Intracranial pressure as a therapeutic target

The BTF has declared that "The optimal ICP monitoring device is one that is accurate, reliable, cost effective, and causes minimal patient morbidity." None of the currently available devices fir that description. The utility of ICP monitoring is therefore weighed against the risk of destructively introducing a potentially infected object into the very delicate organ which you are trying to protect. The advantages and disadvantages of ICP as a therapeutic target have been interrogated in Question 27 from the first paper of 2014, as well as Question 4 from the first paper of 2005.

What kind of ICP monitor to use

The advantages and disadvantages of various ICP monitoring techniques are debated elsewhere.

In short, the gold standard is still the EVD. Its cheap and effective.

The EVD complies with all of the BTF's criteria for the "ideal" ICP monitor, with the exception perhaps of the morbidity part. It is still a slightly thicker object to insert than the internal strain transducer, so in that regard it tends to damage more parenchyma.

It can also be recalibrated, so that when its accuracy drifts, one can reset the zero reference value. This cannot be done with the internal strain gauges- they are zeroed before they are inserted, and they can never be rezeroed. This, with the new gauges, is not such a major issue - a recent study has discovered that they drift by no more than 5mmHg from atmospheric zero.

Risks of ICP monitoring

Shoving something into a person's brain parenchyma cannot be without risk.

What are the risks?

  • Risks of anaesthesia
  • Risks of craniotomy
  • Risks of haemorrhage
  • Risk of infection
  • Malposition and poor monitoring quality
  • Incorrect readings may stimulate incorrect management
  • EVDs may clog with debris; parenchymal monitors may "drift" from their zero calibration value
  • ICP-guided and CPP-guided therapy may not improve outcomes.

Benefits of ICP-guided therapy

In their model answer to Question 16 of the first paper of 2009, the college refeer to a study by O.L Cremer, whose 2005 retrospective cohort study associated ICP-guided therapy with increased intensity of therapy and more prolonged mechanical ventilation, without a benefit to either survival or functional outcome. In the same answer the examiners also mention Shahid Shafi's 2008 analysis of The National Trauma Data Bank (1994–2001) which found that ICP monitoring was associated with a 45% reduction in survival. A 2012 randomised controlled trial of ICP monitoring versus imaging and clinical examination did not demonstrate superiority of one over the other in terms of mortality or functional outcome. In 2014, a meta-analysis scraped together 11,038 patients worth of trial and cohort data, also concluding "no benefit" in the face of severe heterogeneity.

However, an earlier (2000) analysis by Lane et al concluded that ICP monitoring was associated with increased survival. Similarly, a 2013 prospective observational study of ICP monitoring in TBI revealed that the overall in-hospital mortality was significantly higher in patients who did not undergo ICP monitoring (53.9% vs 32.7%), possibly due to missed episodes of brain herniation. In 2015 another supportive retrospective study was published, again finding a substantial decrease in mortality (30.7% vs. 45.7%).

At this point, the BTF Guidelines recommend ICP monitoring be carried out in those patients which meet their indications. These guidelines were put together in 2007, and do not reflect more recent data; however it is unlikely that ICP monitoring will be abandoned entirely in future versions. "Multimodal" monitoring is the new catchphrase, and recent position statements from various eminent Societies suggest that there is a move to integrate several different bedside monitoring techniques for simultaneous observation of multiple important parameters, with fewer "hard" universal physiological targets.

Furthermore, patient selection probably plays a major role. Recent observational data suggest that certain groups might benefit from ICP monitoring more than others.

Specifically, groups which benefit in terms of mortality are as follows:

  • GCS of 3-5 at admission.
  • GCS of 9-12 which drops to 3-8 within 24 hours.
  • Those who had a probability of death greater than 60% at 6 months.

What if you had no ICP monitor

Or it fell out. Or you removed it because of infection or calibration drift. Or perhaps you work in an austere environment and aren't made of money. Either way, occasionally one must make do without any direct intracranial pressure monitoring. In these situations, one is able to rely on clinical signs and imaging to decide whether to use ICP-lowering therapies. This has not appeared in any of the exams, but it is fair game, considering the CREVICE protocol was published in 2020, and BEST:TRIP in 2012. The latter trial had a protocol for the management of their control group, and found no difference in mortality between controls and patients who had ICP monitors.

