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Review Article Intracranial Pressure Monitoring: Invasive versus Non-Invasive Methods—A Review
P. H. Raboel,1 J. Bartek Jr.,1, 2 M. Andresen,1 B. M. Bellander,2 and B. Romner1
1 Department 2 Department
of Neurosurgery, Copenhagen University Hospital Rigshospitalet, DK-2100, Copenhagen, Denmark of Neurosurgery, Karolinska University Hospital, SE-17176, Stockholm, Sweden
Correspondence should be addressed to P. H. Raboel, email@example.com Received 2 December 2011; Revised 28 February 2012; Accepted 27 March 2012 Academic Editor: John F. Stover Copyright © 2012 P. H. Raboel et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Monitoring of intracranial pressure (ICP) has been used for decades in the ﬁelds of neurosurgery and neurology. There are multiple techniques: invasive as well as noninvasive. This paper aims to provide an overview of the advantages and disadvantages of the most common and well-known methods as well as assess whether noninvasive techniques (transcranial Doppler, tympanic membrane displacement, optic nerve sheath diameter, CT scan/MRI and fundoscopy) can be used as reliable alternatives to the invasive techniques (ventriculostomy and microtransducers). Ventriculostomy is considered the gold standard in terms of accurate measurement of pressure, although microtransducers generally are just as accurate. Both invasive techniques are associated with a minor risk of complications such as hemorrhage and infection. Furthermore, zero drift is a problem with selected microtransducers. The non-invasive techniques are without the invasive methods’ risk of complication, but fail to measure ICP accurately enough to be used as routine alternatives to invasive measurement. We conclude that invasive measurement is currently the only option for accurate measurement of ICP.
The Scottish anatomist Alexander Monro ﬁrst described the intracranial pressure in 1783 [1, 2]. Monro proposed that (1) the brain is encased in a rigid structure; (2) the brain is incompressible; (3) the volume of the blood in the cranial cavity must therefore be constant; (4) a constant drainage of venous blood is necessary to make room for the arterial supply. Monro’s colleague George Kellie of Leith supported Monro’s observations some years later based on autopsies of humans and animals . These assertions became known as the Monro-Kellie hypothesis or doctrine. However, both were missing a crucial component: the cerebrospinal ﬂuid (CSF). The Flemish anatomist Vesalius had described ﬂuidﬁlled ventricles back to the sixteenth century, though this view had never been broadly accepted. Not until the French physiologist Franc ¸ ois Magendie in 1842 through animal experiments punctured the cisterna magna and analyzed the CSF, was the idea of ﬂuid in the brain accepted . With this new knowledge in mind, the English physician George Burrows proposed in 1846 the idea of a reciprocal
relationship between the volumes of CSF and blood, that is, an increase in one causes a decrease in the other and introduced CSF as a factor in the Monro-Kellie doctrine . In 1926, Harvey Cushing, American neurosurgeon, formulated the doctrine as we know it today , namely, that with an intact skull, the volume of the brain, blood, and CSF is constant. An increase in one component will cause a decrease in one or both of the other components. This relationship provides a compensatory reserve, also called spatial compensation. It is 60–80 mL in young persons and 100–140 mL in elderly, mainly due to cerebral atrophy . The volume/pressure curve is shown in Figure 1. The ﬁrst part of the curve is characterized by a very limited increase in pressure due to the compensatory reserve being large enough to accommodate the extra volume. With increasing volume, the compensatory reserve is eventually exceeded, causing a rapid increase in pressure. Normal ICP varies with age and body posture but is generally considered to be 5–15 mmHg in healthy supine adults, 3–7 mmHg in children and 1,5–6 mmHg in infants [7–12].
