The use of noninvasive measurements of intracranial pressure in patients with traumatic brain injury: a narrative review

Faria, Bárbara Caroline Dias; Sacramento, Luiz Gustavo Guimarães; Queiroz, André Vitor Rocha; Leite, Fernanda de Andrade Dias; Oliveira, Henrique Lacerda Lage Lopes de; Kimura, Thais Yuki; Faleiro, Rodrigo Moreira

doi:10.1055/s-0043-1764411

Brasil

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View and Review • Arq. Neuro-Psiquiatr. 81 (6) • June 2023 • https://doi.org/10.1055/s-0043-1764411 linkcopy

The use of noninvasive measurements of intracranial pressure in patients with traumatic brain injury: a narrative review

Avaliação não invasiva da pressão intracraniana em pacientes com traumatismo cranioencefálico: uma revisão narrativa

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background The most frequent cause of death in neurosurgical patients is due to the increase in intracranial pressure (ICP); consequently, adequate monitoring of this parameter is extremely important.

Objectives In this study, we aimed to analyze the accuracy of noninvasive measurement methods for intracranial hypertension (IH) in patients with traumatic brain injury (TBI).

Methods The data were obtained from the PubMed database, using the following terms: intracranial pressure, noninvasive, monitoring, assessment, and measurement. The selected articles date from 1980 to 2021, all of which were observational studies or clinical trials, in English and specifying ICP measurement in TBI. At the end of the selection, 21 articles were included in this review.

Results The optic nerve sheath diameter (ONSD), pupillometry, transcranial doppler (TCD), multimodal combination, brain compliance using ICP waveform (ICPW), HeadSense, and Visual flash evoked pressure (FVEP) were analyzed. Pupillometry was not found to correlate with ICP, while HeadSense monitor and the FVEP method appear to have good correlation, but sensitivity and specificity data are not available. The ONSD and TCD methods showed good-to-moderate accuracy on invasive ICP values and potential to detect IH in most studies. Furthermore, multimodal combination may reduce the error possibility related to each technique. Finally, ICPW showed good accuracy to ICP values, but this analysis included TBI and non-TBI patients in the same sample.

Conclusions Noninvasive ICP monitoring methods may be used in the near future to guide TBI patients’ management.

Keywords
Brain Injuries, Traumatic; Intracranial Pressure; Intracranial Hypertension

