Stein Kevin Y, Froese Logan, Gomez Alwyn, Sainbhi Amanjyot Singh, Vakitbilir Nuray, Ibrahim Younis, Zeiler Frederick A
Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
Neurotrauma Rep. 2023 Aug 7;4(1):478-494. doi: 10.1089/neur.2023.0031. eCollection 2023.
Since its introduction in the 1960s, intracranial pressure (ICP) monitoring has become an indispensable tool in neurocritical care practice and a key component of the management of moderate/severe traumatic brain injury (TBI). The primary utility of ICP monitoring is to guide therapeutic interventions aimed at maintaining physiological ICP and preventing intracranial hypertension. The rationale for such ICP maintenance is to prevent secondary brain injury arising from brain herniation and inadequate cerebral blood flow. There exists a large body of evidence indicating that elevated ICP is associated with mortality and that aggressive ICP control protocols improve outcomes in severe TBI patients. Therefore, current management guidelines recommend a cerebral perfusion pressure (CPP) target range of 60-70 mm Hg and an ICP threshold of >20 or >22 mm Hg, beyond which therapeutic intervention should be initiated. Though our ability to achieve these thresholds has drastically improved over the past decades, there has been little to no change in the mortality and morbidity associated with moderate-severe TBI. This is a result of the "one treatment fits all" dogma of current guideline-based care that fails to take individual phenotype into account. The way forward in moderate-severe TBI care is through the development of continuously derived individualized ICP thresholds. This narrative review covers the topic of ICP monitoring in TBI care, including historical context/achievements, current monitoring technologies and indications, treatment methods, associations with patient outcome and multi-modal cerebral physiology, present controversies surrounding treatment thresholds, and future perspectives on personalized approaches to ICP-directed therapy.
自20世纪60年代引入以来，颅内压（ICP）监测已成为神经重症监护实践中不可或缺的工具，也是中重度创伤性脑损伤（TBI）管理的关键组成部分。ICP监测的主要作用是指导旨在维持生理ICP并预防颅内高压的治疗干预措施。维持这种ICP的基本原理是防止因脑疝和脑血流量不足而导致的继发性脑损伤。有大量证据表明，ICP升高与死亡率相关，积极的ICP控制方案可改善重度TBI患者的预后。因此，当前的管理指南建议脑灌注压（CPP）目标范围为60 - 70 mmHg，ICP阈值为>20或>22 mmHg，超过该阈值应启动治疗干预。尽管在过去几十年中我们实现这些阈值的能力有了显著提高，但中重度TBI相关的死亡率和发病率几乎没有变化。这是当前基于指南的护理中“一刀切”教条的结果，该教条没有考虑个体表型。中重度TBI护理的前进方向是制定持续推导的个体化ICP阈值。这篇叙述性综述涵盖了TBI护理中ICP监测的主题，包括历史背景/成就、当前的监测技术和适应症、治疗方法、与患者预后和多模态脑生理学的关联、围绕治疗阈值的当前争议以及ICP导向治疗个性化方法的未来展望。