the danger of localized elevations of ICP should be taken into account when ICP and clinical symptoms diﬀer markedly. 18]. elevated ICP can cause herniation with high risk of irreversible brain damage and death [7. ICP Volume Figure 1: The relationship between intracranial pressure and volume. ICP monitoring is indicated in all cases of traumatic brain injury with a Glasgow Coma Scale score (GCS) between 3–8 and an abnormal CT scan. in patients with subarachnoid hemorrhage or spontaneous ganglionic hemorrhage. CPP is calculated by subtracting ICP from the mean artery pressure (MAP). 13– 16]. To date no studies have conclusively been able to demonstrate how often—and under what circumstances— pressure gradients appear as well as whether bilateral ICP monitoring should be undertaken routinely. another useful review is available addressing this topic . 32]. there seems to be a consensus that smaller pressure gradients within the central nervous system do exist across speciﬁc compartments. Additionally. This will not be addressed further in this paper. Several questions arise when performing ICP monitoring. Access to a high-resolution view of the intracranial pressure waveform enables more accurate analysis of the obtained ICP as highlighted by the following examples. Another pitfall in the clinical use of ICP monitoring is in determining the validity of the obtained pressure value. Treatment designed to lower ICP should be initiated at pressures above 15–20 mmHg. However. thereby promoting edema formation. but also concerning the optimal location of monitoring and where local pressure gradients may inﬂuence measurements. there does not seem to be evidence to support claims of signiﬁcant pressure gradients under physiological conditions [25. Traumatic head injury Intracerebral hemorrhage Subarachnoid hemorrhage Hydrocephalus Malignant infarction Cerebral edema CNS infections Hepatic encephalopathy Modiﬁed from Smith . where autoregulation is “set out of play. it is important to address speciﬁc conditions. Under normal physiological conditions. not only concerning the type of pressure monitor. which may escape the attention of the clinician . 8. in the evaluation of trauma patients. 38]. swelling. the cerebral autoregulation maintains a constant ﬂow of blood to the brain by dilating or constricting the arterioles. one showing hematomas.” and cerebral blood ﬂow is entirely dependent on CPP [7. In cases of elevated ICP or circulatory hypotension. however. According to the American Brain Trauma Foundation . Pressure above the upper limit of autoregulation will cause hyperemia and cerebral edema. in which there seems to be no transmantle pressure gradient across the ventricular wall [24.2 Critical Care Research and Practice Table 1: Conditions where ICP-monitoring is used. and ICP monitoring is used in patients with various neurological. Electrostatic discharges may cause both rapid shifts of ICP as well as gradual drifts. Any lesion of the brain can cause a state of vasomotoric paralysis. and even medical conditions such as hepatic encephalopathy (Table 1). uni. or compressed basal cisterns. while ICP shifts due to electrostatic discharges will not be accompanied by increasing . 27]. 8.or bi-lateral motor posturing. depending on the cause of elevated pressure [8. Causes of elevated ICP are numerous. Additionally. which is ultimately associated with a poor patient prognosis. Early descriptions of pressure gradients [33–36] described diﬀerences in pressure between diﬀerent compartments in the cranial vault as well as along the craniospinal axis. that is. 20–22]. In this context. ICP monitoring in the pediatric population poses special challenges as well as additional noninvasive techniques of ICP measurement. the cerebral perfusion pressure (CPP) is decreased. 17]. or systolic blood pressure under 90 mmHg. 25]. the true intracranial pressure may be estimated by lumbar cerebrospinal ﬂuid pressure [26. this autoregulation is only eﬀective with a MAP between 50 and 150 mmHg. and indications for ICP monitoring vary considerably between hospitals [8. In general. However. 17. neurosurgical. At present. herniation. 37. Attention to the mean wave amplitude will show increasing amplitude at increasing ICP. such as communicating or noncommunicating hydrocephalus as well as patients with idiopathic intracranial hypertension. indicating that ICP may possibly be best monitored as close as possible to an expanding mass lesion. deﬁned as the sum of the diastolic pressure added to a third of the diﬀerence between systolic and diastolic pressure. Pressures below the limit lead to insuﬃcient blood ﬂow and cerebral ischemia. Patients with a GCS of 3–8 but a normal CT scan should be monitored if two or more of the following conditions are present: age over 40. contusion. Later reports—as well as experiments in a porcine model—showed compartmentalized ICP pressure gradients [28. No universally accepted guidelines exist. and that they may be exacerbated due to trauma both with and without acute expanding lesions [28–31].
P1 P2 P3 ICP 0 100 200 300 Milliseconds 400 500 Figure 2: Propagation of the cardiac pulse pressure signal. with reversal of the P1 and P2 notches reﬂecting a state of disturbed autoregulation. where a deﬁnable. where a catheter is placed into one of the ventricles through a burr hole. and subarachnoidal. This encompasses a wide array of conditions. though only 10. In the elderly. as mentioned earlier (Figure 3(b)). traditionally. in which the patients were CT scanned after EVD placement. than in those who were not routinely scanned after surgery (1. ICP measuring can be undertaken in diﬀerent intracranial anatomical locations: intraventricular. mean wave amplitude.53%) developed a subdural hematoma requiring surgical drainage. ICP may under certain circumstances be assessed by lumbar puncture [26. causing neurological deﬁcits. In these cases. P2.and B-waves . Depending on ventricular size. Keen’s point (posterior-parietal) and Dandy’s point (occipital) as secondary options. intraparenchymal. possibly resulting from EVD placement itself. indicating propagation of the cardiac pulse pressure signal (Figure 2). required surgical intervention. is considered the gold standard [8. with alternative methods such as the Frazier burr-hole (occipital-parietal). as mentioned in the above chapter. The majority of hemorrhages discovered were of no clinical importance. Surgical placement of EVD is seen as a minor surgical procedure with few risks. In addition to measuring ICP.53%). 27. abnormal mass is responsible for intracranial hypertension.6% had hemorrhages larger than 15 mL or with an intraventricular component. A word of caution applies for those cases. but has nevertheless been associated with hemorrhagic and infectious complications. A complete absence of a pressure curve may additionally be seen following craniectomy and in postoperative pneumencephalon. caution is advised. Additionally. we often see a widened ventricular system due to age-dependent atrophy. with the tip of the EVD located in the 3rd ventricle is seen as the method of choice. Another study  with a total of 188 patients with EVDs. and in severe cases even provoke subinkarceration . 