Evolving concepts in intracranial pressure monitoring - from traditional monitoring to precision medicine.

A wide range of acute brain injuries, including both traumatic and non-traumatic causes, can result in elevated intracranial pressure (ICP), which in turn can cause further secondary injury to the brain, initiating a vicious cascade of propagating injury. Elevated ICP is therefore a neurological injury that requires intensive monitoring and time-sensitive interventions. Patients at high risk for developing elevated ICP undergo placement of invasive ICP monitors including external ventricular drains, intraparenchymal ICP monitors, and lumbar drains. These monitors all generate an ICP waveform, but each has its own unique caveats in monitoring and accuracy. Current ICP monitoring and management clinical guidelines focus on the mean ICP derived from the ICP waveform, with standard thresholds of treating ICP greater than 20 ​mmHg or 22 ​mmHg applied broadly to a wide range of patients. However, this one-size fits all approach has been criticized and there is a need to develop personalized, evidence-based and possibly multi-factorial precision-medicine based approaches to the problem. This paper provides historical and physiological context to the problem of elevated ICP, provides an overview of the challenges of the current paradigm of ICP management strategies, and discusses advances in ICP waveform analysis, emerging non-invasive ICP monitoring techniques, and applications of machine learning to create predictive algorithms.
Competing Interests: Declaration of competing interest RM was supported through an NIH Ruth L. Kirschstein Research Service Award T32-GM075774-16 and additional funding awarded through the Department of Anesthesiology and Critical Care Medicine at Johns Hopkins. Vishank Shah disclosures: VS received honoraria (<$1000 USD) from Astra Zeneca and serves on the Editorial Board for Neurohospitalist. Sudha Yellapantula works as a Researcher for Medical Informatics Corp (MIC, Houston TX) and reports no competing interests. MIC is a company that provides the Sickbay platform to various hospitals, for clinical and research use of the data. Medical Informatics provided no funding and/or support for this review paper. Jose I Suarez disclosures: ex-officio member of the Board of Directors of the Neurocritical Care Society; member of the Scientific Advisory Board for Cyban; Member of the Data Safety Monitoring Board for clinical trials sponsored by Acasti and Perfuze; member of the Advisory Board for AstraZeneca for Andexxa Medical Strategy. Susanne Muehlschlegel disclosures: ex-officio member of the Board of Directors of the Neurocritical Care Society; Consultant for Acasti Pharma as a member of the clinical endpoint adjudication committee. Has received speaking and writing honoraria from the American Academy of Neurology. Serves on the Editorial Board for Neurocritical Care and Stroke (unpaid).
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