Search

Background: Traumatic brain injury (TBI) is a highly prevalent and potentially severe medical condition. Challenges regarding TBI management are related to accurate diagnostics, defining its severity, and establishing prompt interventions to affect outcomes. Among the health care components in the TBI handling strategy is intracranial pressure (ICP) monitoring, which is fundamental to therapy decisions. However, ICP monitoring is an Achilles tendon, imposing a significant financial burden on health care systems, particularly in middle and low-income communities. This article arises from the understanding from the authors that there is insufficient scientific evidence about the potential economic impacts from the use of noninvasive technologies in the monitoring of TBI. Based on personal experience, as well as from reading other, clinically focused studies, the thesis is that the use of such technologies could greatly affect the health care system and this article seeks to address this lack of literature, show ways in which such systems could be evaluated, and show estimations of possible results from these investigations., Objective: This review primarily investigates the economic burden of TBI and whether new technologies are suitable to reduce its health care costs without compromising the quality of care, according to the levels of evidence available. The objective is to stimulate more research and attention in the area., Methods: For this narrative review, a PubMed search was conducted for articles discussing TBI health care costs, as well as monitoring technologies (tomography, magnetic resonance imaging, optic nerve sheath diameter, transcranial Doppler, pupillometry, and noninvasive ICP waveform) and their application in managing TBI. Strategies were first evaluated from a medical noninferiority perspective before calculating the average savings of each selected strategy. All applicable studies were analyzed for quality using the Consolidated Health Economic Evaluation Reporting Standards 2022 Statement 117 and this article was written to conform as much as possible with it., Results: The review included 109 references and showed a consistent potential in noninvasive technologies to reduce costs and maintain or improve the quality of care., Conclusions: TBI prevalence has increased with a disproportionate health care burden in the last decades. Noninvasive monitoring techniques seem to be effective in reducing TBI health care costs, with few limitations, especially the need for more supporting scientific evidence. The undeniable clinical and financial potential of these techniques is compelling to further investigate their role in TBI management, as well as the creation of more comprehensive monitoring models to the understanding of complex phenomena occurring in the injured brain., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Intracranial pressure monitor (ICPm) procedure rates are a quality metric for American College of Surgeons trauma center verification. However, ICPm procedure rates may not accurately reflect the quality of care in TBI. We hypothesized that ICPm and craniotomy/craniectomy procedure rates for severe TBI vary across the United States by geography and institution., Methods: We identified all patients with a severe traumatic brain injury (head Abbreviated Injury Scale, ≥3) from the 2016 Trauma Quality Improvement Program data set. Patients who received surgical decompression or ICPm were identified via International Classification of Diseases codes. Hospital factors included neurosurgeon group size, geographic region, teaching status, and trauma center level. Two multiple logistic regression models were performed identifying factors associated with (1) craniotomy with or without ICPm or (2) ICPm alone. Data are presented as medians (interquartile range) and odds ratios (ORs) (95% confidence interval)., Results: We identified 75,690 patients (66.4% male; age, 59 [36-77] years) with a median Injury Severity Score of 17 (11-25). Overall, 6.1% had surgical decompression, and 4.8% had ICPm placement. Logistic regression analysis showed that region of the country was significantly associated with procedure type: hospitals in the West were more likely to use ICPm (OR, 1.34 [1.20-1.50]), while Northeastern (OR, 0.80 [0.72-0.89]), Southern (OR, 0.84 [0.78-0.92]), and Western (OR, 0.88 [0.80-0.96]) hospitals were less likely to perform surgical decompression. Hospitals with small neurosurgeon groups (<3) were more likely to perform surgical intervention. Community hospitals are associated with higher odds of surgical decompression but lower odds of ICPm placement., Conclusion: Both geographic differences and hospital characteristics are independent predictors for surgical intervention in severe traumatic brain injury. This suggests that nonpatient factors drive procedural decisions, indicating that ICPm rate is not an ideal quality metric for American College of Surgeons trauma center verification., Level of Evidence: Epidemiological, level III; Care management/Therapeutic level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Because there are no head-to-head studies of the efficacy of surgical options in the treatment of medically-intractable idiopathic intracranial hypertension (IIH), procedure selection is often based on expected complications. Cerebrospinal fluid (CSF) diversion by shunting has been reported to have a 23%-67% rate of shunt failure. But these figures derive from small cohorts or studies that do not separate the complication rates of the different shunt options-ventriculoperitoneal (VP), lumboperitoneal (LP), and ventriculoatrial (VA). The complication rate of LP shunts seems to be higher than that for VP shunts, the procedure currently in widest use. Our experience with VP shunts for IIH over the past decades suggests that the complication rate for that option is lower than reported series would suggest., Methods: Retrospective single-institutional study using a search engine that finds all text mentions of particular terms. We searched for the terms ("IIH" OR "Idiopathic intracranial hypertension" OR "PTC OR "pseudotumor") AND ("VP Shunt" OR "ventriculoperitoneal") over the period 1998 to 2018. From 490 "hits," only 32 patients met entry criteria: diagnosis of IIH confirmed at our institution, including examination in a neuro-ophthalmology clinic showing papilledema, elevated opening pressure on lumbar puncture or a consistently elevated intraparenchymal pressure on Codman intracranial pressure (ICP) monitoring, neuroimaging and CSF studies consistent with a diagnosis of IIH, and at least 1 year of follow-up in our neuro-ophthalmology or neurosurgery clinics., Results: Shunt failures occurred in 6 (18.7%) of 32 patients, which included elevated ICP due to obstruction or discontinuity of the shunt, over-drainage, infection of the shunt system, or intractable abdominal pain or infection. None of these failures caused permanent worsening of vision, neurologic morbidity, or death. But they entailed considerable medical care. Placement of VP shunts also aroused patient fear of complications, precipitating 38 emergency visits in 14 patients for "false alarms.", Conclusions: In this series of 32 patients, the largest retrospective study of VP shunts for IIH, there was an 18.7% failure rate, lower than previously published smaller series have disclosed. But among patients who suffered complications, a saga of intensive medical care often occurred. Placement of the shunt also aroused patient fear of complications, leading to many medical encounters required to rule out complications., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 by North American Neuro-Ophthalmology Society.)