44–48] of ICP monitoring. EVD placement may be diﬃcult. They are a sign of more severe loss of cerebral autoregulation. Awaves (also known as plateau waves) are characterized by rapid increase and decrease of pressure to 50–100 mmHg lasting from 5 to 20 minutes. 42. . Not surprisingly. meningitis. This number covers signiﬁcant diﬀerences in incidence. Depending on the technique. subdural. and an EVD is inserted for pressure relief. for example. Furthermore. from benign skin infections to ventriculitis. compression of the ventricular system due to progressive edema formation may arise and block proper EVD drainage. that is. in patients with communicating CSF pathways. EVD placement may be indicated to drain posttraumatic hemorrhage. Of the total amount of hemorrhages. One patient (0.1. 43]. More advanced pressure curve analysis may also be employed by identifying Lundberg A. Invasive monitoring using the EVD technique.” a review  including articles from 1970 and onwards. and there has been no general consensus in this ﬁeld . this technique can also be used for drainage of CSF and administering of medicine intrathecally. since the acute CSF drainage can displace the intracerebral structures. 0. or were fatal.7% of cases on average. depending on whether a routine CT scan was performed after the procedure. During longterm CSF drainage through an EVD. a coronal burr-hole approach at the Kocher’s point. especially in younger patients with a very slender ventricular system (Figure 3(a)). and may be a sign of cerebral dysfunction.61% were of clinical importance. 2. External Ventricular Drainage (EVD). epidural. Regarding the technique and placement for the EVD.Critical Care Research and Practice 3 2. in performing basic checks of whether the ICP signal is truly representative of the intracranial pressure. Another complication in EVD treatment is bacterial colonization of the catheter with subsequent retrograde infection.06%). showed “postoperative hemorrhages” in 41% of cases. the issue is still under debate. hemorrhages were discovered more often in patients who underwent a CT scan (10. The rhythmic oscillating B-waves appear with a frequency of 1/2–2 per minute. Invasive Methods of Measuring ICP Several diﬀerent invasive methods of measuring ICP exist. and P3 notches present. but may in certain cases also be physiological phenomena . Nevertheless. the clinician should ensure that there is in fact an oscillating pressure curve with the progressively decreasing P1. Additionally. found hemorrhagic complications in 5. and fatal septicaemia. Their duration varies and will often appear irregularly without forewarning. Further information is found in the pulse pressure signal. antibiotic administration in cases of ventriculitis. Focusing on “postoperative hemorrhage.
by performing the procedure in the sterile environment of a operating theatre. However. a factor contributing to higher infection rate. avoiding routine sampling of CSF (unless clinically indicated) and by not changing the catheter (unless clinically indicated). such as cutaneous contamination during the removal process. and therefore a larger study with higher statistical power or more centers reproducing the results is needed in order to draw any ﬁrm conclusions. Over 4 years a mean infection rate of 2. A pilot study conducted by Lackner et al. The primary factor disposing towards a lower infection rate was the subcutaneous tunneling . . however. Another option is using catheters impregnated with silver nanoparticles. thalamus. they present the same risks concerning resistance [53. Minimizing the above predisposing factors. that neither the duration of EVD treatment. Antibiotic impregnated catheters are an alternative and have proved very eﬀective in reducing the rate of infection [59. nor preoperative intracranial hemorrhage increased the risk of infection. the internal capsule. colonization of the catheter tip.7%. and liquor pleocytosis in the silver-bearing EVD group compared to the group with standard EVD (18. showed a signiﬁcant lower incidence of catheterassociates ventriculitis in the test population (zero) than the controls (ﬁve).9% versus 33. Factors shown to predispose towards a higher infection rate included. frequent CSF sampling rate. both studies are relatively small. however. for example. Review articles on this subject [53.  with 19 patients treated with silver nanoparticle impregnated catheters. that 12. prolonged EVD treatment time of more than ﬁve days. Saladino et al. and found a signiﬁcant reduction in the occurrence of: a positive CSF culture. with the use of prophylactic antibiotics. 57]. This in turn resulted in reoperation in several cases. and 20 controls with regular intraventricular catheters.  argue against this because of the risk of infection with more virulent organisms as well as a theoretically increased resistance to antibiotics. basal ganglia.3% of all catheters were malplaced either intraparenchymal or extraventricular. They also found. P = 0. Another factor contributing to increased infection rate is incorrect placement of the catheter or a defect catheter.  managed to achieve a signiﬁcant decrease in the rate of infection. surgical revision. Concerning the use of prophylactic antibiotics prior to surgery. it is important to note that a positive CSF culture can stem from other sources. 54] have shown a frequency of catheter-related infections in the range of 0– 27%. 60]. that retrospectively reviewed a total of 164 consecutive patients.  found by retrospectively reviewing a patient population of 138. . but has not been tested thoroughly in vivo.98% was reported.—the reason for the low rate of infection in another large retrospective study with 328 patients and 368 EVDs . Beer et al. cranial fracture with CSF leakage and nonsterile EVD insertion [54–56].4 Critical Care Research and Practice (a) (b) Figure 3: Diﬀerences in ventricular size in (a) young and (b) elderly patients. the deﬁnition of a catheter-related infection varies tremendously . in 95 patients with a total of 113 EVD insertions. 90 with a standard EVD and 74 with a silver-bearing EVD. This technique has good antimicrobial properties in vitro . urokinase installation. and even penetration of the ﬂoor of the 3rd ventricle. intraventricular or subarachnoid hemorrhage. tunneling the catheter subcutaneously at least 10 centimeters from the burr-hole. 04). Similar optimistic results were reported from Fichtner et al. The majority of reviewed articles used a positive CSF culture obtained from the EVD or drawn via a lumbar puncture . Dasic et al. These malplacements can also result in injuries to important cerebral structures. from 27 to 12%. However. Strict adherence to sterile practice is also—according to Tse et al.
