Is Neuromonitoring an expensive waste of

time in Severe Traumatic Brain Injury

Ross Bullock MD PhD Director Neurotrauma-

University of Miami Jackson Memorial Hospital Miami

EngorgementEngorgementEdemaEdema

DiffuseAxonal Injury

DiffuseAxonal Injury

HypoxiaHypoxia

HematomaHematoma ContusionContusion

Subcellular mechanisms in TBI SAH ICH Stroke

ldquoMonitors alone cannot save patients but wise application of the data from monitoring

the injured brain canrdquo Saul Ducker 1983 Monitoring vs serial imaging

Severe TBI-- Does it all make a difference

bull Mortality rates fallinghellip~80 before WWII ndash 60 in 1960rsquos 40 in 1980rsquos ~20 in 2000hellip ndash Most cost effective surgical procedure of all is craniotomy

for EDHhellip

Age (years)

Prob

abilit

y of

out

com

e (

)

20 40 60 80

0

20

40

60

80

100

Probability of deathhellipsevere TBI-2007

Ischemic Tissue Damage and Infarction is Dependent on Reduction of Oxygen Delivery

and the Duration of the Ischemic Insult

Substrate delivery Monitoringhellip pannecrosis

Why is ICP Monitoring so Important

bull 80 in hospital deaths from high ICP

bull ldquobarometerrdquo of ldquostandard of carerdquohelliprdquolevel II guidelinerdquo

bull Best way to implement more ICP monitoring maybe by concentrating patients at hospitals who do ithellip

bull ldquoGold bookrdquo requirement for Level 1 centershellip

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

The NIH-NINDS Trial of ICP Monitoring in BoliviaLABIChellip

4 hospitals PRCT~350 pts

bull ldquoWe are still likely to continue to doubt clinical

bull signs which indeed do not reflect global pressure inside the cranium but stupor coma posturing and dilatation of the pupils indicate compression of the midbrain and according to this study they are very suitable observations to

bull use in directing treatmentrdquohellip

ldquoIn the future there may be other means of detecting

early compression of the brain stem Until then

clinical methods are finerdquo

Why the Chesnut Bolivia ICP monitoring trial is not ldquogeneralisablerdquo to rest of the

worldhellip bull Only about 50 of severe TBI cases got into ICUhellipbed limitationshellip bull No prehospital care no rehab poor

ldquo subacute ldquophase care40 mortalityhellip bull ~47 decompressive craniotomy used in

both groups ~23 barbiturates 1 ventricular drainage

bull mean~ 20 hours with ICPgt20mmHg

bull Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

Arash Farahvar MD PhD1 Linda M Gerber PhD2 Ya-Lin Chiu MS2 bull Nancy Carney PhD3 Roger Haumlrtl MD4 and Jam shid Ghaja r MD PhD45 bull 1Department of Neurosurgery University of Rochester Medical Center Rochester Departments of 2Public bull Health and 4Neurological Surgery Weill Cornell Medical College and 5Brain Trauma Foundation bull New York New York and 3Department of Medical Informatics and Clinical Epidemiology Oregon bull Health amp Science University Portland Oregon bull Object Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe bull traumatic brain injury (TBI) but there is limited evidence that monitoring and treating intracranial hypertension

reduces bull mortality This study uses a large prospectively collected database to examine the effect on 2-week mortality bull of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP

monitor bull Methods From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score lt 9) 1446 bull patients were treated with ICP-lowering therapies Of those 1202 had an ICP monitor inserted and 244 were

treated bull without monitoring Patients were admitted to one of 20 Level I and two Level II trauma centers part of a New

York bull State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009 bull Results Age initial GCS score hypotension and CT scan findings were associated with 2-week mortality In bull addition patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 002)

than those bull treated without an ICP monitor after adjusting for parameters that independently affect mortality bull Conclusions In patients with severe TBI treated for intracranial

hypertension the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor Based on these findings the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring

bull (httpthejnsorgdoiabs10317120127JNS111816)

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

Related Articles Links

Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring Vespa PM Nuwer MR Nenov V Ronne-Engstrom E Hovda DA Bergsneider M Kelly DF Martin NA Becker DP Department of Neurology University of California at Los Angeles School of Medicine 90024 USA Convulsive and nonconvulsive seizures occurred in 21 (22) of the 94 patients with six of them displaying status epilepticus In more than half of the patients (52) the seizures were nonconvulsive and were diagnosed on the basis of EEG studies alone All six patients with status epilepticus died compared with a mortality rate of 24 (18 of 73) in the nonseizure group (plt0001) The patients with status epilepticus had a shorter mean length of stay (914+-59 days compared with 14+-9 days [t-test plt0031) Seizures occurred despite initiation of prophylactic phenytoin on admission to the emergency room with maintenance at mean levels of 166+-28 mgdlCONCLUSIONS Seizures occur in more than one in five patients during the 1st week after moderate-to-severe brain injury and may play a role in the pathobiological conditions associated with brain injury

J Neurosurg 1999 Nov91(5)750-60

Subcellular mechanisms in TBI SAH ICH Stroke

ldquoMonitors alone cannot save patients but wise application of the data from monitoring

the injured brain canrdquo Saul Ducker 1983 Monitoring vs serial imaging

Severe TBI-- Does it all make a difference

bull Mortality rates fallinghellip~80 before WWII ndash 60 in 1960rsquos 40 in 1980rsquos ~20 in 2000hellip ndash Most cost effective surgical procedure of all is craniotomy

for EDHhellip

Age (years)

Prob

abilit

y of

out

com

e (

)

20 40 60 80

0

20

40

60

80

100

Probability of deathhellipsevere TBI-2007

Ischemic Tissue Damage and Infarction is Dependent on Reduction of Oxygen Delivery

and the Duration of the Ischemic Insult

Substrate delivery Monitoringhellip pannecrosis

Why is ICP Monitoring so Important

bull 80 in hospital deaths from high ICP

bull ldquobarometerrdquo of ldquostandard of carerdquohelliprdquolevel II guidelinerdquo

bull Best way to implement more ICP monitoring maybe by concentrating patients at hospitals who do ithellip

bull ldquoGold bookrdquo requirement for Level 1 centershellip

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

The NIH-NINDS Trial of ICP Monitoring in BoliviaLABIChellip

4 hospitals PRCT~350 pts

bull ldquoWe are still likely to continue to doubt clinical

bull signs which indeed do not reflect global pressure inside the cranium but stupor coma posturing and dilatation of the pupils indicate compression of the midbrain and according to this study they are very suitable observations to

bull use in directing treatmentrdquohellip

ldquoIn the future there may be other means of detecting

early compression of the brain stem Until then

clinical methods are finerdquo

Why the Chesnut Bolivia ICP monitoring trial is not ldquogeneralisablerdquo to rest of the

worldhellip bull Only about 50 of severe TBI cases got into ICUhellipbed limitationshellip bull No prehospital care no rehab poor

ldquo subacute ldquophase care40 mortalityhellip bull ~47 decompressive craniotomy used in

both groups ~23 barbiturates 1 ventricular drainage

bull mean~ 20 hours with ICPgt20mmHg

bull Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

Arash Farahvar MD PhD1 Linda M Gerber PhD2 Ya-Lin Chiu MS2 bull Nancy Carney PhD3 Roger Haumlrtl MD4 and Jam shid Ghaja r MD PhD45 bull 1Department of Neurosurgery University of Rochester Medical Center Rochester Departments of 2Public bull Health and 4Neurological Surgery Weill Cornell Medical College and 5Brain Trauma Foundation bull New York New York and 3Department of Medical Informatics and Clinical Epidemiology Oregon bull Health amp Science University Portland Oregon bull Object Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe bull traumatic brain injury (TBI) but there is limited evidence that monitoring and treating intracranial hypertension

reduces bull mortality This study uses a large prospectively collected database to examine the effect on 2-week mortality bull of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP

monitor bull Methods From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score lt 9) 1446 bull patients were treated with ICP-lowering therapies Of those 1202 had an ICP monitor inserted and 244 were

treated bull without monitoring Patients were admitted to one of 20 Level I and two Level II trauma centers part of a New

York bull State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009 bull Results Age initial GCS score hypotension and CT scan findings were associated with 2-week mortality In bull addition patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 002)

than those bull treated without an ICP monitor after adjusting for parameters that independently affect mortality bull Conclusions In patients with severe TBI treated for intracranial

hypertension the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor Based on these findings the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring

bull (httpthejnsorgdoiabs10317120127JNS111816)

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

Related Articles Links

Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring Vespa PM Nuwer MR Nenov V Ronne-Engstrom E Hovda DA Bergsneider M Kelly DF Martin NA Becker DP Department of Neurology University of California at Los Angeles School of Medicine 90024 USA Convulsive and nonconvulsive seizures occurred in 21 (22) of the 94 patients with six of them displaying status epilepticus In more than half of the patients (52) the seizures were nonconvulsive and were diagnosed on the basis of EEG studies alone All six patients with status epilepticus died compared with a mortality rate of 24 (18 of 73) in the nonseizure group (plt0001) The patients with status epilepticus had a shorter mean length of stay (914+-59 days compared with 14+-9 days [t-test plt0031) Seizures occurred despite initiation of prophylactic phenytoin on admission to the emergency room with maintenance at mean levels of 166+-28 mgdlCONCLUSIONS Seizures occur in more than one in five patients during the 1st week after moderate-to-severe brain injury and may play a role in the pathobiological conditions associated with brain injury

