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Updated: Jul 12, 2025
A Bedside, Single Burr Hole Approach to Multimodality Monitoring in Severe Brain Injury
Published on: March 26, 2019
Multimodal monitoring intracranial pressure by invasive and noninvasive means
Fabiano Moulin de Moraes1, Erica Navarro Borba Adissy2, Eva Rocha2
1Neurology and Neurosurgery Department, Federal University of São Paulo, São Paulo, Brazil. fabianomoulin@yahoo.com.br.
Insights
Noninvasive methods for diagnosing intracranial hypertension (ICH) show promise, correlating with invasive intracranial pressure (ICP) monitoring. Combining transcranial Doppler (TCD) pulsatility index and brain wave morphology may improve ICH diagnosis accuracy.
Area of Science:
- Neurosurgery
- Critical Care Medicine
- Neurology
Background:
- Intracranial hypertension (ICH) diagnosis relies on invasive intraventricular catheter placement, posing risks.
- Current noninvasive methods for ICH detection lack robust clinical evidence.
- Developing reliable noninvasive techniques is crucial for safer ICH monitoring.
Purpose of the Study:
- To evaluate the diagnostic discriminative power of four noninvasive methods for intracranial hypertension (ICH).
- To explore the potential of combining noninvasive techniques for improved ICH detection.
- To generate hypotheses for future research on noninvasive ICH monitoring.
Main Methods:
- Prospective data collection from ICU patients with subarachnoid hemorrhage, intraparenchymal hemorrhage, and ischemic stroke.
- Simultaneous measurement of intracranial pressure (ICP) via invasive monitoring and noninvasive methods: optic nerve sheath diameter (ONSD), transcranial Doppler pulsatility index (PI), CT visual scale, and Brain4Care (B4c) wave morphology (P2/P1 ratio, time-to-peak).
- ICH defined as sustained ICP > 20 mmHg for at least 5 minutes.
Main Results:
- All tested noninvasive methods (ONSD, PI, CT scale, P2/P1 ratio, TTP) showed significant statistical correlation with invasive ICP measurements (p < 0.001).
- Areas under the curve (AUC) for diagnosing ICH ranged from 0.64 to 0.79 for individual noninvasive methods.
- A combined approach yielded a higher AUC of 0.86; the combination of TCD PI and B4c achieved an AUC of 0.80.
Conclusions:
- Noninvasive techniques demonstrate acceptable discrimination ability for diagnosing intracranial hypertension (ICH).
- Multimodal combination, particularly TCD pulsatility index and brain wave morphology, may enhance diagnostic accuracy for ICH.
- Further comprehensive investigations are needed to optimize noninvasive ICP estimation methods across diverse clinical scenarios.
Abstract:
Although the placement of an intraventricular catheter remains the gold standard method for the diagnosis of intracranial hypertension (ICH), the technique has several limitations including but not limited to its invasiveness. Current noninvasive methods, however, still lack robust evidence to support their clinical use. We aimed to estimate, as an exploratory hypothesis generating analysis, the discriminative power of four noninvasive methods to diagnose ICH. We prospectively collected data from adult intensive care unit (ICU) patients with subarachnoid hemorrhage (SAH), intraparenchymal hemorrhage (IPH), and ischemic stroke (IS) in whom invasive intracranial pressure (ICP) monitoring had been placed. Measures were simultaneously collected from the following noninvasive methods: optic nerve sheath diameter (ONSD), pulsatility index (PI) using transcranial Doppler (TCD), a 5-point visual scale designed for brain Computed Tomography (CT), and two parameters (time-to-peak [TTP] and P2/P1 ratio) of a noninvasive ICP wave morphology monitor (Brain4Care[B4c]). ICH was defined as a sustained ICP > 20 mmHg for at least 5 min. We studied 18 patients (SAH = 14; ICH = 3; IS = 1) on 60 occasions with a mean age of 52 ± 14.3 years. All methods were recorded simultaneously, except for the CT, which was performed within 24 h of the other methods. The median ICP was 13 [9.8-16.2] mmHg, and intracranial hypertension was present on 18 occasions (30%). Median values from the noninvasive techniques were ONSD 4.9 [4.40-5.41] mm, PI 1.22 [1.04-1.43], CT scale 3 points [IQR: 3.0], P2/P1 ratio 1.16 [1.09-1.23], and TTP 0.215 [0.193-0.237]. There was a significant statistical correlation between all the noninvasive techniques and invasive ICP (ONSD, r = 0.29; PI, r = 0.62; CT, r = 0.21; P2/P1 ratio, r = 0.35; TTP, r = 0.35, p < 0.001 for all comparisons). The area under the curve (AUC) to estimate intracranial hypertension was 0.69 [CIs = 0.62-0.78] for the ONSD, 0.75 [95% CIs 0.69-0.83] for the PI, 0.64 [95%Cis 0.59-069] for CT, 0.79 [95% CIs 0.72-0.93] for P2/P1 ratio, and 0.69 [95% CIs 0.60-0.74] for TTP. When the various techniques were combined, an AUC of 0.86 [0.76-0.93]) was obtained. The best pair of methods was the TCD and B4cth an AUC of 0.80 (0.72-0.88). Noninvasive technique measurements correlate with ICP and have an acceptable discrimination ability in diagnosing ICH. The multimodal combination of PI (TCD) and wave morphology monitor may improve the ability of the noninvasive methods to diagnose ICH. The observed variability in non-invasive ICP estimations underscores the need for comprehensive investigations to elucidate the optimal method-application alignment across distinct clinical scenarios.