A large study by Koskinen and Olivecrona  state. but comparable parameters of pulsatile ICP (mean wave amplitude and wave rise time) . usually placed in the right frontal region at a depth of approximately 2 cm. In 6 cases (0.5% of cases. an excellent correlation was found between the lumbar and subdural pressure measurements. infection. none of which required surgical intervention. without any incidence of hemorrhage among all 87 patients (all patients were CT-scanned after insertion). and the diﬀerences in intensity of the reﬂected light are translated to an ICP value.3%.2% of patient cases and showed an incidence of hemorrhage in 2. the placement can be modiﬁed.66%). a leak related to the sensor resulted in incorrect measurements. The ICP microtransducers most widely used. however.  additionally tested the Spiegelberg sensor for use in continuous intracranial compliance (cICC) monitoring in ten patients with TBI and found poor overall cICC data quality as well as poor predictive capabilities in identifying increased ICP and correlation with cerebral hypoxia. The two types of sensors performed much alike. Another study . currently it does not provide the necessary accuracy for routine use. For current use in critical care. most often related to the ﬁber optic cable itself.14%. one patient had a fever and a positive bacterial culture from the catheter tip. mainly the risk of hemorrhage and infection. The relatively new Pressio sensor has yet to be tested thoroughly in vivo. the cause often being intraparenchymal placement. Microtransducer ICP Monitoring Devices. In a newer study comparing lumbar cerebrospinal ﬂuid pressure to epidural and subdural ICP . 2. subdural. however. intraparenchymal. among 120 patients with a Codman MicroSensor. Technical errors were present in 4. Another study showed a markedly diﬀering mean ICP.2.  found 10% faulty sensors in a study that included a total of 50 Camino monitors. in which 328 patients with a Camino monitor were examined. not requiring intervention. epidural. and pneumatic sensors. Complications were not recorded. that after insertion of almost 1000 Codman MicroSensors. . monitoring can be done in the intraventricular. 2 patients had smaller hemorrhages. found retrospectively. The authors state that no infections were diagnosed in the study population. Changes in ICP will move the mirror. a clinically signiﬁcant hemorrhage was found (4 intraparenchymal and 2 epidural). is that by Lescot et al. Hong et al. the Raumedic Neurovent-P ICP sensor. strain gauge devices. In three patients. depending on known or suspected pressure gradients across intracranial compartments.5% of cases. looking at the accuracy of 15 Pressio sensors and 15 Codman MicroSensors in comparison to ICP measurements undertaken by an EVD. A large study including 1000 patients with a total of 1071 Camino ICP Monitors . but obtaining almost equal ICP values in intervals above 20 mmHg. None of the patients showed clinical signs of meningitis. transmit light via a ﬁber optic cable towards a displaceable mirror. The Spiegelberg sensor has been tested by Lang et al. such as the Camino ICP Monitor. Kiening et al. The Codman MicroSensor has also been thoroughly examined in several studies. One report shows that the epidural Camino sensor considerably overestimated ICP with a mean of about 9 mmHg but extending to almost 30 mmHg . according to a survey amongst American neurosurgeons. This group of invasive ICP monitoring devices can be divided into ﬁber optic devices. or subarachnoidal compartment. Fiber optic devices. are those measuring ICP intraparenchymally. showed hemorrhage in 1. subdural sensors may be considered for use if there is no suspicion of focal ICP elevations with potential for causing intercompartmental pressure gradients.Critical Care Research and Practice A so-called “Ghajar guide” has been shown to increase the amount of correctly positioned catheters as compared to insertion by hand . Similar study by Piper et al.5% were positive for bacterial growth by subsequent cultivation. in 4. The rate of defective ventricular catheters has been found to be 6. and additionally allows quantitative measurement of intracranial compliance. 5 and intraparenchymal or intraventricular monitors should be considered the standard choice. only 3 incidents of surgically related hemorrhages were found. . that of the 574 probe tips examined. Only clinical study currently available. Regarding epidural ICP monitoring. When the transducer is bent because of the ICP. . and the Pressio sensor belong to the group of piezoelectric strain gauge devices. and an ICP can be calculated. even though a positive culture growth could stem from cutaneous contamination during the removal process. A control CT scan was undertaken in 92. However. No CNS infections were registered. this will seldom be the case. albeit with a mean diﬀerence of ±7 mmHg compared to ICP values acquired by the EVDs. However. only 3% use the guide on a regular basis . A comparison between epidurally and subdurally placed pressure sensors  showed lower ICP values measured in the subdural space. No infections were linked to the placement of the MicroSensor.75% and technical errors in 3. blockage with pieces of brain matter and blood clots [67–69]. Despite unsatisfactory results in the current clinical care setting. Complications are.  tested a total of 99 sensors in an equal number of patients. but no bacterial growth in the CSF. The Codman MicroSensor. higher pressure values were consistently found for ICP measured in the epidural space with increasing distance between the lumbar and epidural values at higher pressure intervals. Depending on the technique. However.1% of cases. Pneumatic sensors (Spiegelberg) use a small balloon in the distal end of the catheter to register changes in pressure. its resistance changes. the same authors  later found a correlation between increasing age and decreasing compliance and speculated that this correlation might contribute to the poorer outcome seen in elderly patients after TBI. The authors concluded that the higher ICP in the epidural space was due to physiologically diﬀerent pressures in the two compartments and not due to technical aspects. 8. Citerio et al.  found no incidents of hemorrhage postoperatively (85% of the included patient were CT scanned after insertion). Regarding the Raumedic Neurovent-P Sensors. as with EVDs.