J Neurosurg 1999 Nov91(5)750-60

ldquoMonitors alone cannot save patients but wise application of the data from monitoring

the injured brain canrdquo Saul Ducker 1983 Monitoring vs serial imaging

Severe TBI-- Does it all make a difference

bull Mortality rates fallinghellip~80 before WWII ndash 60 in 1960rsquos 40 in 1980rsquos ~20 in 2000hellip ndash Most cost effective surgical procedure of all is craniotomy

for EDHhellip

Age (years)

Prob

abilit

y of

out

com

e (

)

20 40 60 80

0

20

40

60

80

100

Probability of deathhellipsevere TBI-2007

Ischemic Tissue Damage and Infarction is Dependent on Reduction of Oxygen Delivery

and the Duration of the Ischemic Insult

Substrate delivery Monitoringhellip pannecrosis

Why is ICP Monitoring so Important

bull 80 in hospital deaths from high ICP

bull ldquobarometerrdquo of ldquostandard of carerdquohelliprdquolevel II guidelinerdquo

bull Best way to implement more ICP monitoring maybe by concentrating patients at hospitals who do ithellip

bull ldquoGold bookrdquo requirement for Level 1 centershellip

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

The NIH-NINDS Trial of ICP Monitoring in BoliviaLABIChellip

4 hospitals PRCT~350 pts

bull ldquoWe are still likely to continue to doubt clinical

bull signs which indeed do not reflect global pressure inside the cranium but stupor coma posturing and dilatation of the pupils indicate compression of the midbrain and according to this study they are very suitable observations to

bull use in directing treatmentrdquohellip

ldquoIn the future there may be other means of detecting

early compression of the brain stem Until then

clinical methods are finerdquo

Why the Chesnut Bolivia ICP monitoring trial is not ldquogeneralisablerdquo to rest of the

worldhellip bull Only about 50 of severe TBI cases got into ICUhellipbed limitationshellip bull No prehospital care no rehab poor

ldquo subacute ldquophase care40 mortalityhellip bull ~47 decompressive craniotomy used in

both groups ~23 barbiturates 1 ventricular drainage

bull mean~ 20 hours with ICPgt20mmHg

bull Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

Arash Farahvar MD PhD1 Linda M Gerber PhD2 Ya-Lin Chiu MS2 bull Nancy Carney PhD3 Roger Haumlrtl MD4 and Jam shid Ghaja r MD PhD45 bull 1Department of Neurosurgery University of Rochester Medical Center Rochester Departments of 2Public bull Health and 4Neurological Surgery Weill Cornell Medical College and 5Brain Trauma Foundation bull New York New York and 3Department of Medical Informatics and Clinical Epidemiology Oregon bull Health amp Science University Portland Oregon bull Object Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe bull traumatic brain injury (TBI) but there is limited evidence that monitoring and treating intracranial hypertension

reduces bull mortality This study uses a large prospectively collected database to examine the effect on 2-week mortality bull of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP

monitor bull Methods From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score lt 9) 1446 bull patients were treated with ICP-lowering therapies Of those 1202 had an ICP monitor inserted and 244 were

treated bull without monitoring Patients were admitted to one of 20 Level I and two Level II trauma centers part of a New

York bull State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009 bull Results Age initial GCS score hypotension and CT scan findings were associated with 2-week mortality In bull addition patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 002)

than those bull treated without an ICP monitor after adjusting for parameters that independently affect mortality bull Conclusions In patients with severe TBI treated for intracranial

hypertension the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor Based on these findings the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring

bull (httpthejnsorgdoiabs10317120127JNS111816)

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

Related Articles Links

Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring Vespa PM Nuwer MR Nenov V Ronne-Engstrom E Hovda DA Bergsneider M Kelly DF Martin NA Becker DP Department of Neurology University of California at Los Angeles School of Medicine 90024 USA Convulsive and nonconvulsive seizures occurred in 21 (22) of the 94 patients with six of them displaying status epilepticus In more than half of the patients (52) the seizures were nonconvulsive and were diagnosed on the basis of EEG studies alone All six patients with status epilepticus died compared with a mortality rate of 24 (18 of 73) in the nonseizure group (plt0001) The patients with status epilepticus had a shorter mean length of stay (914+-59 days compared with 14+-9 days [t-test plt0031) Seizures occurred despite initiation of prophylactic phenytoin on admission to the emergency room with maintenance at mean levels of 166+-28 mgdlCONCLUSIONS Seizures occur in more than one in five patients during the 1st week after moderate-to-severe brain injury and may play a role in the pathobiological conditions associated with brain injury

J Neurosurg 1999 Nov91(5)750-60

Severe TBI-- Does it all make a difference

bull Mortality rates fallinghellip~80 before WWII ndash 60 in 1960rsquos 40 in 1980rsquos ~20 in 2000hellip ndash Most cost effective surgical procedure of all is craniotomy

for EDHhellip

Age (years)

Prob

abilit

y of

out

com

e (

)

20 40 60 80

0

20

40

60

80

100

Probability of deathhellipsevere TBI-2007

Ischemic Tissue Damage and Infarction is Dependent on Reduction of Oxygen Delivery

and the Duration of the Ischemic Insult

Substrate delivery Monitoringhellip pannecrosis

Why is ICP Monitoring so Important

bull 80 in hospital deaths from high ICP

bull ldquobarometerrdquo of ldquostandard of carerdquohelliprdquolevel II guidelinerdquo

bull Best way to implement more ICP monitoring maybe by concentrating patients at hospitals who do ithellip

bull ldquoGold bookrdquo requirement for Level 1 centershellip

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

The NIH-NINDS Trial of ICP Monitoring in BoliviaLABIChellip

4 hospitals PRCT~350 pts

bull ldquoWe are still likely to continue to doubt clinical

bull signs which indeed do not reflect global pressure inside the cranium but stupor coma posturing and dilatation of the pupils indicate compression of the midbrain and according to this study they are very suitable observations to

bull use in directing treatmentrdquohellip

ldquoIn the future there may be other means of detecting

early compression of the brain stem Until then

clinical methods are finerdquo

Why the Chesnut Bolivia ICP monitoring trial is not ldquogeneralisablerdquo to rest of the

worldhellip bull Only about 50 of severe TBI cases got into ICUhellipbed limitationshellip bull No prehospital care no rehab poor

ldquo subacute ldquophase care40 mortalityhellip bull ~47 decompressive craniotomy used in

both groups ~23 barbiturates 1 ventricular drainage

bull mean~ 20 hours with ICPgt20mmHg

bull Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

Arash Farahvar MD PhD1 Linda M Gerber PhD2 Ya-Lin Chiu MS2 bull Nancy Carney PhD3 Roger Haumlrtl MD4 and Jam shid Ghaja r MD PhD45 bull 1Department of Neurosurgery University of Rochester Medical Center Rochester Departments of 2Public bull Health and 4Neurological Surgery Weill Cornell Medical College and 5Brain Trauma Foundation bull New York New York and 3Department of Medical Informatics and Clinical Epidemiology Oregon bull Health amp Science University Portland Oregon bull Object Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe bull traumatic brain injury (TBI) but there is limited evidence that monitoring and treating intracranial hypertension

reduces bull mortality This study uses a large prospectively collected database to examine the effect on 2-week mortality bull of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP

monitor bull Methods From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score lt 9) 1446 bull patients were treated with ICP-lowering therapies Of those 1202 had an ICP monitor inserted and 244 were

treated bull without monitoring Patients were admitted to one of 20 Level I and two Level II trauma centers part of a New

York bull State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009 bull Results Age initial GCS score hypotension and CT scan findings were associated with 2-week mortality In bull addition patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 002)

than those bull treated without an ICP monitor after adjusting for parameters that independently affect mortality bull Conclusions In patients with severe TBI treated for intracranial

hypertension the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor Based on these findings the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring

bull (httpthejnsorgdoiabs10317120127JNS111816)

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

Related Articles Links

Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring Vespa PM Nuwer MR Nenov V Ronne-Engstrom E Hovda DA Bergsneider M Kelly DF Martin NA Becker DP Department of Neurology University of California at Los Angeles School of Medicine 90024 USA Convulsive and nonconvulsive seizures occurred in 21 (22) of the 94 patients with six of them displaying status epilepticus In more than half of the patients (52) the seizures were nonconvulsive and were diagnosed on the basis of EEG studies alone All six patients with status epilepticus died compared with a mortality rate of 24 (18 of 73) in the nonseizure group (plt0001) The patients with status epilepticus had a shorter mean length of stay (914+-59 days compared with 14+-9 days [t-test plt0031) Seizures occurred despite initiation of prophylactic phenytoin on admission to the emergency room with maintenance at mean levels of 166+-28 mgdlCONCLUSIONS Seizures occur in more than one in five patients during the 1st week after moderate-to-severe brain injury and may play a role in the pathobiological conditions associated with brain injury

