Care based on intracranial pressure monitoring may not be superior to care based on imaging and clinical examination for patients with traumatic brain injury (TBI), according to research published in the December 27, 2012, New England Journal of Medicine. There was no significant difference in survival time, impaired consciousness, functional status, or neuropsychologic status among patients with TBI randomized to one of the two types of care.
Randall M. Chesnut, MD, Professor of Neurologic Surgery at the University of Washington in Seattle, and colleagues conducted a multicenter, controlled trial in which 324 patients with severe TBI were randomly assigned to guidelines-based management (ie, intracranial pressure monitoring) or imaging and clinical examination. Trained examiners who were unaware of treatment assignments assessed patients’ outcomes at three and six months after study onset. Tests included measures of mental status, working memory, information processing speed, episodic memory and learning, verbal fluency, executive function, and motor dexterity.
Eligible patients were 13 or older and had a Glasgow Coma Scale (GCS) score of 3 to 8. Patients with a GCS score of 3 and bilateral fixed and dilated pupils and those with an injury deemed unsurvivable were excluded. Patients’ median age was 29, and nearly 88% of patients were male.
Survival rates were similar for the two patient groups. For patients in the imaging and clinical examination group, 14-day mortality was 30%, compared with 21% for the pressure-monitoring group. Six-month mortality was 41% in the imaging and clinical examination group and 39% in the pressure-monitoring group. The median length of stay in the ICU was 12 days for patients in the pressure-monitoring group, compared with nine days for the imaging and clinical examination group.
“The value of knowing the precise intracranial pressure is not being challenged here, nor is the value of aggressively treating severe TBI being questioned,” said Dr. Chesnut. “Rather, our data suggest that a reassessment of the role of manipulating monitored intracranial pressure as part of multimodality monitoring and targeted treatment of severe TBI is in order,” he concluded.