50% (0. 81]. Generally.6 mmHg/100 hours of monitoring  Mean 2. Problems often arise due to incorrect setup of the system.” A large diﬀerence between these two ICP measurements indicates. 3. 3.1%  10%  3.45%  It is worth mentioning.36 mmHg (range −2 to 3 mmHg)  In vitro: 0. divided by the mean ﬂow velocity. the cumulative pressure diﬀerence can have important implications for the treatment and prognosis of the patient. and correlation coeﬃcients between 0.1 ± 1. The TCD technique applies ultrasound to initially measure the blood ﬂow velocity in the middle cerebral artery.6 ± 0.1 mmHg (range −17 to 21 mmHg)  Mean −0.96 mmHg (range 0 to 2 mmHg)  Mean −0.938 have been found. as complications seen in relation to the invasive methods of ICP measuring. A deviation of this small magnitude .7 ± 1. Data regarding diﬀerences between microtransducer ICP monitoring devices is summarized in Table 2.3 ± 5. that is. as well as false ICP measurements du to incorrect use of the “three-way” valve. Technology Rate of Rate of hemorrhaging Technical errors infection 2. Therefore.7 ± 1. so that the true ICP is measured. otherwise it will be the drainage pressure that is recorded. However.02% (0% clinical signiﬁcant)  n/a Mean 0. the Spiegelberg sensor and the Codman MicroSensor are compatible with magnetic resonance imaging (MRI) without any danger to the patient. When recording ICP. microtransducers share a common disadvantage.2 mmHg from invasively measured ICP.66% clinical Fiber optic 8. The diﬀerence between systolic and diastolic ﬂow velocity. have the advantage of that they can be recalibrated at any time. that the Neurovent-P sensor. are avoidable. The EVDs.05 mmHg  Mean < ± 2 mmHg  Pressio Strain gauge n/a n/a n/a Spiegelberg Pneumatic 0%  0%  3.0 mmHg (range −6 to 15 mmHg)  Camino ICP Monitor Codman MicroSensor Strain gauge n/a signiﬁcant)  Raumedic Neurovent-P ICP Strain gauge sensor 0%  2. mean ﬂow velocity (1) PI is found to correlate with invasively measured ICP [90– 92]. as it recalibrates itself every hour. several of the above studies concluded that when it comes to measuring ICP.2 mmHg (range −5 to 4 mmHg)  Mean 0. on other hand.9 ± 0. was not the “true” ICP at any given moment. and the ICP value that is measured when the sensor is removed is termed “zero drift. though the Spiegelberg catheter is an exception from this rule. Bellner et al.6 Critical Care Research and Practice Table 2: Comparison of microtransducer ICP monitoring devices. in that no recalibration is possible after placement.439 and 0. however.5%  4.5 ± 3. The diﬀerence between the starting ICP value when the sensor is calibrated (0 mmHg). This means that the position of the drip chamber relative to the CSF space is the crucial factor for the amount of drained CSF.  reported the best correlation and a mean deviation of ±4. The lack of continuous calibration can cause the sensor to report imprecise ICP values.67 mmHg (range −13 to 22 mmHg)  Mean 3. is called the pulsatility index (PI): PI = systolic ﬂow velocity − diastolic ﬂow velocity . Noninvasive Methods of Measuring The idea of a noninvasive method of measuring ICP is captivating. in this paper we will focus on the ones most widely familiar.3% (0% clinical Zero drift Mean 7. simply by resetting the transducer to atmospheric pressure at the level of the so called zero reference point (Foramen of Monro/Tragus). Transcranial Doppler Ultrasonography (TCD). Diﬀerent techniques have been proposed. the resistance being deﬁned by the pressure gradient of the CSF has to overcome to reach the level of the drip chamber.1. The amount of CSF drained depends on the pressure gradient inside the CSF cavity and the resistance of the CSF drainage.14%  0%  0%  0%  ∼0. microtransducers are just as accurate as the EVDs [69. and therefore patients with these devices cannot undergo MRI [84–86]. The Camino monitor and Pressio sensor contain ferromagnetic components. that the ICP measured while the device was implanted in the patient.2 mmHg (range −4 to +8 mmHg)  1.6 mmHg/100 hours of monitoring  In vitro: 7-day drift <0.8 ± 2. it is also of utmost importance that the “three-way” valve system is closed to drainage. mainly resulting in a false pressure gradient and secondarily problems in insuﬃcient CSF drainage.5%  signiﬁcant)  4.1 mmHg (range 0 to 12 mmHg)  Mean 0.75%  1. hemorrhage and infection.