J Neurosurg 1999 Nov91(5)750-60

Ischemic Tissue Damage and Infarction is Dependent on Reduction of Oxygen Delivery

and the Duration of the Ischemic Insult

Substrate delivery Monitoringhellip pannecrosis

Why is ICP Monitoring so Important

bull 80 in hospital deaths from high ICP

bull ldquobarometerrdquo of ldquostandard of carerdquohelliprdquolevel II guidelinerdquo

bull Best way to implement more ICP monitoring maybe by concentrating patients at hospitals who do ithellip

bull ldquoGold bookrdquo requirement for Level 1 centershellip

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

The NIH-NINDS Trial of ICP Monitoring in BoliviaLABIChellip

4 hospitals PRCT~350 pts

bull ldquoWe are still likely to continue to doubt clinical

bull signs which indeed do not reflect global pressure inside the cranium but stupor coma posturing and dilatation of the pupils indicate compression of the midbrain and according to this study they are very suitable observations to

bull use in directing treatmentrdquohellip

ldquoIn the future there may be other means of detecting

early compression of the brain stem Until then

clinical methods are finerdquo

Why the Chesnut Bolivia ICP monitoring trial is not ldquogeneralisablerdquo to rest of the

worldhellip bull Only about 50 of severe TBI cases got into ICUhellipbed limitationshellip bull No prehospital care no rehab poor

ldquo subacute ldquophase care40 mortalityhellip bull ~47 decompressive craniotomy used in

both groups ~23 barbiturates 1 ventricular drainage

bull mean~ 20 hours with ICPgt20mmHg

bull Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

Arash Farahvar MD PhD1 Linda M Gerber PhD2 Ya-Lin Chiu MS2 bull Nancy Carney PhD3 Roger Haumlrtl MD4 and Jam shid Ghaja r MD PhD45 bull 1Department of Neurosurgery University of Rochester Medical Center Rochester Departments of 2Public bull Health and 4Neurological Surgery Weill Cornell Medical College and 5Brain Trauma Foundation bull New York New York and 3Department of Medical Informatics and Clinical Epidemiology Oregon bull Health amp Science University Portland Oregon bull Object Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe bull traumatic brain injury (TBI) but there is limited evidence that monitoring and treating intracranial hypertension

reduces bull mortality This study uses a large prospectively collected database to examine the effect on 2-week mortality bull of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP

monitor bull Methods From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score lt 9) 1446 bull patients were treated with ICP-lowering therapies Of those 1202 had an ICP monitor inserted and 244 were

treated bull without monitoring Patients were admitted to one of 20 Level I and two Level II trauma centers part of a New

York bull State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009 bull Results Age initial GCS score hypotension and CT scan findings were associated with 2-week mortality In bull addition patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 002)

than those bull treated without an ICP monitor after adjusting for parameters that independently affect mortality bull Conclusions In patients with severe TBI treated for intracranial

hypertension the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor Based on these findings the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring

bull (httpthejnsorgdoiabs10317120127JNS111816)

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

Related Articles Links

Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring Vespa PM Nuwer MR Nenov V Ronne-Engstrom E Hovda DA Bergsneider M Kelly DF Martin NA Becker DP Department of Neurology University of California at Los Angeles School of Medicine 90024 USA Convulsive and nonconvulsive seizures occurred in 21 (22) of the 94 patients with six of them displaying status epilepticus In more than half of the patients (52) the seizures were nonconvulsive and were diagnosed on the basis of EEG studies alone All six patients with status epilepticus died compared with a mortality rate of 24 (18 of 73) in the nonseizure group (plt0001) The patients with status epilepticus had a shorter mean length of stay (914+-59 days compared with 14+-9 days [t-test plt0031) Seizures occurred despite initiation of prophylactic phenytoin on admission to the emergency room with maintenance at mean levels of 166+-28 mgdlCONCLUSIONS Seizures occur in more than one in five patients during the 1st week after moderate-to-severe brain injury and may play a role in the pathobiological conditions associated with brain injury

J Neurosurg 1999 Nov91(5)750-60

Why is ICP Monitoring so Important

bull 80 in hospital deaths from high ICP

bull ldquobarometerrdquo of ldquostandard of carerdquohelliprdquolevel II guidelinerdquo

bull Best way to implement more ICP monitoring maybe by concentrating patients at hospitals who do ithellip

bull ldquoGold bookrdquo requirement for Level 1 centershellip

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

The NIH-NINDS Trial of ICP Monitoring in BoliviaLABIChellip

4 hospitals PRCT~350 pts

bull ldquoWe are still likely to continue to doubt clinical

bull signs which indeed do not reflect global pressure inside the cranium but stupor coma posturing and dilatation of the pupils indicate compression of the midbrain and according to this study they are very suitable observations to

bull use in directing treatmentrdquohellip

ldquoIn the future there may be other means of detecting

early compression of the brain stem Until then

clinical methods are finerdquo

Why the Chesnut Bolivia ICP monitoring trial is not ldquogeneralisablerdquo to rest of the

worldhellip bull Only about 50 of severe TBI cases got into ICUhellipbed limitationshellip bull No prehospital care no rehab poor

ldquo subacute ldquophase care40 mortalityhellip bull ~47 decompressive craniotomy used in

both groups ~23 barbiturates 1 ventricular drainage

bull mean~ 20 hours with ICPgt20mmHg

bull Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

Arash Farahvar MD PhD1 Linda M Gerber PhD2 Ya-Lin Chiu MS2 bull Nancy Carney PhD3 Roger Haumlrtl MD4 and Jam shid Ghaja r MD PhD45 bull 1Department of Neurosurgery University of Rochester Medical Center Rochester Departments of 2Public bull Health and 4Neurological Surgery Weill Cornell Medical College and 5Brain Trauma Foundation bull New York New York and 3Department of Medical Informatics and Clinical Epidemiology Oregon bull Health amp Science University Portland Oregon bull Object Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe bull traumatic brain injury (TBI) but there is limited evidence that monitoring and treating intracranial hypertension

reduces bull mortality This study uses a large prospectively collected database to examine the effect on 2-week mortality bull of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP

monitor bull Methods From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score lt 9) 1446 bull patients were treated with ICP-lowering therapies Of those 1202 had an ICP monitor inserted and 244 were

treated bull without monitoring Patients were admitted to one of 20 Level I and two Level II trauma centers part of a New

York bull State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009 bull Results Age initial GCS score hypotension and CT scan findings were associated with 2-week mortality In bull addition patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 002)

than those bull treated without an ICP monitor after adjusting for parameters that independently affect mortality bull Conclusions In patients with severe TBI treated for intracranial

hypertension the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor Based on these findings the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring

bull (httpthejnsorgdoiabs10317120127JNS111816)

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

Related Articles Links

Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring Vespa PM Nuwer MR Nenov V Ronne-Engstrom E Hovda DA Bergsneider M Kelly DF Martin NA Becker DP Department of Neurology University of California at Los Angeles School of Medicine 90024 USA Convulsive and nonconvulsive seizures occurred in 21 (22) of the 94 patients with six of them displaying status epilepticus In more than half of the patients (52) the seizures were nonconvulsive and were diagnosed on the basis of EEG studies alone All six patients with status epilepticus died compared with a mortality rate of 24 (18 of 73) in the nonseizure group (plt0001) The patients with status epilepticus had a shorter mean length of stay (914+-59 days compared with 14+-9 days [t-test plt0031) Seizures occurred despite initiation of prophylactic phenytoin on admission to the emergency room with maintenance at mean levels of 166+-28 mgdlCONCLUSIONS Seizures occur in more than one in five patients during the 1st week after moderate-to-severe brain injury and may play a role in the pathobiological conditions associated with brain injury

J Neurosurg 1999 Nov91(5)750-60

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

The NIH-NINDS Trial of ICP Monitoring in BoliviaLABIChellip

4 hospitals PRCT~350 pts

bull ldquoWe are still likely to continue to doubt clinical

bull signs which indeed do not reflect global pressure inside the cranium but stupor coma posturing and dilatation of the pupils indicate compression of the midbrain and according to this study they are very suitable observations to

bull use in directing treatmentrdquohellip

ldquoIn the future there may be other means of detecting

early compression of the brain stem Until then

clinical methods are finerdquo

Why the Chesnut Bolivia ICP monitoring trial is not ldquogeneralisablerdquo to rest of the

worldhellip bull Only about 50 of severe TBI cases got into ICUhellipbed limitationshellip bull No prehospital care no rehab poor

ldquo subacute ldquophase care40 mortalityhellip bull ~47 decompressive craniotomy used in

both groups ~23 barbiturates 1 ventricular drainage

bull mean~ 20 hours with ICPgt20mmHg

bull Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

Arash Farahvar MD PhD1 Linda M Gerber PhD2 Ya-Lin Chiu MS2 bull Nancy Carney PhD3 Roger Haumlrtl MD4 and Jam shid Ghaja r MD PhD45 bull 1Department of Neurosurgery University of Rochester Medical Center Rochester Departments of 2Public bull Health and 4Neurological Surgery Weill Cornell Medical College and 5Brain Trauma Foundation bull New York New York and 3Department of Medical Informatics and Clinical Epidemiology Oregon bull Health amp Science University Portland Oregon bull Object Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe bull traumatic brain injury (TBI) but there is limited evidence that monitoring and treating intracranial hypertension

reduces bull mortality This study uses a large prospectively collected database to examine the effect on 2-week mortality bull of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP

monitor bull Methods From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score lt 9) 1446 bull patients were treated with ICP-lowering therapies Of those 1202 had an ICP monitor inserted and 244 were

treated bull without monitoring Patients were admitted to one of 20 Level I and two Level II trauma centers part of a New