Background: An association between idiopathic intracranial hypertension (IIH) and anemia has been speculated from previous case reports and case series. Retrospective studies to date have not used matched case controls to compare standardized complete blood count (CBC) values for the presence of anemia., Methods: At our tertiary care facility, 50 patients with IIH were matched with 50 case-control patients to compare CBC values from laboratory affiliates with standardized ranges., Results: No significant difference was found for any CBC parameters for IIH vs control patients. For female IIH and control patients as well as male IIH patients, values for red blood cell count, hemoglobin (HGB), and hematocrit (HCT) tended to trend on the lower end of "normal" range, whereas this was not seen in male control patients., Conclusions: In this retrospective, matched case-control study, no significant association was found between IIH and anemia when comparing standardized CBC values. In accordance with previous studies, the prevalence of anemia may be relatively higher in the IIH population due to a prominent demographic overlap of females of child-bearing age.

Background: Utilization of ICP monitors for pediatric patients is low and varies between centers. We hypothesized that in more severely injured patients (GCS 3-4), there would be a decreased mortality associated with invasive monitoring devices., Methods: The pediatric Trauma Quality Improvement Program (TQIP) was queried for patients aged ≤ 16 years meeting criteria for invasive monitors. Our primary outcome was mortality. Patients with ICP monitoring were compared to those without. A logistic regression was used to examine the risk of mortality., Results: Of 3,808 patients, 685 (18.0%) underwent ICP monitoring. ICP monitors were associated with increased risk of mortality (OR 1.82, CI 1.36-2.44, p < 0.001). A secondary analysis including type of invasive ICP monitor and dividing GCS into 3 categories revealed both intraventricular drain (OR 1.89, CI 1.3-2.7, p = 0.001) and intraparenchymal pressure monitor (OR 1.86, CI 1.32-2.6, p < 0.001) to be independently associated with an increased likelihood of mortality regardless of GCS, while intraparenchymal oxygen monitoring was not (OR 0.47, CI 0.11-2.05, p = 0.316). The strongest effect was seen in those patients with a GCS of 5-6., Conclusion: ICP monitors are an independent risk factor for mortality, particularly with intraventricular drains and intraparenchymal monitors in patients with a GCS 5-6.