Several studies [103–106] have investigated the correlation between the nerve sheath diameter and invasively measured ICP.73 has been found. 005). thus precluding the method for clinical use . At higher ICP values. hospitals without access to a neurosurgeon. The apparently high correlation includes great individual variations in the data. Magnetic Resonance Imaging (MRI) & Computer Tomography (CT). 30 mmHg. where 10 patients with idiopathic normal pressure hydrocephalus had their ICP artiﬁcially heightened or lowered by lumbar infusion. A quantitative measurement of this movement is the fundament of this technique. By using motion-sensitive MRI. as with all ultrasonography. the examination takes around 5 minutes per patient . the technique requires training and repetitive exercise . An elastance index was derived from the ratio of pressure to volume change and found to correlate well with invasively measured ICP (R2 = 0. with sensitivity of 96% and a speciﬁcity of 94% for increased ICP (>20 mmHg) for a ONSD cutoﬀ value of 4. intersubject variability was so great that the predictive limits of the regression analysis was an order of magnitude greater than normal ICP range. requiring for . . which yielded a mean diﬀerence of −3. It was noted. 965. the technique cannot be used on 10–15% of the patients due to the ultrasound not being able to penetrate the skull (the so-called bone window) . P < 0. 109]. Lesions of the orbita or the optic nerve are present in 10% of all head trauma cases. Stapes rests on the oval window. However. and there is also intra. However. However.3.8 mmHg.and inter-observer variations as noted earlier [95–98].  also came to the conclusion that PIcalculated ICP is too uncertain. A review article  showed that all included studies found a cutoﬀ value of 5. Another study by Rajajee et al. However. and the following change in pressure was estimated from CSF velocity.4.2 ± 12.90 mm for predicting increased ICP. The technique is cheap and eﬃcient. Furthermore. which can render measurements with the ONSD impossible. which communicates with the subarachnoid space surrounding the brain.2. This means that this technique can potentially be used as a screening method for detecting raised ICP in settings. 45 sedated patients with severe traumatic brain injury. pulsatile arterial. inﬂammation.3 mm was found in recent studies [105. it requires training and has intra. In cases of increased ICP.6 mmHg. However. this small magnitude of deviation only applies to ICP values lower than approx. care is required in the selection of representative image slides as well as choosing the representative blood vessels . Brandi et al. the technique is not without ﬂaws. Furthermore. and sarcoidosis [105.8 mm. which is shown to correlate to ICP [100. whether the technique can be applied on patients with these common conditions. the magnitude of deviation increases. Furthermore. A variation of this magnitude is clearly unacceptable for clinical use. 108]. the technique does not seem to be accurate enough to be used as a replacement for invasive ICP measuring methods. Furthermore. that the low rate of success was mainly due to the perilymphatic duct being less passable with age.1-0. In 2000. Shimbles et al. ICP calculated from PI was compared to ICP measured by a Codman MicroSensor. Graves disease. meaning that the pressure of the ﬂuid in the cochlea aﬀects how the membrane and stapes are positioned and how they move. The optic nerve is part of the central nervous system. In their study. Behrens et al. as Marshall and colleagues pointed out. At present. Between the sheath and the white matter is a small 0.and inter-observer variance. each monitored with a Raumedic probe. though these variations are minor.  recently published even better results. investigated the possibilities of using MRI as a noninvasive method of ICP measurement . Their PI and calculated ICP were compared to the invasively found ICP. Changes in the diameter of the nerve sheath can be visualized using transocular ultrasound. that is. A small volume change (about 1 mL) during the cardiac cycle was found and calculated from the net transcranial CSF and blood volumetric ﬂow rates. It is seen that a PI of 1 can mean anything from a few mmHg to about 40 mmHg. Even when the above was addressed. Alperin et al. distinguish between normal and increased (>20 mmHg) ICP. for example. 101]. Optic Nerve Sheath Diameter (ONSD). were examined daily using TCD. This membrane is ﬂexible.00–5. and it is therefore uncertain. the sheath expands. a subgroup of cases in the patient population were invasively ICP monitored at the time of the experiment. It can. The technique was applied successfully on 70% of the healthy subjects. A correlation between the invasively and the TMD measured ICP values were found. it is important to mention that several conditions can aﬀect optic nerve diameter.2 mm subarachnoid space.1-0. Mean intraobserver variance ± 0. Stimulation of the stapedial reﬂex causes a movement of the tympanic membrane.8 to 43. especially after the age of 40. 107.  described a similar large spread in their experiment. and therefore surrounded 7 by the dural sheath. which is covered by a membrane. 3. where invasive ICP monitoring capabilities are not available. 3. venous. The best correlation was found by using the calculations proposed by Bellner et al. however. Tympanic Membrane Displacement (TMD). A correlation coeﬃcient of between 0. Sensitivity was 74–95% and speciﬁcity 79–100%. The technique takes advantage of the communication of the CSF and the perilymph via the perilymphatic duct. some subjects displayed signiﬁcant variation between repeated measurements. 3. Patients with glaucoma and cataract have been excluded from the above study population. the technique is very sensitive to diﬀerences in heart rate measured in the circulation contra the CSF ﬂow rate as well as CSF measurements. and CSF ﬂow in and out of the cranial vault during the cardiac cycle was measured. making accurate ICP measurements impossible.  tested the technique on 148 patients with intracranial pathology (hydrocephalus and benign intracranial hypertension) and on 77 healthy controls. but only on 40% in the patient population.2 mm and mean interobserver variance ± 0. tumors.2-0. They reported that an ICP of 20 mmHg found by using PI had 95% conﬁdence intervals of −3.59–0.Critical Care Research and Practice is clinically acceptable. Apart from being imprecise.