York bull State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009 bull Results Age initial GCS score hypotension and CT scan findings were associated with 2-week mortality In bull addition patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 002)

than those bull treated without an ICP monitor after adjusting for parameters that independently affect mortality bull Conclusions In patients with severe TBI treated for intracranial

hypertension the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor Based on these findings the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring

bull (httpthejnsorgdoiabs10317120127JNS111816)

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

Related Articles Links

Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring Vespa PM Nuwer MR Nenov V Ronne-Engstrom E Hovda DA Bergsneider M Kelly DF Martin NA Becker DP Department of Neurology University of California at Los Angeles School of Medicine 90024 USA Convulsive and nonconvulsive seizures occurred in 21 (22) of the 94 patients with six of them displaying status epilepticus In more than half of the patients (52) the seizures were nonconvulsive and were diagnosed on the basis of EEG studies alone All six patients with status epilepticus died compared with a mortality rate of 24 (18 of 73) in the nonseizure group (plt0001) The patients with status epilepticus had a shorter mean length of stay (914+-59 days compared with 14+-9 days [t-test plt0031) Seizures occurred despite initiation of prophylactic phenytoin on admission to the emergency room with maintenance at mean levels of 166+-28 mgdlCONCLUSIONS Seizures occur in more than one in five patients during the 1st week after moderate-to-severe brain injury and may play a role in the pathobiological conditions associated with brain injury

J Neurosurg 1999 Nov91(5)750-60

The NIH-NINDS Trial of ICP Monitoring in BoliviaLABIChellip

4 hospitals PRCT~350 pts

bull ldquoWe are still likely to continue to doubt clinical

bull signs which indeed do not reflect global pressure inside the cranium but stupor coma posturing and dilatation of the pupils indicate compression of the midbrain and according to this study they are very suitable observations to

bull use in directing treatmentrdquohellip

ldquoIn the future there may be other means of detecting

early compression of the brain stem Until then

clinical methods are finerdquo

Why the Chesnut Bolivia ICP monitoring trial is not ldquogeneralisablerdquo to rest of the

worldhellip bull Only about 50 of severe TBI cases got into ICUhellipbed limitationshellip bull No prehospital care no rehab poor

ldquo subacute ldquophase care40 mortalityhellip bull ~47 decompressive craniotomy used in

both groups ~23 barbiturates 1 ventricular drainage

bull mean~ 20 hours with ICPgt20mmHg

bull Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

Arash Farahvar MD PhD1 Linda M Gerber PhD2 Ya-Lin Chiu MS2 bull Nancy Carney PhD3 Roger Haumlrtl MD4 and Jam shid Ghaja r MD PhD45 bull 1Department of Neurosurgery University of Rochester Medical Center Rochester Departments of 2Public bull Health and 4Neurological Surgery Weill Cornell Medical College and 5Brain Trauma Foundation bull New York New York and 3Department of Medical Informatics and Clinical Epidemiology Oregon bull Health amp Science University Portland Oregon bull Object Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe bull traumatic brain injury (TBI) but there is limited evidence that monitoring and treating intracranial hypertension

reduces bull mortality This study uses a large prospectively collected database to examine the effect on 2-week mortality bull of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP

monitor bull Methods From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score lt 9) 1446 bull patients were treated with ICP-lowering therapies Of those 1202 had an ICP monitor inserted and 244 were

treated bull without monitoring Patients were admitted to one of 20 Level I and two Level II trauma centers part of a New

York bull State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009 bull Results Age initial GCS score hypotension and CT scan findings were associated with 2-week mortality In bull addition patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 002)

than those bull treated without an ICP monitor after adjusting for parameters that independently affect mortality bull Conclusions In patients with severe TBI treated for intracranial

hypertension the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor Based on these findings the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring

bull (httpthejnsorgdoiabs10317120127JNS111816)

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

Related Articles Links

Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring Vespa PM Nuwer MR Nenov V Ronne-Engstrom E Hovda DA Bergsneider M Kelly DF Martin NA Becker DP Department of Neurology University of California at Los Angeles School of Medicine 90024 USA Convulsive and nonconvulsive seizures occurred in 21 (22) of the 94 patients with six of them displaying status epilepticus In more than half of the patients (52) the seizures were nonconvulsive and were diagnosed on the basis of EEG studies alone All six patients with status epilepticus died compared with a mortality rate of 24 (18 of 73) in the nonseizure group (plt0001) The patients with status epilepticus had a shorter mean length of stay (914+-59 days compared with 14+-9 days [t-test plt0031) Seizures occurred despite initiation of prophylactic phenytoin on admission to the emergency room with maintenance at mean levels of 166+-28 mgdlCONCLUSIONS Seizures occur in more than one in five patients during the 1st week after moderate-to-severe brain injury and may play a role in the pathobiological conditions associated with brain injury

J Neurosurg 1999 Nov91(5)750-60

bull ldquoWe are still likely to continue to doubt clinical

bull signs which indeed do not reflect global pressure inside the cranium but stupor coma posturing and dilatation of the pupils indicate compression of the midbrain and according to this study they are very suitable observations to

bull use in directing treatmentrdquohellip

ldquoIn the future there may be other means of detecting

early compression of the brain stem Until then

clinical methods are finerdquo

Why the Chesnut Bolivia ICP monitoring trial is not ldquogeneralisablerdquo to rest of the

worldhellip bull Only about 50 of severe TBI cases got into ICUhellipbed limitationshellip bull No prehospital care no rehab poor

ldquo subacute ldquophase care40 mortalityhellip bull ~47 decompressive craniotomy used in

both groups ~23 barbiturates 1 ventricular drainage

bull mean~ 20 hours with ICPgt20mmHg

bull Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

Arash Farahvar MD PhD1 Linda M Gerber PhD2 Ya-Lin Chiu MS2 bull Nancy Carney PhD3 Roger Haumlrtl MD4 and Jam shid Ghaja r MD PhD45 bull 1Department of Neurosurgery University of Rochester Medical Center Rochester Departments of 2Public bull Health and 4Neurological Surgery Weill Cornell Medical College and 5Brain Trauma Foundation bull New York New York and 3Department of Medical Informatics and Clinical Epidemiology Oregon bull Health amp Science University Portland Oregon bull Object Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe bull traumatic brain injury (TBI) but there is limited evidence that monitoring and treating intracranial hypertension

reduces bull mortality This study uses a large prospectively collected database to examine the effect on 2-week mortality bull of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP

monitor bull Methods From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score lt 9) 1446 bull patients were treated with ICP-lowering therapies Of those 1202 had an ICP monitor inserted and 244 were

treated bull without monitoring Patients were admitted to one of 20 Level I and two Level II trauma centers part of a New

York bull State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009 bull Results Age initial GCS score hypotension and CT scan findings were associated with 2-week mortality In bull addition patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 002)

than those bull treated without an ICP monitor after adjusting for parameters that independently affect mortality bull Conclusions In patients with severe TBI treated for intracranial

hypertension the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor Based on these findings the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring

bull (httpthejnsorgdoiabs10317120127JNS111816)

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

Related Articles Links

Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring Vespa PM Nuwer MR Nenov V Ronne-Engstrom E Hovda DA Bergsneider M Kelly DF Martin NA Becker DP Department of Neurology University of California at Los Angeles School of Medicine 90024 USA Convulsive and nonconvulsive seizures occurred in 21 (22) of the 94 patients with six of them displaying status epilepticus In more than half of the patients (52) the seizures were nonconvulsive and were diagnosed on the basis of EEG studies alone All six patients with status epilepticus died compared with a mortality rate of 24 (18 of 73) in the nonseizure group (plt0001) The patients with status epilepticus had a shorter mean length of stay (914+-59 days compared with 14+-9 days [t-test plt0031) Seizures occurred despite initiation of prophylactic phenytoin on admission to the emergency room with maintenance at mean levels of 166+-28 mgdlCONCLUSIONS Seizures occur in more than one in five patients during the 1st week after moderate-to-severe brain injury and may play a role in the pathobiological conditions associated with brain injury

J Neurosurg 1999 Nov91(5)750-60

Why the Chesnut Bolivia ICP monitoring trial is not ldquogeneralisablerdquo to rest of the

worldhellip bull Only about 50 of severe TBI cases got into ICUhellipbed limitationshellip bull No prehospital care no rehab poor

ldquo subacute ldquophase care40 mortalityhellip bull ~47 decompressive craniotomy used in

both groups ~23 barbiturates 1 ventricular drainage

bull mean~ 20 hours with ICPgt20mmHg

bull Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

Arash Farahvar MD PhD1 Linda M Gerber PhD2 Ya-Lin Chiu MS2 bull Nancy Carney PhD3 Roger Haumlrtl MD4 and Jam shid Ghaja r MD PhD45 bull 1Department of Neurosurgery University of Rochester Medical Center Rochester Departments of 2Public bull Health and 4Neurological Surgery Weill Cornell Medical College and 5Brain Trauma Foundation bull New York New York and 3Department of Medical Informatics and Clinical Epidemiology Oregon bull Health amp Science University Portland Oregon bull Object Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe bull traumatic brain injury (TBI) but there is limited evidence that monitoring and treating intracranial hypertension

reduces bull mortality This study uses a large prospectively collected database to examine the effect on 2-week mortality bull of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP

monitor bull Methods From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score lt 9) 1446 bull patients were treated with ICP-lowering therapies Of those 1202 had an ICP monitor inserted and 244 were

treated bull without monitoring Patients were admitted to one of 20 Level I and two Level II trauma centers part of a New