Background: Automated pupillometry is becoming widely accepted as an objective measure of pupillary function, especially in neurocritical care units. Normative reference values and thresholds to denote a significant change are necessary for integrating automated pupillometry into practice., Objective: Providing point estimates of normal ranges for pupillometry data will help clinicians intuit meaning from these data that will drive clinical interventions., Methods: This study used a planned descriptive analysis using data from a multicenter registry including automated pupillometry assessments in 2140 subjects from 3 US hospitals collected during a 3-year period., Results: We provide a comprehensive list of admission pupillometry data. Our data demonstrate significant differences in pupillary values for Neurological Pupil Index, latency, and constriction velocity when stratified by age, sex, or severity of illness defined by the Glasgow Coma Scale score., Conclusion: This study provides a greater understanding of expected distributions for automated pupillometry values in a wide range of neurocritical care populations.

Although existing guidelines support the utilization of intracranial pressure (ICP) monitoring in patients with traumatic brain injury (TBI), the evidence suggesting benefit is limited. To evaluate the impact on outcome, we determined the relationship between ICP monitoring and mortality in centers participating in the American College of Surgeons Trauma Quality Improvement Program (TQIP). Data on 10,628 adults with severe TBI were derived from 155 TQIP centers over 2009-2011. Random-intercept multilevel modeling was used to evaluate the association between ICP monitoring and mortality after adjusting for important confounders. We evaluated this relationship at the patient level and at the institutional level. Overall mortality (n=3769) was 35%. Only 1874 (17.6%) patients underwent ICP monitoring, with a mortality of 32%. The adjusted odds ratio (OR) for mortality was 0.44 [95% confidence interval (CI), 0.31-0.63], when comparing patients with ICP monitoring to those without. It is plausible that patients receiving ICP monitoring were selected because of an anticipated favorable outcome. To overcome this limitation, we stratified hospitals into quartiles based on ICP monitoring utilization. Hospitals with higher rates of ICP monitoring use were associated with lower mortality: The adjusted OR of death was 0.52 (95% CI, 0.35-0.78) in the quartile of hospitals with highest use, compared to the lowest. ICP monitoring utilization rates explained only 9.9% of variation in mortality across centers. Results were comparable irrespective of the method of case-mix adjustment. In this observational study, ICP monitoring utilization was associated with lower mortality. However, variability in ICP monitoring rates contributed only modestly to variability in institutional mortality rates. Identifying other institutional practices that impact on mortality is an important area for future research.

Objectives: To describe between-hospital and patient-level variation in intracranial pressure (ICP) monitoring and to evaluate ICP monitoring in association with hospital features and outcome in children with traumatic brain injury (TBI)., Design: Retrospective cohort study. SETTING Children's hospitals participating in the Pediatric Health Information System database (January 2001 to June 2011)., Participants: Children (aged <18 years) with TBI and head Abbreviated Injury Scale scores of at least 3 who were ventilated for at least 96 consecutive hours or who died in the first 4 days after hospital admission., Main Outcome Measures: Monitoring of ICP., Results: A total of 4667 children met the study criteria. Hospital mortality was 41% (n = 1919). Overall, 55% of patients (n = 2586) received ICP monitoring. Expected hospital ICP monitoring rates after adjustment for patient age, cardiac arrest, inflicted injury, craniotomy or craniectomy, head Abbreviated Injury Scale score, and Injury Severity Score were 47% to 60%. Observed hospital ICP monitoring rates were 14% to 83%. Hospitals with more observed ICP monitoring, relative to expected, and hospitals with higher patient volumes had lower rates of mortality or severe disability. After adjustment for between-hospital variation and patient severity of injury, ICP monitoring was independently associated with age 1 year and older (odds ratio, 3.1; 95% CI, 2.5-3.8) vs age younger than 1 year., Conclusions: There was significant between-hospital variation in ICP monitoring that cannot be attributed solely to differences in case mix. Hospitals that monitor ICP more frequently and hospitals with higher patient volumes had better patient outcomes. Infants with TBI are less likely to receive ICP monitoring than are older children.