with subsequent risk of increased mortality and morbidity.. 46]. Nevertheless. The rate of nonfunctioning EVDs has been found to be 6. who concluded. and approximately the same percentage applies for microtransducer techniques [74. even though fundoscopy is often used as a screening method in cases of suspected increase in ICP. 81]. after which the devices can be applied multiple times without further costs apart from wages and maintenance. However. 76–78. pseudotumor cerebri. In most part. However. i. Critical Care Research and Practice On the other hand. Similar results were observed by Hiler et al. 69]. no method of estimating ICP on the basis of cranial CT scans currently exists. . the noninvasive techniques are favored. the technique could have a role as a screening tool for identiﬁcation of patients in need of invasive ICP monitoring after moderate head trauma. The cost for placing an EVD amounts to around $200 in materials [45. To summarize. In 10–15% of patients investigated using TCD. trauma . given that they require a monitor.5% of cases with EVDs [51. As Dasic et al. 81]. considering 4.  showed. It could also play a role in diagnosis and evaluation of several chronic disorders potentially associated with increased ICP values. One would like to think that this relative simple technology would be more reliable than the more complex microtransducers. The noninvasive techniques have their greatest shortcomings in this ﬁeld. A clinically relevant hemorrhage percentage of 0. 69]. hydrocephalus. microtransducers are only defective in 3. the examiner requiring good visualization of the optic disc to be able to detect papilledema . the only way to minimize the risk for postoperative infection is to strictly follow sterile guidelines. the cost of the device as well as the possible complications and mechanical problems associated with the individual techniques. The technique itself is limited to the abilities of the examiner.5. infarcts. which are often associated with the invasive techniques. For the reviewed noninvasive techniques. those causing neurological deﬁcits or requiring surgical intervention occur in about 0. especially given the fact that general guidelines for ICP monitoring are not widely accepted. 81]. Papilledema. It is also worth mentioning that patients with microtransducers generally have a lower rate of postoperative infections than patients with EVDs. 22. Clinically relevant hemorrhaging. the majority of studies were conducted in the late 1980s and early 1990s and failed to show consistent correlation between ICP and CT scan characteristics . Microtransducers are more expensive.e. as well as the circumstances surrounding the examination. intracranial mass lesions. none of the above-mentioned noninvasive techniques are accurate enough to be used in a critical (intensive) care setting. resulting in variations for application of invasive ICP monitoring among hospitals [8. In addition to the equipment comes also the subsequent cost of maintaining and replacing it. The noninvasive techniques require only the single expense of purchasing the device. the technique cannot be applied in emergency situations with sudden increases in ICP. the ﬁgure was 60% . several factors need to be considered. or cranial nerve palsy . no valid measurements could be made . hydrocephalus. Overall. there are several patient categories for which the measuring technique cannot be applied in critical care practice. A signiﬁcant number of these patients will develop systemic or cerebral infections. the noninvasive techniques have their advantages in completely avoiding complications such as hemorrhages and infections. ranging between 0–8. and for ONSD 10% [103. At present. 76–78. after looking at 126 patients with severe traumatic brain injury. Fundoscopy and Papilledema. but one has to keep in mind that this means one in 200 patients will have a worsened clinical outcome solely due to the application of an invasive ICP monitoring technique. Discussion ICP monitoring techniques are multiple and diverse. epilepsy. EVDs are considered the gold standard. A linear. 81]. without the monitoring itself having any relevance to the way these patients are treated. Eide reported no signiﬁcant correlation between actual size (or change in size) of cerebral ventricles by cranial CT scans and invasively monitored ICP in 184 consecutive patients . and the transducers themselves costing at least $400–600 each [45. A study employing fundus photographs showed good reproducibility of this grading scale among diﬀerent observers. the grading scale is not widely applicable or accepted. Furthermore. Nevertheless. This is an intensely debated issue. due to raised ICP can be visualized by fundoscopy and graded by the Fris´ en Scale into 5 categories depending on signs of disturbed axoplasmic transport. for example. that mean ICP values in the ﬁrst 24 hours cannot be predicted by using the Marshall CT scan classiﬁcation . 52]. which measure ICP almost just as accurately [69. In 2003. In measurements using TMD. before choosing the technique to apply in critical care. One could fear that a too liberal approach for invasive ICP monitoring could result in unnecessary worsened clinical patient outcome. the precision of measurements made. However. with the total cost easily around several thousand dollars.5% [74.8 the data gathered from individual cases to be interpreted with caution . The same words of caution can then applied in relation to the relatively high postoperative infection frequencies of up to 27%  in relation to the insertion of an EVD. or optic disc swelling. if we can accept these shortcomings. since the process of optic disc swelling in cases of raised ICP takes time. economically and complication wise. but ultimately nonpredictive relationship between baseline ICP and initial head CT scan characteristics was found by Miller and colleagues . In regards to precision of measuring accurate ICP values.5% associated to the invasive techniques may not seem as much. that is. 105]. the relatively high percentage of malfunctioning EVDs is due to the EVD being placed intraparenchymaly or blocked with pieces of brain matter and blood clots [67–69]. such as. closely followed by microtransducers.14–5.0% of cases [74–76. 3. speciﬁcity ranging between 88–96% and sensitivity between 93–100% . A way of interpreting ICP values from cranial CT scans has also been investigated. and so forth .3% .