York bull State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009 bull Results Age initial GCS score hypotension and CT scan findings were associated with 2-week mortality In bull addition patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 002)

than those bull treated without an ICP monitor after adjusting for parameters that independently affect mortality bull Conclusions In patients with severe TBI treated for intracranial

hypertension the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor Based on these findings the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring

bull (httpthejnsorgdoiabs10317120127JNS111816)

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

Related Articles Links

Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring Vespa PM Nuwer MR Nenov V Ronne-Engstrom E Hovda DA Bergsneider M Kelly DF Martin NA Becker DP Department of Neurology University of California at Los Angeles School of Medicine 90024 USA Convulsive and nonconvulsive seizures occurred in 21 (22) of the 94 patients with six of them displaying status epilepticus In more than half of the patients (52) the seizures were nonconvulsive and were diagnosed on the basis of EEG studies alone All six patients with status epilepticus died compared with a mortality rate of 24 (18 of 73) in the nonseizure group (plt0001) The patients with status epilepticus had a shorter mean length of stay (914+-59 days compared with 14+-9 days [t-test plt0031) Seizures occurred despite initiation of prophylactic phenytoin on admission to the emergency room with maintenance at mean levels of 166+-28 mgdlCONCLUSIONS Seizures occur in more than one in five patients during the 1st week after moderate-to-severe brain injury and may play a role in the pathobiological conditions associated with brain injury

J Neurosurg 1999 Nov91(5)750-60

bull Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

Arash Farahvar MD PhD1 Linda M Gerber PhD2 Ya-Lin Chiu MS2 bull Nancy Carney PhD3 Roger Haumlrtl MD4 and Jam shid Ghaja r MD PhD45 bull 1Department of Neurosurgery University of Rochester Medical Center Rochester Departments of 2Public bull Health and 4Neurological Surgery Weill Cornell Medical College and 5Brain Trauma Foundation bull New York New York and 3Department of Medical Informatics and Clinical Epidemiology Oregon bull Health amp Science University Portland Oregon bull Object Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe bull traumatic brain injury (TBI) but there is limited evidence that monitoring and treating intracranial hypertension

reduces bull mortality This study uses a large prospectively collected database to examine the effect on 2-week mortality bull of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP

monitor bull Methods From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score lt 9) 1446 bull patients were treated with ICP-lowering therapies Of those 1202 had an ICP monitor inserted and 244 were

treated bull without monitoring Patients were admitted to one of 20 Level I and two Level II trauma centers part of a New

York bull State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009 bull Results Age initial GCS score hypotension and CT scan findings were associated with 2-week mortality In bull addition patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 002)

than those bull treated without an ICP monitor after adjusting for parameters that independently affect mortality bull Conclusions In patients with severe TBI treated for intracranial

hypertension the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor Based on these findings the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring

bull (httpthejnsorgdoiabs10317120127JNS111816)

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

Related Articles Links

Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring Vespa PM Nuwer MR Nenov V Ronne-Engstrom E Hovda DA Bergsneider M Kelly DF Martin NA Becker DP Department of Neurology University of California at Los Angeles School of Medicine 90024 USA Convulsive and nonconvulsive seizures occurred in 21 (22) of the 94 patients with six of them displaying status epilepticus In more than half of the patients (52) the seizures were nonconvulsive and were diagnosed on the basis of EEG studies alone All six patients with status epilepticus died compared with a mortality rate of 24 (18 of 73) in the nonseizure group (plt0001) The patients with status epilepticus had a shorter mean length of stay (914+-59 days compared with 14+-9 days [t-test plt0031) Seizures occurred despite initiation of prophylactic phenytoin on admission to the emergency room with maintenance at mean levels of 166+-28 mgdlCONCLUSIONS Seizures occur in more than one in five patients during the 1st week after moderate-to-severe brain injury and may play a role in the pathobiological conditions associated with brain injury

J Neurosurg 1999 Nov91(5)750-60

Neuromonitoring Methodshellip bull Functional status of the CNShellip

ndash GCS Neuro exam EEG Evoked potentials EcoG Pupillometer

Substrate delivery to the injured Brainhellip -CBF ICP CPP MABP PtiO2 Jugular Bulb oximetry

AVDO2 NIR spectroscopy Microdialysis

Combined methodshellip ldquoBrain Biomarkersrdquo--the future S100B alpha Spectrin beta amyloid

Related Articles Links

Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring Vespa PM Nuwer MR Nenov V Ronne-Engstrom E Hovda DA Bergsneider M Kelly DF Martin NA Becker DP Department of Neurology University of California at Los Angeles School of Medicine 90024 USA Convulsive and nonconvulsive seizures occurred in 21 (22) of the 94 patients with six of them displaying status epilepticus In more than half of the patients (52) the seizures were nonconvulsive and were diagnosed on the basis of EEG studies alone All six patients with status epilepticus died compared with a mortality rate of 24 (18 of 73) in the nonseizure group (plt0001) The patients with status epilepticus had a shorter mean length of stay (914+-59 days compared with 14+-9 days [t-test plt0031) Seizures occurred despite initiation of prophylactic phenytoin on admission to the emergency room with maintenance at mean levels of 166+-28 mgdlCONCLUSIONS Seizures occur in more than one in five patients during the 1st week after moderate-to-severe brain injury and may play a role in the pathobiological conditions associated with brain injury

J Neurosurg 1999 Nov91(5)750-60

Related Articles Links

Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring Vespa PM Nuwer MR Nenov V Ronne-Engstrom E Hovda DA Bergsneider M Kelly DF Martin NA Becker DP Department of Neurology University of California at Los Angeles School of Medicine 90024 USA Convulsive and nonconvulsive seizures occurred in 21 (22) of the 94 patients with six of them displaying status epilepticus In more than half of the patients (52) the seizures were nonconvulsive and were diagnosed on the basis of EEG studies alone All six patients with status epilepticus died compared with a mortality rate of 24 (18 of 73) in the nonseizure group (plt0001) The patients with status epilepticus had a shorter mean length of stay (914+-59 days compared with 14+-9 days [t-test plt0031) Seizures occurred despite initiation of prophylactic phenytoin on admission to the emergency room with maintenance at mean levels of 166+-28 mgdlCONCLUSIONS Seizures occur in more than one in five patients during the 1st week after moderate-to-severe brain injury and may play a role in the pathobiological conditions associated with brain injury

J Neurosurg 1999 Nov91(5)750-60

Human TBIhellipand COSBID suppression of large amplitude delta activity (eg PLEDs)

EEG

DC

1 s

1 min

Temperature ranges

All temps during monitoring

Temp during CSD

lt 350 17 10

350-380 58 23

gt380 25 68

Chi-square plt0001

N=~130 USAEU

Expl

aine

d Va

rianc

e N

agel

kerk

ersquos R

2

Univariate Analysis-outcome

0002004006008

01012014016018

Significance at plt005

350355360365370375380385390395400

1800 00

060

012

0018

00 000

600

1200

1800 00

060

012

0018

00 000

600

Synergistic pathomechanisms are commonesthellip

Do we need synergistic THERAPIES For multiple damage Mechanisms

0

100

200

300

400

500

600

700

800

0 20 40 60 80 100

Between 24 - 48 h after Injury

Brain tissue oxygen tension (PtiO2)

0

50

100

150

200

250

300

350

0 20 40 60 80 100

Brain tissue oxygen tension (PtiO2)H

Between 6 -24 h after Injury

Tissue Oxygen Tension in Humans after TBI

Brain pO2 Outcome lt20 mmHg Poor 20-30 mmHg Moderate gt30 mmHg Good

Therapy in both patient groups was aimed at maintaining an ICP less than 20 mm Hg and a CPP greater than 60 mm Hg Among patients

whose brain tissue PO2 was monitored oxygenation was maintained at levels greater

than 25 mm Hg

J Neurosurg 103805ndash811 2005

Reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring

M STIEFEL MD PHD M S GRADY MD AND P D LE ROUX MD U Penn

Patients treated with ICP and brain tissue PO2 monitoring

were compared with historical controls

The mortality rate in patients treated using conventional ICP and CPP management was 44 Patients who also

underwent brain tissue PO2 monitoring had a significantly reduced mortality rate of 25 (p 005)

PtO2

TBI Clinical Trials--ongoinghellip2013 Clinical trials Gov n= 762 (n= 307 in 2010) DOD effecthellip$120M in 2007hellip

80 observationalhellip

bull Brain 0xygen ndashdirected therapyhellipBOOSTUT NIH

bull COSBIDmdashEcoGhellipfor Spreading depolarisations

bull IMPACThellip bull TRACK II-III bull Non ndashinvasive ICPrdquoECHODIA ldquo systemX2 bull PET to trace Neuroinflammation in STBINIH