Author	Study design	Sample of TBI patients	Noninvasive ICP monitoring method	Summary of findings
Raffiz et al., 2017¹	Prospective observational study	41	ONSD	– ONSD values and ICP: r = 0.820; p = 0.01. – Including TBI and non-TBI groups: AUC of 0.964 (CI 95% 0.921–1.0) – Best cutoff point: 5.205 mm with 95.8% sensitivity and 80.4% specificity – Sensitivity and specificity of 5.47 mm in TBI group were higher than in non-TBI group (94.4% vs 83.3% and 95.2% vs 93.3%)
Singer et al., 2021²	Prospective observational study	135P	ONSD Pupillometry TCD	ONSD – ONSD differs significantly bilaterally between mild TBI, non-TBI, and severe TBI on postinjury days 2 and 3 – ONSD was not found to correlate with ICP. Pupillometry – Significant bilaterally percent changes in pupil diameters (p < 0.01), constriction velocity (p < 0.01) and dilatation velocity (p < 0.01) on postinjury days 1 and 2 – Values obtained from dynamic changes of pupil reliably differentiated severe TBI from mild brain injuries on postinjury days 2 and 3. – Pupillometry values and ICP: p > 0.05 TCD – Middle cerebral artery (MCA) peak systolic velocity, MCA flow velocity and common carotid artery flow velocity showed a statistically significant correlation with ICP in severe TBI patients
Maissan et al., 2015¹²	Prospective observational study	18	ONSD	– ONSD values and ICP: R2 = 0.80 – Cutoff point ≥ 5.00 mm: sensitivity = 94% and specificity = 98% – AUC 0.99 (0.97–1.00) was found for detection of IH
Strumwasser et al., 2011¹³	Prospective observational study	10	ONSD	ONSD values and ICP in unilateral (R2 = 0.45, p < 0.01) and bilateral (R2 = 0.21, p = 0.01) lesions. AUC = 0.36; p = 0.01 Sensitivity was 36%, specificity 38%, PPV 40%, the NPV 16% and the accuracy for estimating ICP with the ONSD was 37%.
Rajajee et al., 2011⁴	Prospective observational study	65	ONSD	– Optimal cutoff point of 4.8 mm: sensitivity = 96% (91–99%) and specificity = 94% (92–96%). – AUC = 0.98 (CI 5 A% 0.96–0.99; p < 0.96–0.99; p < 0.0001 for AUC = 0.5)
Soldatos et al., 2008⁹	Prospective observational study	76	ONSD	ONSD and ICPi values: r = 0.68; p = 0.002 Best cutoff point: 5.7 mm – sensitivity = 74,1% and specificity = 100% ONSD and estimated ICP (eICP): o Severe brain injury: 6.1 ± 0.7 mm and 26.2 ± 8.7 mmHg, respectively; p < 0.0001 o Moderate brain injury: 4, 2 ± 1.2 mm and 12.0 ± 3.6 mmHg o Control patients: 3.6 ± 0.6 mm and 10.3 ± 3.1 mmHg – Strong correlation between the values of ONSD, eICP (r = 0.80, p < 0.0001) and the neuroimaging scale (r = 0.82, p < 0.001)
Stevens et al., 2019¹⁰	Prospective observational study	41	Pupillometry	– Pupillometry and ICP: OR 3.36; (95% CI 0.93–13.53; p = 0.07) – Decrease in the pupil reactivity may indicate a raised ICP
Cardim et al., 2020¹⁶	Prospective observational study	100	TCD	ICPtcd and IPCi: r = - 0.17; p = 0.097
Rasulo et al., 2017¹⁵	Prospective observational study	20	TCD	– AUC of 0.96 (0.898–1.00), with an estimated best threshold at ICPi of 24.8 mmHg (corresponding a sensitivity of 100% and specificity of 91.2% of the ICPtcd detection of IH)
Robba et al., 2017⁶	Prospective observational study	41	ONSD TCD	ONSD – ONSD and ICP: r = 0.76; p < 0.05 – AUC of 0.91 (0.88–0.95) to detect cases with IH TCD – Straight sinus FVsv and ICP: r = 0.72; p < 0.05 – Combined ONSD and FVsv: r = 0.78; AUC for prediction of ICP 20 mm Hg was 0.93
Cardim et al., 2016¹⁷	Prospective observational study	40	TCD	− ICPtcd pulsatility index: o The best correlation with iICP, including spontaneous changes in ICP > 7 mmHg (R = 0.61) o The best efficacy for ICP dynamics monitoring
Schmidt et al., 2005⁷	Prospective observational study	103	TCD	− FV and ABP comparative parameters could infer the ICP with a median absolute difference of 5.7 mmHg when compared to the invasive method.
Ragauskas et al., 20053	Prospective observational study	57	TCD	− The difference in the ICP when comparing the 2 methods was 0.939 mmHg, suggesting the effectiveness of the noninvasive method.
Schmidt et al., 2003⁸	Prospective observational study	145	TCD	– Mx and nMx: r = 0.90; p < 0.001. – PRx and nPRx: r = 0.62; p < 0.001. – The sensitivity of nMx to estimate Mx was 0.92, the specificity of Mx was 0.79 and the fuzzy values were 0.97 and 0.92. – The sensitivity of nPRx to estimate PRx was 0.61 and its specificity was 0.67. – ABP and FV signals cannot be evaluated alone to estimate nICP.
Czosnyka et al., 1998¹⁸	Prospective observational study	96	TCD	– PPV of 94% for the detection of a low CPP (60 mmHg), with r = 0.73 – Estimation error of less than 10 mmHg in 71% of the cases.
Mursch et al., 1995¹⁹	Prospective observational study	28	TCD	– Reductions in diameter were observed: 0.3 to 1.1 mm when there was an increase in ICP. – The relationship between this drop and ICP was not specifically analyzed
Klingelhöfer et al., 1987²⁰	Prospective observational study	5	TCD	– Changes in the ICP significantly influenced flow patterns – TCD is a useful noninvasive method for gathering information regarding the development of ICP. – The study did not correlate in detail changes in flow patterns and ICP.
Herklots et al., 2017²¹	Prospective observational study	14	HeadSense monitor	– HeadSense and ICPi: r = 0.604; p < 0.001 – Sensitivity and specificity data were not presented in the study
Zhao et al., 2005¹¹	Prospective observational study	16	FVEP	– FVEP and ICP: r = 0.97 – No significant difference between the results from noninvasive and ICPi examinations – Sensibility and specificity data were not analyzed in this study
Brasil et al., 2021²⁶	Prospective observational study	21	Brain compliance using ICPW (B4C monitor)	– B4C sensor measurements and ICP: P2/P1 ratio (r = 0.72) and TTP (r = 0.85) – The B4C P2/P1 ratio threshold of ≥ 1.1 resulted in AUC 0.77 (0.62–0.92), p < 0.001, sensitivity 0.88, specificity 0.60) to detect IH
Robba et al., 2020¹⁴	Prospective observational study	30	ONSD PI eICP using TCD NPI using pupillometry	ONSD – AUC of 0.78 (0.62–0.95) to detect IH – Cutoff point of ONSD > 5.3 mm: sensitivity = 67% and specificity = 73% PI – AUC of 0.79 (0.63–0.96) to detect IH – Cutoff point of PI > 1.10: sensitivity = 61% and specificity = 80% eICP using TCD – AUC of 0.83 (CI 0.69–0.98) to detect IH – Cutoff point was eICP > 20 mmHg: sensitivity = 67% and specificity = 87%. NPI – AUC was 0.61 (95% CI 0.49-0.83) to detect IH – Cut-off point of NPI < 4.0: sensitivity = 61% and specificity = 73% COMBINED METHODS – All four methods: AUC 0.91 (0.80–1.00) to detect IH – ONSD with eICP using TCD: AUC 0.92 (0.81–1.00)

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[TFN1] Abbreviations: ABP, arterial blood pressure; CPP, cerebral perfusion pressure; CPPn, cerebral perfusion noninvasively; eICP, estimated ICP; FV, flow velocity; FVd, diastolic flow velocity; FVEP, visual flash evoked pressure; FVsd, straight sinus systolic flow velocity; ICP, intracranial pressure; ICPi, standard ICPi; ICPtcd, ICP TCD-derived measurement; IH, intracranial hypertension; ONSD, optic nerve sheath diameter; Mx, autoregulation index invasive; PRx, pressure reactivity index invasive; nMx, autoregulation index noninvasive; nPRx, pressure reactivity index noninvasive; PI, pulsatility index; PPV, positive predictive value; TBI, traumatic brain injury; TCD, transcranial doppler.