal injuries") or ("persistent vegetative state") OR
((unconscious * OR coma * OR concuss *) AND (injury *OR injuriesOR
traumaOR damage OR damagedOR wound * OR fracture * OR contusion *
OR haematoma * OR hematoma * OR haemorrhag * OR hemorrhag * OR
bleed * OR pressure))

#2((randomized controlled trial[pt]OR controlled clinical
trial[pt])OR (randomizedOR randomised OR randomly OR placebo[tiab])
OR (trial[ti]) OR ("Clinical Trials as Topic"[MeSH Major Topic]))
NOT (("Animals"[Mesh]) NOT ("Humans"[Mesh] AND "Animals"[Mesh]))

#3(intracranial AND pressure) OR (cerebrospinal AND pressure)

#4(patient AND monitor*) OR (physiologic* AND monitor*)

#5#1 AND #2 AND #3 AND #4

COCHRANE INJURIES GROUP'S

("intracranial pressure" or "cerebrospinal pressure" or
"cerebrospinal fluid") and (monitor*) and (traumatic brain injury
OR head trauma OR Craniocerebral Trauma OR head injuries OR Brain
injuries)

COCHRANE CENTRAL REGISTER OF CONTROLLED TRIALS

#1MeSH descriptor Craniocerebral Trauma explode all trees

#2MeSH descriptor Cerebrovascular Trauma explode all trees

#3MeSH descriptor Brain Edema explode all trees

#4(brain or cerebral or intracranial) next (oedema or edema or
swell*)

#5MeSH descriptor Glasgow Coma Scale explode all trees

#6MeSH descriptor Glasgow Outcome Scale explode all trees

#7MeSH descriptor Unconsciousness explode all trees

#8glasgow next (coma or outcome) next (score or scale)

#9(Unconscious * or coma * or concuss * or 'persistent vegetative
state') near5 (injur * or trauma * or damag * or wound * or
fracture *)

#10"Rancho Los Amigos Scale"

#11(head or crani * or cerebr * or capitis or brain * or forebrain
* or skull * or hemispher * or intra-cran * or inter-cran*) near3
(injur * or trauma * or damag * or wound * or fracture * or
contusion *)

#12Diffuse next axonal next injur *

#13(head or crani * or cerebr * or brain * or intra-cran * or
inter-cran *) near3 (haematoma * or hematoma * or haemorrhag * or
hemorrhag * or bleed * or pressure)

#14MeSH descriptor Coma explode all trees

#15(#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR
#11 OR #12 OR #13 OR #14)

#16MeSH descriptor Intracranial Pressure explode all trees

#17MeSH descriptor Cerebrospinal Fluid Pressure explode all trees

#18intracranial near3 pressure

#19cerebrospinal near5 pressure

#20(#16 OR #17 OR #18 OR #19)

#21MeSH descriptor Monitoring, Physiologic explode all trees

#22(patient near3 monitor *) or (physiologic * near3 monitor *)

#23monitor *: ti, ab

#24(#21 OR #22 OR #23)

#25(#15 AND #20 AND #24)

EMBASE

1. exp Brain Injury/

2. exp Brain Edema/

3. exp Glasgow Coma Scale/

4. exp Glasgow Outcome Scale/

5. exp Rancho Los Amigos Scale/

6. exp Unconsciousness/

7. ((brain or cerebral or intracranial) adj5 (oedema or edema or
swell *)).ab,ti.

8. ((head or crani * or cerebr * or capitis or brain * or forebrain
* or skull * or hemispher * or intra-cran * or inter-cran *) adj5
(injur * or trauma * or damag * or wound * or fracture * or
contusion *)). ab, ti.

9. (Glasgow adj (coma or outcome) adj (scale * or score *)). ab,
ti.

10. Rancho Los Amigos Scale. ab, ti.

11. ((unconscious * or coma * or concuss * or 'persistent
vegetative state') adj3 (injur * or trauma * or damag * or wound *
or fracture *)). ti, ab.

12. Diffuse axonal injur *. ab, ti.

13. ((head or crani * or cerebr * or brain * or intra-cran * or
inter-cran *) adj3 (haematoma * or hematoma * or haemorrhag * or
hemorrhag * or bleed * or pressure)). ab, ti.

14. exp Coma/

15.or/1-14

16. exp Intracranial Pressure/

17. exp Cerebrospinal Fluid Pressure/

18. (intracranial adj3 pressure).ab,ti.

19. (cerebrospinal adj5 pressure).ab,ti.

20.16 or 17 or 18 or 19

21. exp Patient Monitoring/

22. ((physiologic * adj3 monitor *) or patient * monitor *). ab,
ti.

23. 21 or 22

24. 23 and 20

25.exp Intracranial Pressure Monitoring/

26.24 or 25 27.26 and 15

30. exp Randomized Controlled Trial/

31. exp controlled clinical trial/

32. randomi?ed.ab,ti.

33. placebo.ab.

34. * Clinical Trial/

35. randomly.ab.

36. trial.ti.

37.28 or29 or 30 or 31 or 32 or 33 or 34

38.exp animal/ not (exp human/ and exp animal/)

39.36 not 37

40.28 and 38

MEDLINE

1. exp Craniocerebral Trauma/

2. exp Brain Edema/

3. exp Glasgow Coma Scale/

4. exp Glasgow Outcome Scale/

5. exp Unconsciousness/

6. exp Cerebrovascular Trauma/

7. ((head or crani * or cerebr * or capitis or brain * or forebrain
* or skull * or hemispher * or intra-cran * or inter-cran *) adj5
(injur * or trauma * or damag * or wound * or fracture * or
contusion *)). ab, ti.

8. ((head or crani * or cerebr * or brain * or intra-cran * or
inter-cran *) adj5 (haematoma * or hematoma * or haemorrhag * or
hemorrhag * or bleed * or pressure)). ti, ab.

9. (Glasgow adj (coma or outcome) adj (scale * or score *)). ab,
ti.

10. "rancho los amigos scale". ti, ab.

11. ("diffuse axonal injury" or "diffuse axonal injuries"). ti, ab.

12. ((brain or cerebral or intracranial) adj3 (oedema or edema or
swell *)). ab, ti.

13. ((unconscious * or coma * or concuss * or 'persistent
vegetative state') adj3 (injur * or trauma * or damag * or wound *
or fracture *)). ti, ab.

14. exp coma/

15. or/1-14

16. exp Intracranial Pressure/

17. exp Cerebrospinal Fluid Pressure/

18. (intracranial adj3 pressure). ab, ti.

19. (cerebrospinal adj5 pressure). ab, ti.

20. 16 or 17 or 18 or 19

21. exp Monitoring, Physiologic/

22. ((patient adj3 monitor *) or (physiologic * adj3 monitor *)).
ab, ti.

23. 22 or 21

24. 23 and 20 and 15

25. randomi?ed. ab, ti.

26. randomized controlled trial.pt.

27. controlled clinical trial.pt.

28. placebo.ab.

29. clinical trials as topic.sh.

30. randomly.ab.

31. trial.ti.

32.25 or 26 or 27 or 28 or 29 or 30 or 31 33.(animals not (humans
and animals)).sh.

34.32 not 33 35.34 and 24

HINARI

#1 Craniocerebral Trauma [mh] OR Brain Edema [mh] OR Glasgow Coma
Scale [mh] OR Glasgow Outcome Scale [mh] OR Unconsciousness [mh] OR
Cerebrovascular Trauma [mh] OR ((head or cranial or cerebral or
brain * or intra-cranial or intercranial)

AND (haematoma * or hematoma * or haemorrhag * or hemorrhage * or
bleed * or pressure)) OR (Glasgow AND scale) OR ("diffuse axonal
injury" OR "diffuse axonal injuries") or ("persistent vegetative
state") OR ((unconscious * OR coma * OR concuss *) AND (injury * OR
injuriesOR traumaOR damage OR damagedOR wound * OR fracture * OR
contusion * OR haematoma * OR hematoma * OR haemorrhag * OR
hemorrhag * OR bleed * OR pressure))

#2 (randomized OR randomized OR randomly OR random order OR random
sequence OR random allocation OR randomly allocated OR at random OR
randomized controlled trial [pt] OR controlled clinical trial [pt]
OR randomized controlled trials [mh]) NOT ((models, animal[mh] OR
Animals[mh] OR Animal Experimentation[mh] OR Disease Models,
Animal[mh] OR Animals, Laboratory[mh]) NOT (Humans[mh]))

#4 #1 and #2


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Mario F. Quesada [2] M.D., Miguel A. Duran [1] M.D, Edgard F. Laiseca [1] M.D, William A. Florez [1] M.D.

[1] South Colombian University, medical school, Department of clinical sciences.

[2] Foundation Universitary Navarra.

Corresponding author:

William Andres Florez Perdomo, M.D.

South Colombian University, department clinical sciences.

William-florez@hotmail.com

Caption: Figure 1. Study flow diagram.

Caption: Figure 2. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Table 1. Characteristics of included studies

Author year,   Study    Exclusion     ICP
patients       desing   criteria      monitored
numbers

Kostic 2011    RCT      Died before   32
N = 61                  admission     (52,45%)
                        hospital

Chesnut 2012   RCT      Dead in       157
N = 324                 24 Hours      (48,45%)

Author year,   Type of       Outcome      Evidence
patients       ICP monitor   ICP group    quality
numbers

Kostic 2011    Not           Mortality    ++++ HIGH
N = 61         specified     disability

Chesnut 2012   EVD 100%      Mortality    ++++ HIGH
N = 324                      disability

Shown study type, clinic outcome and quality of evidence form
included studies.

Figure 3. Forest plot of comparison: 1 Monitoring Intracranial
Pressure (ICP) vs No Monitoring ICP, outcome 1.1 Mortality to six
mounth.

                    Monitoring ICP   No Monitoring ICP

Study or            Events   Total   Events   Total  Weight
Subgroup

Chesnut 2012           56     144       67     153    76.5%
Jostic 2011            15      32       19      29    23.5%

Total (95% CI)                176              182   100.0%
Total events           71               86

                        Risk Ratio

Study or               M-H, Fixed,       Risk Ratio M-H,
Subgroup                  95% CI          Fixed, 95% CI

Chesnut 2012        0.89 [0.68, 1.17]
Jostic 2011         0.72 [0.45, 1.13]

Total (95% CI)      0.85 [0.67, 1.07]
Total events

Heterogeneity: [Chi.sup.2] = 0.65, df = 1 (P = 0.42); [I.sup.2] = 0%
Test for overall effect: Z = 1.38 (P = 0.17)

Figure 4. Forest plot of comparison: 1 Monitoring Intracranial
Pressure (ICP) vs No Monitoring ICP, outcome 1.2 Good prognosis.

                    Monitoring ICP   No Monitoring ICP

Study or            Events   Total   Events   Total  Weight
Subgroup

Chesnut 2012           63     144       60     153    73.5%
Jostic 2011            19      32       20      29    26.5%

Total (95% CI)                176              182   100.0%
Total events           82               80

                        Risk Ratio

Study or               M-H, Fixed,       Risk Ratio M-H,
Subgroup                  95% CI          Fixed, 95% CI

Chesnut 2012        1.12 [0.85, 1.46]
Jostic 2011         0.86 [0.59, 1.25]

Total (95% CI)      1.05 [0.84, 1.31]
Total events

Heterogeneity: [Chi.sup.2] = 1.25, df = 1 (P = 0.26); [I.sup.2] = 20%
Test for overall effect: Z = 0.41 (P = 0.69)

Figure 5. Forest plot of comparison: 1 Monitoring Intracranial
Pressure (ICP) vs No Monitoring ICP, outcome 1.3 Poor prognosis.

                    Monitoring ICP   No Monitoring ICP

Study or            Events   Total   Events   Total  Weight
Subgroup

Chesnut 2012           80     144       93     153    90.5%
Jostic 2011            13      32        9      29     9.5%

Total (95% CI)                176              182   100.0%
Total events           93              102

                        Risk Ratio

Study or               M-H, Fixed,       Risk Ratio M-H,
Subgroup                  95% CI          Fixed, 95% CI

Chesnut 2012        0.91 [0.75, 1.11]
Jostic 2011         1.31 [0.66, 2.60]

Total (95% CI)      0.95 [0.79, 1.15]
Total events

Heterogeneity: [Chi.sup.2] = 1.00, df = 1 (P = 0.32); [I.sup.2] = 0%
Test for overall effect: Z = 0.52 (P = 0.60)

Figure 6. Forest plot of comparison: 1 Monitoring Intracranial
Pressure (ICP) vs No Monitoring ICP, outcome 1.4 duration of stay
in ICU.

                 Monitoring ICP      No Monitoring ICP

Study or         Mean   SD   Total   Mean   SD   Total  Weight
Subgroup

Chesnut 2012      12    5       1       9   4     157   100.0%

Total (95% CI)                157                 157   100.0%

                    Risk Ratio

Study or            M-H, Fixed,      Risk Ratio M-H,
Subgroup              95% CI          Fixed, 95% CI

Chesnut 2012     3.00 [2.00, 4.00]

Total (95% CI)   3.00 [2.00, 4.00]

Heterogeneity: Not applicable
Test for overall effect: Z = 5.87 (P < 0.00001)

Figure 7. Forest plot of comparison: 1 Monitoring Intracranial
Pressure (ICP) vs No Monitoring ICP, outcome 1.5 stay in ICU
specific medical support for brain injuries.

                 Monitoring ICP      No Monitoring ICP

Study or         Mean   SD   Total   Mean   SD   Total  Weight
Subgroup

Chesnut 2012     3.4    5     167    4.8    4     167        1

Total (95% CI)                167                 167   100.0%

                      Risk Ratio

Study or             M-H, Fixed,        Risk Ratio M-H,
Subgroup                95% CI           Fixed, 95% CI

Chesnut 2012     -1.40 [-2.37, -0.43]

Total (95% CI)   -1.40 [-2.37, -0.43]

Heterogeneity: Not applicable
Test for overall effect: Z = 2.83 (P = 0.005)
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Author:Quesada, Mario F.; Duran, Miguel A.; Laiseca, Edgard F.; Florez, William A.
Publication:Revista Chilena de Neurocirugia
Date:Jul 1, 2016
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