CBF monitoring

bull Transcranial Doppler Monitoring bull Easy to use noninvasive

repeatable bull Measures basal cerebral bld flow

velocity flow via doppler equation bull Used to differentiate vasospasm

from hyperaemia (Lindegaard Index)

Expl

aine

d Va

rianc

e N

agel

kerk

ersquos R

2

Univariate Analysis-outcome

0002004006008

01012014016018

Significance at plt005

350355360365370375380385390395400

1800 00

060

012

0018

00 000

600

1200

1800 00

060

012

0018

00 000

600

Synergistic pathomechanisms are commonesthellip

Do we need synergistic THERAPIES For multiple damage Mechanisms

0

100

200

300

400

500

600

700

800

0 20 40 60 80 100

Between 24 - 48 h after Injury

Brain tissue oxygen tension (PtiO2)

0

50

100

150

200

250

300

350

0 20 40 60 80 100

Brain tissue oxygen tension (PtiO2)H

Between 6 -24 h after Injury

Tissue Oxygen Tension in Humans after TBI

Brain pO2 Outcome lt20 mmHg Poor 20-30 mmHg Moderate gt30 mmHg Good

Therapy in both patient groups was aimed at maintaining an ICP less than 20 mm Hg and a CPP greater than 60 mm Hg Among patients

whose brain tissue PO2 was monitored oxygenation was maintained at levels greater

than 25 mm Hg

J Neurosurg 103805ndash811 2005

Reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring

M STIEFEL MD PHD M S GRADY MD AND P D LE ROUX MD U Penn

Patients treated with ICP and brain tissue PO2 monitoring

were compared with historical controls

The mortality rate in patients treated using conventional ICP and CPP management was 44 Patients who also

underwent brain tissue PO2 monitoring had a significantly reduced mortality rate of 25 (p 005)

PtO2

TBI Clinical Trials--ongoinghellip2013 Clinical trials Gov n= 762 (n= 307 in 2010) DOD effecthellip$120M in 2007hellip

80 observationalhellip

bull Brain 0xygen ndashdirected therapyhellipBOOSTUT NIH

bull COSBIDmdashEcoGhellipfor Spreading depolarisations

bull IMPACThellip bull TRACK II-III bull Non ndashinvasive ICPrdquoECHODIA ldquo systemX2 bull PET to trace Neuroinflammation in STBINIH

CBF monitoring

bull Transcranial Doppler Monitoring bull Easy to use noninvasive

repeatable bull Measures basal cerebral bld flow

velocity flow via doppler equation bull Used to differentiate vasospasm

from hyperaemia (Lindegaard Index)

350355360365370375380385390395400

1800 00

060

012

0018

00 000

600

1200

1800 00

060

012

0018

00 000

600

Synergistic pathomechanisms are commonesthellip

Do we need synergistic THERAPIES For multiple damage Mechanisms

0

100

200

300

400

500

600

700

800

0 20 40 60 80 100

Between 24 - 48 h after Injury

Brain tissue oxygen tension (PtiO2)

0

50

100

150

200

250

300

350

0 20 40 60 80 100

Brain tissue oxygen tension (PtiO2)H

Between 6 -24 h after Injury

Tissue Oxygen Tension in Humans after TBI

Brain pO2 Outcome lt20 mmHg Poor 20-30 mmHg Moderate gt30 mmHg Good

Therapy in both patient groups was aimed at maintaining an ICP less than 20 mm Hg and a CPP greater than 60 mm Hg Among patients

whose brain tissue PO2 was monitored oxygenation was maintained at levels greater

than 25 mm Hg

J Neurosurg 103805ndash811 2005

Reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring

M STIEFEL MD PHD M S GRADY MD AND P D LE ROUX MD U Penn

Patients treated with ICP and brain tissue PO2 monitoring

were compared with historical controls

The mortality rate in patients treated using conventional ICP and CPP management was 44 Patients who also

underwent brain tissue PO2 monitoring had a significantly reduced mortality rate of 25 (p 005)

PtO2

TBI Clinical Trials--ongoinghellip2013 Clinical trials Gov n= 762 (n= 307 in 2010) DOD effecthellip$120M in 2007hellip

80 observationalhellip

bull Brain 0xygen ndashdirected therapyhellipBOOSTUT NIH

bull COSBIDmdashEcoGhellipfor Spreading depolarisations

bull IMPACThellip bull TRACK II-III bull Non ndashinvasive ICPrdquoECHODIA ldquo systemX2 bull PET to trace Neuroinflammation in STBINIH

CBF monitoring

bull Transcranial Doppler Monitoring bull Easy to use noninvasive

repeatable bull Measures basal cerebral bld flow

velocity flow via doppler equation bull Used to differentiate vasospasm

from hyperaemia (Lindegaard Index)

Synergistic pathomechanisms are commonesthellip

Do we need synergistic THERAPIES For multiple damage Mechanisms

0

100

200

300

400

500

600

700

800

0 20 40 60 80 100

Between 24 - 48 h after Injury

Brain tissue oxygen tension (PtiO2)

0

50

100

150

200

250

300

350

0 20 40 60 80 100

Brain tissue oxygen tension (PtiO2)H

Between 6 -24 h after Injury

Tissue Oxygen Tension in Humans after TBI

Brain pO2 Outcome lt20 mmHg Poor 20-30 mmHg Moderate gt30 mmHg Good

Therapy in both patient groups was aimed at maintaining an ICP less than 20 mm Hg and a CPP greater than 60 mm Hg Among patients

whose brain tissue PO2 was monitored oxygenation was maintained at levels greater

than 25 mm Hg

J Neurosurg 103805ndash811 2005

Reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring

M STIEFEL MD PHD M S GRADY MD AND P D LE ROUX MD U Penn

Patients treated with ICP and brain tissue PO2 monitoring

were compared with historical controls

The mortality rate in patients treated using conventional ICP and CPP management was 44 Patients who also

underwent brain tissue PO2 monitoring had a significantly reduced mortality rate of 25 (p 005)

PtO2

TBI Clinical Trials--ongoinghellip2013 Clinical trials Gov n= 762 (n= 307 in 2010) DOD effecthellip$120M in 2007hellip

80 observationalhellip

bull Brain 0xygen ndashdirected therapyhellipBOOSTUT NIH

bull COSBIDmdashEcoGhellipfor Spreading depolarisations

bull IMPACThellip bull TRACK II-III bull Non ndashinvasive ICPrdquoECHODIA ldquo systemX2 bull PET to trace Neuroinflammation in STBINIH

CBF monitoring

bull Transcranial Doppler Monitoring bull Easy to use noninvasive

repeatable bull Measures basal cerebral bld flow

velocity flow via doppler equation bull Used to differentiate vasospasm

from hyperaemia (Lindegaard Index)

0

100

200

300

400

500

600

700

800

0 20 40 60 80 100

Between 24 - 48 h after Injury

Brain tissue oxygen tension (PtiO2)

0

50

100

150

200

250

300

350

0 20 40 60 80 100

Brain tissue oxygen tension (PtiO2)H

Between 6 -24 h after Injury

Tissue Oxygen Tension in Humans after TBI

Brain pO2 Outcome lt20 mmHg Poor 20-30 mmHg Moderate gt30 mmHg Good

Therapy in both patient groups was aimed at maintaining an ICP less than 20 mm Hg and a CPP greater than 60 mm Hg Among patients

whose brain tissue PO2 was monitored oxygenation was maintained at levels greater

than 25 mm Hg

J Neurosurg 103805ndash811 2005

Reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring

M STIEFEL MD PHD M S GRADY MD AND P D LE ROUX MD U Penn

Patients treated with ICP and brain tissue PO2 monitoring

were compared with historical controls

The mortality rate in patients treated using conventional ICP and CPP management was 44 Patients who also

underwent brain tissue PO2 monitoring had a significantly reduced mortality rate of 25 (p 005)

PtO2

TBI Clinical Trials--ongoinghellip2013 Clinical trials Gov n= 762 (n= 307 in 2010) DOD effecthellip$120M in 2007hellip

80 observationalhellip

bull Brain 0xygen ndashdirected therapyhellipBOOSTUT NIH

bull COSBIDmdashEcoGhellipfor Spreading depolarisations

bull IMPACThellip bull TRACK II-III bull Non ndashinvasive ICPrdquoECHODIA ldquo systemX2 bull PET to trace Neuroinflammation in STBINIH

CBF monitoring

bull Transcranial Doppler Monitoring bull Easy to use noninvasive

repeatable bull Measures basal cerebral bld flow

velocity flow via doppler equation bull Used to differentiate vasospasm

from hyperaemia (Lindegaard Index)

Therapy in both patient groups was aimed at maintaining an ICP less than 20 mm Hg and a CPP greater than 60 mm Hg Among patients

whose brain tissue PO2 was monitored oxygenation was maintained at levels greater

than 25 mm Hg

J Neurosurg 103805ndash811 2005

Reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring

M STIEFEL MD PHD M S GRADY MD AND P D LE ROUX MD U Penn

Patients treated with ICP and brain tissue PO2 monitoring

were compared with historical controls

The mortality rate in patients treated using conventional ICP and CPP management was 44 Patients who also

underwent brain tissue PO2 monitoring had a significantly reduced mortality rate of 25 (p 005)