Objectives: To describe the beliefs and attitudes of U.S. neurosurgeons regarding the use of intracranial pressure monitors among comatose children with meningitis., Design and Setting: A questionnaire was administered by mail between March and July 2009, to a random sample of 500 adult neurosurgeons and to all 228 pediatric neurosurgeons in the Congress of Neurologic Surgeons., Interventions: None., Measurements and Main Results: The response rate was 60%. Abnormal computed tomography scans, either with brain swelling or hydrocephalus, and older child age were likely to prompt neurosurgeons to consider monitoring intracranial pressure, whereas etiology of meningitis did not impact the decision to monitor intracranial pressure. Fifty-two percent of neurosurgeons believed computed tomography scans were inaccurate in detecting elevated intracranial pressure in comatose children with meningitis, 22% believed otherwise, and 26% were uncertain. Only 25% of neurosurgeons felt there was sufficient medical evidence to monitor intracranial pressure in comatose children with meningitis, with higher frequency among adult than pediatric (30% vs. 16%; p < .01) neurosurgeons. Eighty-one percent of neurosurgeons disagreed with the notion that comatose children with meningitis were too ill to benefit from placement of intracranial pressure monitors. Pediatric neurosurgeons reported a higher frequency than adult neurosurgeons of having placed more (more than five) intracranial pressure monitors in comatose children with meningitis (42% vs. 28%; p < .01)., Conclusions: Most neurosurgeons are willing to consider monitoring intracranial pressure among comatose children with meningitis in the presence of abnormal findings on computed tomography scan and with older patient age. These findings are instructive in view of the current uncertainty and equipoise in clinical practice regarding intracranial pressure monitoring in these critically ill children.

Objective: The purpose of this study was three-fold: a) to examine variations in care of patients with severe head injury in academic trauma centers across the United States; b) to determine the proportion of patients who received care according to the Brain Trauma Foundation guidelines; and c) to correlate the outcome from severe traumatic brain injury with the care received., Design: Retrospective data collection for consecutive patients with closed head injury and long bone fracture admitted over an 8-month period., Setting: Thirty-four academic trauma centers in the United States, Patients: All patients admitted with a presenting Glasgow Coma Scale score < or = 8., Measurements and Main Results: Variations in care were assessed, including prehospital intubation, intracranial pressure monitoring, use of osmotic agents, hyperventilation, and computed tomography scan utilization. Aggressive centers were defined as those placing intracranial pressure monitors in >50% of patients meeting the Brain Trauma Foundation criteria for intracranial pressure monitoring. The primary outcome variables were mortality, functional status at discharge, and length of stay. Kaplan-Meier survival analysis was performed for aggressive vs. nonaggressive centers. A Cox proportional hazard model was used to evaluate the association between type of center and mortality rate. Length of stay was evaluated by using linear regression., Results: There was considerable variation in the rates of prehospital intubation, intracranial pressure monitoring, intracranial pressure-directed therapy, and head computed tomography scan utilization across centers. Management at an aggressive center was associated with a significant reduction in the risk of mortality (hazard ratio, 0.43; 95% confidence interval, 0.27-0.66). There was no statistically significant difference in functional status at the time of discharge for survivors. Adjusted length of stay for survivors at aggressive centers was shorter, compared with the length of stay at nonaggressive centers: -6 days (95% confidence interval, -14 to 2 days)., Conclusion: Considerable national variation in the care of severely head-injured patients persists. An "aggressive" management strategy is associated with decreased mortality rate for patients with severe head injury, with no significant difference in functional status at discharge among survivors.