that is. The American Brain Trauma Foundation still has EVDs as their favored method of ICP monitoring . higherintensity treatment with use of ICP monitoring resulted in a 12% lower mortality rate and a 6% better chance of favorable outcome compared to less aggressive treatment and monitoring approach. to this date. no prospective randomized study of the possible beneﬁts of ICP monitoring has been done. However. the low accuracy of the ICP measurements undertaken. but we will comment brieﬂy on the topic. involving more than 125. but not in cases of sudden raise in ICP. Stein et al. Precision wise. This leaves us with the choice between EVDs and microtransducers. in this context it is important to point out that the Camino MicroSensor has problems with a large zero drift [74. several other studies have reached the opposite conclusion. Whether EVD or microtransducers is the optimal ICP measuring technique is a diﬃcult question to answer unambiguously. Overall. Table 3 summarizes the results. It is apparent today that additional neuromonitoring modalities should supplement ICP in the critical care setting.” with recommendation on treatment initiation at ICP levels above 20–25 mmHg . there are no general guidelines. A large part of the evidence advocating ICP monitoring originates from the late nineteen seventies and early eighties [122–124]. But when is ICP monitoring needed in critical care? As mentioned in the background paragraph. but apparently they carry a lower rate of postoperative infections. Nevertheless. EVDs. the noninvasive techniques are less favorable.and CPP-based therapies are based on diﬀering assumptions of “elevated pressure. on the other hand. Current ICP. 75]. but all articles that were obtained had to be excluded since none were of a prospective randomized nature and therefore not deemed as “suﬃcient” evidence. be regarded as good options when ICP monitoring is needed. including controlled tapering . and more importantly. Both can. therefore. trauma the high number of patients where noninvasive techniques cannot be applied. . despite the fact that most microtransducers cannot be recalibrated. Technology External ventricular drainage Microtransducer ICP monitoring devices Transcranial Doppler ultrasonography Tympanic membrane displacement Optic nerve Sheath diameter MRI/CT Accuracy High Rate of infection Low to moderate Rate of hemorrhaging Low Cost per patient Relatively low 9 High Low Low Low Low None None None Low None None None High Low Low Low Low None None Low Fundoscopy (papilledema) Low None None Low Miscellaneous Can be used for drainage of CSF and infusion of antibiotics Some transducers have problems with high zero drift High percentage of unsuccessful measurements High percentage of unsuccessful measurements Can potentially be used as a screening method of detecting raised ICP MRI has potential for being used for noninvasive estimation of ICP Can be used as a screening method of detecting raised ICP. However. most of the reviewed studies are of a methodologically limited quality. Current studies reporting better survival and outcome with ICP monitoring include Patel et al. but these studies are of weaker methodological design. microtransducers are more expensive. there is not a great diﬀerence between these two techniques. A thorough evaluation of the literature is outside the scope of this paper. this has not been shown to better the cerebral perfusion of the patient nor improve the patients’ ﬁnal clinical outcome . 127–129]. However. where ICP monitoring was not applied. as both have advantages and disadvantages as discussed above.  and Fakhry et al. indicating worse outcome as a consequence of ICP monitoring and CPP-oriented therapy [46.  did an extensive review on all available articles on outcome of severe traumatic brain injury from the last forty or so years. Economically.Critical Care Research and Practice Table 3: The diﬀerent technologies compared.000 patients. . The current noninvasive techniques are simply not accurate enough to replace the traditional invasive techniques. have the advantage that they can be used for drainage of CSF and administering of drugs intrathecally. thereby increasing patient safety by more accurately guiding treatment interventions in terms of type. aggressiveness and duration. Drainage of CSF has been used in routine clinical practice for lowering of ICP. However. A recent Cochrane review  also sought to review the literature. resulting in 127 case series.
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