PtO2

TBI Clinical Trials--ongoinghellip2013 Clinical trials Gov n= 762 (n= 307 in 2010) DOD effecthellip$120M in 2007hellip

80 observationalhellip

bull Brain 0xygen ndashdirected therapyhellipBOOSTUT NIH

bull COSBIDmdashEcoGhellipfor Spreading depolarisations

bull IMPACThellip bull TRACK II-III bull Non ndashinvasive ICPrdquoECHODIA ldquo systemX2 bull PET to trace Neuroinflammation in STBINIH

CBF monitoring

bull Transcranial Doppler Monitoring bull Easy to use noninvasive

repeatable bull Measures basal cerebral bld flow

velocity flow via doppler equation bull Used to differentiate vasospasm

from hyperaemia (Lindegaard Index)

TBI Clinical Trials--ongoinghellip2013 Clinical trials Gov n= 762 (n= 307 in 2010) DOD effecthellip$120M in 2007hellip

80 observationalhellip

bull Brain 0xygen ndashdirected therapyhellipBOOSTUT NIH

bull COSBIDmdashEcoGhellipfor Spreading depolarisations

bull IMPACThellip bull TRACK II-III bull Non ndashinvasive ICPrdquoECHODIA ldquo systemX2 bull PET to trace Neuroinflammation in STBINIH

CBF monitoring

bull Transcranial Doppler Monitoring bull Easy to use noninvasive

repeatable bull Measures basal cerebral bld flow

velocity flow via doppler equation bull Used to differentiate vasospasm

from hyperaemia (Lindegaard Index)

CBF monitoring

bull Transcranial Doppler Monitoring bull Easy to use noninvasive

repeatable bull Measures basal cerebral bld flow

velocity flow via doppler equation bull Used to differentiate vasospasm

from hyperaemia (Lindegaard Index)

What has been achieved by monitoring the injured Brain

bull Improved understanding of dynamic pathophysiology after HUMAN TBI SAH

bull Guide design of neuroprotection trialshellip bull Improved patient outcome

Age (years)

Pro

babi

lity

of o

utco

me

()

20 40 60 80

0

20

40

60

80

100

Death rate ndashsevere TBI

bull Australia and NZ bull The Alfred

Royal Melbourne Hospital Royal Adelaide Hospital Royal Perth Hospital Sir Charles Gairdner Hospital Nepean Hospital John Hunter Hospital Royal North Shore Hospital Liverpool Hospital Wollongong Hospital Princess Alexandra Hospital Gold Coast Hospital Flinders Medical Centre Auckland Hospital Waikato Hospital Wellington Hospital

bull Saudi Arabia King Fahad National Guard Hospital

Canada bull Hamilton General hospital

Vancouver General Hospital Sunnybrook Medical Centre Royal Columbian Hospital India

bull Christian Medical College Ludhiana

bull

bull

Early bifrontal decompression Vs medical management No benefit from surgeryhellipmore disabled and vegetative outcomes

3 editorials on the DECRA tria

bull Study design-486 patientshellip ndash Blinded assessment of outcomes ndash Randomization completed in

blocks of 5 stratified according to center

ndash Compared bone flaps of dimension 12x15cm vs 6x8cm

ndash Necrotic tissue debrided ndash Dura closure with graft to expand ndash Otherwise managed as per 1996

AANS guidelines for head trauma ndash Blinded physiatrist performed

follow-up exam at 6 months after injury

Jiang et al 2005 Effect of Standard Trauma Craniotomy for refractory ICP with severe TBI-a multicenter Prospective randomised controlled study J Neurotrauma22623-6282005

Cambridge ndash 34 Leeds ndash 20 Royal London ndash 12 Newcastle ndash 11 Southampton ndash 10 Singapore ndash 8 Milan Italy ndash 6 Manchester ndash 6 Saudi Arabia ndash 5 Edmonton Canada ndash 5 Calgary Canada ndash 4 Hong-Kong ndash 4 Old Church ndash 4 Plymouth ndash 4 Hurstwood Park ndash 3 Kings College ndash 3 Pavia Italy ndash 3 Barcelona Spain ndash 2 Livorno Italy ndash 1 Malaysia ndash 1 Oxford ndash 1 Queenrsquos Square ndash 1 Swansea ndash 1 Ulm Germany - 1

wwwRESCUEicpcom

357 patients recruited -january 2013 Results early 2014hellip

Unilateral large DC Includes High ICP Due to contusions

R 21 Grant NIH NINDS RNS069309ACapacity building for

Decompressive Craniotomy in Colombiahellip

The objective of this proposal is to create a standardized protocol for DC implementation with subsequent implementation of the protocol in three hospitals in Colombia The initial pilot study will accrue 40 adult patients with severe TBI and evaluate outcomes over a 2 year period using the

data registry

• Is Neuromonitoring an expensive waste of time in Severe Traumatic Brain Injury
• Subcellular mechanisms in TBISAH ICH Stroke
• ldquoMonitors alone cannot save patients but wise application of the data from monitoring the injured brain canrdquo
• Severe TBI-- Does it all make a difference
• Ischemic Tissue Damage and Infarction is Dependent on Reduction of Oxygen Delivery and the Duration of the Ischemic Insult
• Why is ICP Monitoring so Important
• Neuromonitoring Methodshellip
• The NIH-NINDS Trial of ICP Monitoring in BoliviaLABIChellip
• Slide Number 9
• Slide Number 10
• Why the Chesnut Bolivia ICP monitoring trial is not ldquogeneralisablerdquo to rest of the worldhellip
• Slide Number 12
• Slide Number 13
• Neuromonitoring Methodshellip
• Slide Number 15
• Slide Number 16
• Slide Number 17
• Slide Number 18
• Slide Number 19
• Tissue Oxygen Tension in Humans after TBI
• Slide Number 21
• TBI Clinical Trials--ongoinghellip2013 Clinical trials Gov n= 762 (n= 307 in 2010) DOD effecthellip$120M in 2007hellip 80 observationalhellip
• CBF monitoring
• What has been achieved by monitoring the injured Brain
• Slide Number 25
• Slide Number 26
• Jiang et al 2005
• Slide Number 28
• R 21 Grant NIH NINDS RNS069309ACapacity building for Decompressive Craniotomy in Colombiahellip

bull Australia and NZ bull The Alfred

Royal Melbourne Hospital Royal Adelaide Hospital Royal Perth Hospital Sir Charles Gairdner Hospital Nepean Hospital John Hunter Hospital Royal North Shore Hospital Liverpool Hospital Wollongong Hospital Princess Alexandra Hospital Gold Coast Hospital Flinders Medical Centre Auckland Hospital Waikato Hospital Wellington Hospital

bull Saudi Arabia King Fahad National Guard Hospital

Canada bull Hamilton General hospital

Vancouver General Hospital Sunnybrook Medical Centre Royal Columbian Hospital India

bull Christian Medical College Ludhiana

bull

bull

Early bifrontal decompression Vs medical management No benefit from surgeryhellipmore disabled and vegetative outcomes

3 editorials on the DECRA tria

bull Study design-486 patientshellip ndash Blinded assessment of outcomes ndash Randomization completed in

blocks of 5 stratified according to center

ndash Compared bone flaps of dimension 12x15cm vs 6x8cm

ndash Necrotic tissue debrided ndash Dura closure with graft to expand ndash Otherwise managed as per 1996

AANS guidelines for head trauma ndash Blinded physiatrist performed

follow-up exam at 6 months after injury

Jiang et al 2005 Effect of Standard Trauma Craniotomy for refractory ICP with severe TBI-a multicenter Prospective randomised controlled study J Neurotrauma22623-6282005

Cambridge ndash 34 Leeds ndash 20 Royal London ndash 12 Newcastle ndash 11 Southampton ndash 10 Singapore ndash 8 Milan Italy ndash 6 Manchester ndash 6 Saudi Arabia ndash 5 Edmonton Canada ndash 5 Calgary Canada ndash 4 Hong-Kong ndash 4 Old Church ndash 4 Plymouth ndash 4 Hurstwood Park ndash 3 Kings College ndash 3 Pavia Italy ndash 3 Barcelona Spain ndash 2 Livorno Italy ndash 1 Malaysia ndash 1 Oxford ndash 1 Queenrsquos Square ndash 1 Swansea ndash 1 Ulm Germany - 1

wwwRESCUEicpcom

357 patients recruited -january 2013 Results early 2014hellip

Unilateral large DC Includes High ICP Due to contusions

R 21 Grant NIH NINDS RNS069309ACapacity building for

Decompressive Craniotomy in Colombiahellip

The objective of this proposal is to create a standardized protocol for DC implementation with subsequent implementation of the protocol in three hospitals in Colombia The initial pilot study will accrue 40 adult patients with severe TBI and evaluate outcomes over a 2 year period using the

data registry

• Is Neuromonitoring an expensive waste of time in Severe Traumatic Brain Injury
• Subcellular mechanisms in TBISAH ICH Stroke
• ldquoMonitors alone cannot save patients but wise application of the data from monitoring the injured brain canrdquo
• Severe TBI-- Does it all make a difference
• Ischemic Tissue Damage and Infarction is Dependent on Reduction of Oxygen Delivery and the Duration of the Ischemic Insult
• Why is ICP Monitoring so Important
• Neuromonitoring Methodshellip
• The NIH-NINDS Trial of ICP Monitoring in BoliviaLABIChellip
• Slide Number 9
• Slide Number 10
• Why the Chesnut Bolivia ICP monitoring trial is not ldquogeneralisablerdquo to rest of the worldhellip
• Slide Number 12
• Slide Number 13
• Neuromonitoring Methodshellip
• Slide Number 15
• Slide Number 16
• Slide Number 17
• Slide Number 18
• Slide Number 19
• Tissue Oxygen Tension in Humans after TBI
• Slide Number 21
• TBI Clinical Trials--ongoinghellip2013 Clinical trials Gov n= 762 (n= 307 in 2010) DOD effecthellip$120M in 2007hellip 80 observationalhellip
• CBF monitoring
• What has been achieved by monitoring the injured Brain
• Slide Number 25
• Slide Number 26
• Jiang et al 2005
• Slide Number 28
• R 21 Grant NIH NINDS RNS069309ACapacity building for Decompressive Craniotomy in Colombiahellip