In short, you have raised ICP if one major or two minor criteria are present:

  • Major:
    • Compressed cisterns
    • Midline shift > 5 mm
    • Non-evacuated mass lesion.
  • Minor:
    • GCS motor score of 4 or less 
    • Pupillary asymmetry
    • Abnormal pupillary reactivity
    • Basal cisterns are present with midline shift 0-5 mm and/or high- or mixed-density lesion of 25 cm3 or less

Additionally, treatment escalation to the next tier is recommended if:

  • Neuroworsening:
    • Decrease in the motor GCS of 1 or more points
    • New loss of pupil reactivity
    • Interval development of pupil asymmetry of > 2mm or bilateral mydriasis d
    • New focal motor deficit 
    • Herniation syndrome (e.g., Cushing’s triad) 
  • No improvement or worsening on follow-up CT imaging 
  • No acceptable response to initial therapy


  • Scheduled (rather than reactive) osmotherapy is first tier
    • Hypertonic saline is recommended for this
  • Mild hyperventilation (35mmHg at the lowest) is second tier
  • Decompressive craniectomy is third tier

Other elements:

  • When tapering therapy, the last treatment initiated should be stopped first
  • MAP aim is 90, which can be tapered to 80 when the patient starts to improve
  • Scan the head more:
    • At 12 hours
    • At 24 hours
    • At 72 hours
  • Sedation should be minimised, for repeated assessments


Our beloved Oh's Intensive Care manual has two excellent chapters to dedicate to this topic:

Chapter 43 (pp. 563) Cerebral protection by Victoria Heaviside and Michelle Hayes, and

Chapter 67 (pp. 765) Severe head injury by John A Myburgh.

However, the discerning reader will recognise this book as an antique, and look instead to the frequently updated Brain Trauma Organisation Guidelines for Management of Traumatic Brain Injury.

Narayan, Raj K., et al. "Intracranial pressure: to monitor or not to monitor? A review of our experience with severe head injury." Journal of neurosurgery 56.5 (1982): 650-659.

Forsyth, Rob J., Susanne Wolny, and Beryl Rodrigues. "Routine intracranial pressure monitoring in acute coma." Cochrane Database Syst Rev 2 (2010).

Badri, Shide, et al. "Mortality and long-term functional outcome associated with intracranial pressure after traumatic brain injury." Intensive care medicine 38.11 (2012): 1800-1809.

Farahvar, Arash, et al. "Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring: Clinical article."Journal of neurosurgery 117.4 (2012): 729-734.

Chesnut, Randall M., et al. "A trial of intracranial-pressure monitoring in traumatic brain injury." New England Journal of Medicine 367.26 (2012): 2471-2481.

Farahvar, Arash, et al. "Response to intracranial hypertension treatment as a predictor of death in patients with severe traumatic brain injury: Clinical article."Journal of neurosurgery 114.5 (2011): 1471-1478.

Meythaler, Jay M., et al. "Current concepts: Diffuse axonal injury - associated traumatic brain injury." Archives of physical medicine and rehabilitation 82.10 (2001): 1461-1471.

Tasker, R. C., et al. "Monitoring in non-traumatic coma. Part I: Invasive intracranial measurements." Archives of disease in childhood 63.8 (1988): 888-894.

Cremer, Olaf L., et al. "Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury*." Critical care medicine 33.10 (2005): 2207-2213.

Shafi, Shahid, et al. "Intracranial pressure monitoring in brain-injured patients is associated with worsening of survival." Journal of Trauma and Acute Care Surgery 64.2 (2008): 335-340.

Lane, Peter L., et al. "Intracranial pressure monitoring and outcomes after traumatic brain injury." Canadian Journal of Surgery 43.6 (2000): 442.

Talving, Peep, et al. "Intracranial pressure monitoring in severe head injury: compliance with Brain Trauma Foundation guidelines and effect on outcomes: a prospective study: Clinical article." Journal of neurosurgery 119.5 (2013): 1248-1254.

Chesnut, Randall M., et al. "A trial of intracranial-pressure monitoring in traumatic brain injury." New England Journal of Medicine 367.26 (2012): 2471-2481.

Su, Shao-Hua, et al. "The Effects of Intracranial Pressure Monitoring in Patients with Traumatic Brain Injury." PloS one 9.2 (2014): e87432.

Dawes, Aaron J., et al. "Intracranial pressure monitoring and inpatient mortality in severe traumatic brain injury: A propensity score–matched analysis." Journal of Trauma and Acute Care Surgery 78.3 (2015): 492-502.

Muizelaar, J. Paul. "Multimodal Monitoring After Traumatic Brain Injury: Useless or Useful?*." Critical care medicine 43.2 (2015): 506-507.

Le Roux, Peter, et al. "The International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care: A List of Recommendations and Additional Conclusions." Neurocritical care (2014): 1-15.

Tisdall, M. M., and M. Smith. "Multimodal monitoring in traumatic brain injury: current status and future directions." British journal of anaesthesia 99.1 (2007): 61-67.

Yuan, Qiang, et al. "Effects and Clinical Characteristics of Intracranial Pressure Monitoring–Targeted Management for Subsets of Traumatic Brain Injury: An Observational Multicenter Study." Critical Care Medicine (2015).

Chesnut, Randall M., et al. "Consensus-based management protocol (CREVICE Protocol) for the treatment of severe traumatic brain injury based on imaging and clinical examination for use when intracranial pressure monitoring is not employed." Journal of neurotrauma 37.11 (2020): 1291-1299.