Intracranial pressure monitoring and outcomes after traumatic brain injury

OBJECTIVE: Uncontrolled intracranial hypertension after traumatic brain inj ury (TBI) contributes significantly to the death rate and to poor functiona l outcome. There is no evidence that intracranial pressure (ICP) monitoring alters the outcome of TBI. The objective of this study was to test the hyp othesis that insertion of ICP monitors in patients who have TBI is not asso ciated with a decrease in the death rate. DESIGN: Study of case records. METHODS: The data files from the Ontario Trauma Registry from 1989 to 1995 were examined. Included were all cases with an Injury Severity Score (ISS) greater than 12 from the 14 trauma centres in Ontario. Cases identifying a Maximum Abbreviated Injury Scale score in the head region (MAIS head) great er than 3 were selected for further analysis. Logistic regression analyses mere conducted to investigate the relationship between ICP and death. RESULTS: Of 9001 registered cases of TBI, an MAIS head greater than 3 was r ecorded in 5507. Of these patients, 541 (66.8% male, mean age 34.1 years) h ad an ICP monitor inserted. Their average ISS was 33.4 and 71.7% survived. There was wide variation among the institutions in the rate of insertion of ICP monitors in these patients (ranging from 0.4% to over 20%). Univariate logistic regression indicated that increased MAIS head, ISS, penetrating t rauma and the insertion of an ICP monitor were each associated with an incr eased death rate. However, multivariate analyses controlling for MAIS head, ISS and injury mechanism indicated that ICP monitoring was associated with significantly improved survival (P < 0.015). CONCLUSIONS: ICP monitor insertion rates vary widely in Ontario's trauma ho spitals. The insertion of an ICP monitor is associated with a statistically significant decrease in death rate among patients with severe TBI. This fi nding strongly supports the need for a prospective randomized trial of mana gement protocols, including ICP monitoring, in patients with severe TBI.