3 editorials on the DECRA tria

bull Study design-486 patientshellip ndash Blinded assessment of outcomes ndash Randomization completed in

blocks of 5 stratified according to center

ndash Compared bone flaps of dimension 12x15cm vs 6x8cm

ndash Necrotic tissue debrided ndash Dura closure with graft to expand ndash Otherwise managed as per 1996

AANS guidelines for head trauma ndash Blinded physiatrist performed

follow-up exam at 6 months after injury

Jiang et al 2005 Effect of Standard Trauma Craniotomy for refractory ICP with severe TBI-a multicenter Prospective randomised controlled study J Neurotrauma22623-6282005

Cambridge ndash 34 Leeds ndash 20 Royal London ndash 12 Newcastle ndash 11 Southampton ndash 10 Singapore ndash 8 Milan Italy ndash 6 Manchester ndash 6 Saudi Arabia ndash 5 Edmonton Canada ndash 5 Calgary Canada ndash 4 Hong-Kong ndash 4 Old Church ndash 4 Plymouth ndash 4 Hurstwood Park ndash 3 Kings College ndash 3 Pavia Italy ndash 3 Barcelona Spain ndash 2 Livorno Italy ndash 1 Malaysia ndash 1 Oxford ndash 1 Queenrsquos Square ndash 1 Swansea ndash 1 Ulm Germany - 1

wwwRESCUEicpcom

357 patients recruited -january 2013 Results early 2014hellip

Unilateral large DC Includes High ICP Due to contusions

R 21 Grant NIH NINDS RNS069309ACapacity building for

Decompressive Craniotomy in Colombiahellip

The objective of this proposal is to create a standardized protocol for DC implementation with subsequent implementation of the protocol in three hospitals in Colombia The initial pilot study will accrue 40 adult patients with severe TBI and evaluate outcomes over a 2 year period using the

data registry

• Is Neuromonitoring an expensive waste of time in Severe Traumatic Brain Injury
• Subcellular mechanisms in TBISAH ICH Stroke
• ldquoMonitors alone cannot save patients but wise application of the data from monitoring the injured brain canrdquo
• Severe TBI-- Does it all make a difference
• Ischemic Tissue Damage and Infarction is Dependent on Reduction of Oxygen Delivery and the Duration of the Ischemic Insult
• Why is ICP Monitoring so Important
• Neuromonitoring Methodshellip
• The NIH-NINDS Trial of ICP Monitoring in BoliviaLABIChellip
• Slide Number 9
• Slide Number 10
• Why the Chesnut Bolivia ICP monitoring trial is not ldquogeneralisablerdquo to rest of the worldhellip
• Slide Number 12
• Slide Number 13
• Neuromonitoring Methodshellip
• Slide Number 15
• Slide Number 16
• Slide Number 17
• Slide Number 18
• Slide Number 19
• Tissue Oxygen Tension in Humans after TBI
• Slide Number 21
• TBI Clinical Trials--ongoinghellip2013 Clinical trials Gov n= 762 (n= 307 in 2010) DOD effecthellip$120M in 2007hellip 80 observationalhellip
• CBF monitoring
• What has been achieved by monitoring the injured Brain
• Slide Number 25
• Slide Number 26
• Jiang et al 2005
• Slide Number 28
• R 21 Grant NIH NINDS RNS069309ACapacity building for Decompressive Craniotomy in Colombiahellip

bull Study design-486 patientshellip ndash Blinded assessment of outcomes ndash Randomization completed in

blocks of 5 stratified according to center

ndash Compared bone flaps of dimension 12x15cm vs 6x8cm

ndash Necrotic tissue debrided ndash Dura closure with graft to expand ndash Otherwise managed as per 1996

AANS guidelines for head trauma ndash Blinded physiatrist performed

follow-up exam at 6 months after injury

Jiang et al 2005 Effect of Standard Trauma Craniotomy for refractory ICP with severe TBI-a multicenter Prospective randomised controlled study J Neurotrauma22623-6282005

Cambridge ndash 34 Leeds ndash 20 Royal London ndash 12 Newcastle ndash 11 Southampton ndash 10 Singapore ndash 8 Milan Italy ndash 6 Manchester ndash 6 Saudi Arabia ndash 5 Edmonton Canada ndash 5 Calgary Canada ndash 4 Hong-Kong ndash 4 Old Church ndash 4 Plymouth ndash 4 Hurstwood Park ndash 3 Kings College ndash 3 Pavia Italy ndash 3 Barcelona Spain ndash 2 Livorno Italy ndash 1 Malaysia ndash 1 Oxford ndash 1 Queenrsquos Square ndash 1 Swansea ndash 1 Ulm Germany - 1

wwwRESCUEicpcom

357 patients recruited -january 2013 Results early 2014hellip

Unilateral large DC Includes High ICP Due to contusions

R 21 Grant NIH NINDS RNS069309ACapacity building for

Decompressive Craniotomy in Colombiahellip

The objective of this proposal is to create a standardized protocol for DC implementation with subsequent implementation of the protocol in three hospitals in Colombia The initial pilot study will accrue 40 adult patients with severe TBI and evaluate outcomes over a 2 year period using the

data registry

• Is Neuromonitoring an expensive waste of time in Severe Traumatic Brain Injury
• Subcellular mechanisms in TBISAH ICH Stroke
• ldquoMonitors alone cannot save patients but wise application of the data from monitoring the injured brain canrdquo
• Severe TBI-- Does it all make a difference
• Ischemic Tissue Damage and Infarction is Dependent on Reduction of Oxygen Delivery and the Duration of the Ischemic Insult
• Why is ICP Monitoring so Important
• Neuromonitoring Methodshellip
• The NIH-NINDS Trial of ICP Monitoring in BoliviaLABIChellip
• Slide Number 9
• Slide Number 10
• Why the Chesnut Bolivia ICP monitoring trial is not ldquogeneralisablerdquo to rest of the worldhellip
• Slide Number 12
• Slide Number 13
• Neuromonitoring Methodshellip
• Slide Number 15
• Slide Number 16
• Slide Number 17
• Slide Number 18
• Slide Number 19
• Tissue Oxygen Tension in Humans after TBI
• Slide Number 21
• TBI Clinical Trials--ongoinghellip2013 Clinical trials Gov n= 762 (n= 307 in 2010) DOD effecthellip$120M in 2007hellip 80 observationalhellip
• CBF monitoring
• What has been achieved by monitoring the injured Brain
• Slide Number 25
• Slide Number 26
• Jiang et al 2005
• Slide Number 28
• R 21 Grant NIH NINDS RNS069309ACapacity building for Decompressive Craniotomy in Colombiahellip

Cambridge ndash 34 Leeds ndash 20 Royal London ndash 12 Newcastle ndash 11 Southampton ndash 10 Singapore ndash 8 Milan Italy ndash 6 Manchester ndash 6 Saudi Arabia ndash 5 Edmonton Canada ndash 5 Calgary Canada ndash 4 Hong-Kong ndash 4 Old Church ndash 4 Plymouth ndash 4 Hurstwood Park ndash 3 Kings College ndash 3 Pavia Italy ndash 3 Barcelona Spain ndash 2 Livorno Italy ndash 1 Malaysia ndash 1 Oxford ndash 1 Queenrsquos Square ndash 1 Swansea ndash 1 Ulm Germany - 1

wwwRESCUEicpcom

357 patients recruited -january 2013 Results early 2014hellip

Unilateral large DC Includes High ICP Due to contusions

R 21 Grant NIH NINDS RNS069309ACapacity building for

Decompressive Craniotomy in Colombiahellip

The objective of this proposal is to create a standardized protocol for DC implementation with subsequent implementation of the protocol in three hospitals in Colombia The initial pilot study will accrue 40 adult patients with severe TBI and evaluate outcomes over a 2 year period using the

data registry

• Is Neuromonitoring an expensive waste of time in Severe Traumatic Brain Injury
• Subcellular mechanisms in TBISAH ICH Stroke
• ldquoMonitors alone cannot save patients but wise application of the data from monitoring the injured brain canrdquo
• Severe TBI-- Does it all make a difference
• Ischemic Tissue Damage and Infarction is Dependent on Reduction of Oxygen Delivery and the Duration of the Ischemic Insult
• Why is ICP Monitoring so Important
• