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Is There an Age Cutoff for Intracranial Pressure Monitoring?: A Propensity Score Matched Analysis of the National
Anna Liveris1, Afshin Parsikia1, Jeffrey Melvin2
1Department of Surgery, 24502Jacobi Medical Center, Bronx, NY, USA.
Insights
Intracranial pressure monitoring (ICPM) did not improve survival in traumatic brain injury (TBI) patients over 55. This age threshold warrants further study for ICPM indications, especially for elderly patients.
Area of Science:
- Neurosurgery
- Critical Care Medicine
- Trauma Surgery
Background:
- Recent data challenge the established indications and utility of intracranial pressure monitoring (ICPM).
- The Fourth Edition Brain Trauma Foundation guidelines provide limited recommendations for ICPM.
- Existing evidence suggests ICPM may reduce mortality in severe traumatic brain injury (TBI) but also indicates decreased survival in elderly populations.
Purpose of the Study:
- To evaluate the association between ICPM and mortality in adult patients with isolated severe TBI.
- To determine if ICPM provides survival benefits across different age strata.
Main Methods:
- Analysis of 23,652 adult patients with isolated TBI (head AIS ≥ 3, GCS ≤ 8) from the National Trauma Data Bank (2008-2014).
- Exclusion of patients with head AIS = 6 or death within 24 hours.
- Propensity-score matching (PSM) to compare outcomes between patients with and without ICPM, with logistic regression analysis for 8 age strata.
Main Results:
- ICPM was associated with increased mortality in the 56-65 year age group.
- ICPM demonstrated an association with improved survival in the 36-45 year age group.
- Overall mortality in the analyzed cohort was 29.2%.
Conclusions:
- ICPM is not associated with improved survival in TBI patients aged over 55 years, based on a large propensity-matched sample.
- The age of 55 years should be considered a threshold for ICPM indications pending further level 1 evidence.
- Prospective studies are recommended to refine ICPM indications for older TBI patients.
Background:
Despite mostly favorable past evidence for use of intracranial pressure monitoring (ICPM), more recent data question not only the indications but also the utility of ICPM. The Fourth Edition Brain Trauma Foundation guidelines offer limited indications for ICPM. Evidence supports ICPM for reducing mortality in patients with severe traumatic brain injury (TBI) and cites decreased survival in elderly patients.
Methods:
All patients ≥ 18 years of age with isolated TBI, head Abbreviated Injury Scale (AIS) ≥ 3, and a Glasgow Coma Scale (GCS) ≤ 8 between 2008 and 2014 were included from the National Trauma Data Bank. Exclusion criteria were head AIS = 6 and death within 24 hours. Patients with and without ICPM were compared using TBI-specific variables. Patients were then matched via propensity-score matching (PSM), and the odds ratio (OR) of death with ICPM was determined using logistic regression modeling for 8 different age strata.
Results:
A total of 23,652 patients with a mean age of 56 years, median head AIS of 4, median GCS of 3, and overall mortality of 29.2% were analyzed. After PSM, ICPM was associated with death beginning at the age stratum of 56-65 years. Intracranial pressure monitoring was associated with survival beginning at the age-group 36-45 years.
Discussion:
Based on a large propensity-matched sample of TBI patients, ICPM was not associated with improved survival for TBI patients above 55 years of age. Until level 1 evidence is available, this age threshold should be considered for further prospective study in determining indications for ICPM.
