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Intracranial Pressure Monitoring in Patients With Spontaneous Intracerebral Hemorrhage: Insights From the SYNAPSE-ICU
Stefania Dallagiacoma1, Chiara Robba1, Francesca Graziano1
1From the Neurology and Clinical Neurophysiology Unit, Department of Medicine, Surgery and Neuroscience (S.D.), University of Siena; Department of Anaesthesia and Intensive Care (C.R.), Policlinico San Martino IRCCS for Oncology and Neuroscience, Genoa; Department of Surgical Science and Diagnostic Integrated (C.R.), University of Genoa; School of Medicine and Surgery (F.G., P.R., S.G., G.C.) and Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center (F.G., P.R., S.G.), University of Milano-Bicocca, Milan, Italy; Department of Neurology (J.C.H.), University of California San Francisco; and Neurointensive Care Unit, Department Neuroscience (G.C.), San Gerardo Hospital, ASST-Monza, Italy.
Background:
Uncertainties exist regarding the indications, management, and effect of intracranial pressure (ICP) monitoring and treatment on outcome in patients with spontaneous intracranial hemorrhage (ICH).
Methods:
We performed an analysis of patients with spontaneous ICH enrolled in the SYNAPSE-ICU study, an international prospective observational study on the use of ICP monitoring. This study aimed to describe, in a large cohort of patients with spontaneous ICH admitted to the intensive care unit (ICU), the clinical practice of ICP monitoring, the occurrence of intracranial hypertension, and its therapeutic management. We assessed in-hospital mortality and the association between ICP monitoring and 6-month mortality and outcome by a propensity score approach with inverse probability weighting.
Results:
A total of 587 patients with ICH were included in this study; 281 (47.9%) received ICP monitoring. ICP-monitored patients, compared with nonmonitored patients, were younger (61 vs 67 years; p < 0.001), presented more frequently with both reactive pupils (67.2% vs 55.2%; p = 0.008), with better neurologic status at admission (Glasgow Coma Scale ≤8, 82.3% vs 88.8%; p = 0.038), and received higher therapy intensity level during the ICU stay. In 70.5% (170 out of 241) of ICP-monitored patients, the ICH score was equal to 3 or 4. Nearly half of monitored patients (46.6%) had at least one episode of ICP ≥20 mm Hg during the first week. An intraventricular catheter (53.6%) was the most frequently used device and was associated with fewer episodes of intracranial hypertension compared with the other monitoring devices (43.7% vs 64.9%, respectively). At weighted Cox regression model, ICP monitoring was associated with a significant reduction of 6-month mortality (hazard ratio 0.49 [95% CI 0.35-0.71; p = 0.001), but not with neurologic outcome (odds ratio 0.83 [95% CI 0.41-1.68]; p = 0.6077).
Conclusions:
ICP monitoring in ICH was utilized mainly in moderately severe cases. ICP monitoring was associated with a reduction of in-hospital and 6-month mortality but did not improve 6-month functional outcomes. Further research and randomized controlled trials to generate higher-level medical evidence to support guidelines regarding ICP use and treatment in patients with ICH are needed.
Trial Registration Information:
SYNAPSE-ICU: ClinicalTrials.gov NCT03257904.
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