Visualization of the Intracranial Pressure and Time Burden in Childhood Brain Trauma: What We Have Learned One Decade
Bavo Kempen1, Bart Depreitere1,2, Ian Piper3,4
1Department of Neurosciences, KU Leuven, Leuven, Belgium.
Insights
The intracranial pressure (ICP) dose-response plot, validated in pediatric traumatic brain injury (pTBI), shows higher ICP is tolerated for shorter durations. ICP above 20 mmHg and cerebral perfusion pressure (CPP) below 50 mmHg correlate with poor outcomes.
Area of Science:
- Pediatric Traumatic Brain Injury
- Neurocritical Care
- Intracranial Pressure Monitoring
Background:
- Intracranial pressure (ICP) management is critical in pediatric traumatic brain injury (pTBI).
- Previous studies suggest an ICP dose-response relationship, but validation in novel datasets is needed.
- Understanding ICP intensity-duration effects is crucial for optimizing patient outcomes.
Purpose of the Study:
- To validate the ICP dose-response visualization plot in a new, prospectively collected pTBI dataset.
- To correlate ICP intensity-duration episodes with 6-month Glasgow Outcome Score (GOS).
- To investigate the influence of cerebrovascular reactivity and cerebral perfusion pressure (CPP) on outcomes.
Main Methods:
- Minute-by-minute ICP and mean arterial blood pressure data from 104 pTBI patients were analyzed.
- ICP intensity-duration episodes were categorized and correlated with GOS.
- ICP dose-response plots were generated and compared to previous findings, incorporating CPP and cerebrovascular reactivity analysis.
Main Results:
- The ICP dose-response plot was successfully reproduced in the novel pTBI dataset.
- Higher ICP episodes were tolerated for shorter durations, following an exponential decay curve.
- ICP > 20 mmHg or CPP < 50 mmHg for any duration was associated with poor outcomes, irrespective of other factors.
Conclusions:
- The ICP dose-response plot is a valid tool for assessing pTBI severity and predicting outcomes.
- Current therapeutic ICP thresholds may need re-evaluation, suggesting a need for lower bedside targets.
- CPP < 50 mmHg is a critical threshold associated with worse outcomes in pTBI.
Abstract:
To validate the intracranial pressure (ICP) dose-response visualization plot for the first time in a novel prospectively collected pediatric traumatic brain injury (pTBI) data set from the multi-center, multi-national KidsBrainIT consortium. Prospectively collected minute-by-minute ICP and mean arterial blood pressure time series of 104 pTBI patients were categorized in ICP intensity-duration episodes. These episodes were correlated with the 6-month Glasgow Outcome Score (GOS) and displayed in a color-coded ICP dose-response plot. The influence of cerebrovascular reactivity and cerebral perfusion pressure (CPP) were investigated. The generated ICP dose-response plot on the novel data set was similar to the previously published pediatric plot. This study confirmed that higher ICP episodes were tolerated for a shorter duration of time, with an approximately exponential decay curve delineating the positive and negative association zones. ICP above 20 mm Hg for any duration in time was associated with poor outcome in our patients. Cerebrovascular reactivity state did not influence their respective transition curves above 10 mm Hg ICP. CPP below 50 mm Hg was not tolerated, regardless of ICP and duration, and was associated with worse outcome. The ICP dose-response plot was reproduced in a novel and independent pTBI data set. ICP above 20 mm Hg and CPP below 50 mm Hg for any duration in time were associated with worse outcome. This highlighted a pressing need to reduce pediatric ICP therapeutic thresholds used at the bedside.
Related Concept Videos
01:28Traumatic Brain Injury l: Introduction
01:14Increased Intracranial Pressure l: Introduction
01:29Increased Intracranial Pressure ll: Pathophysiology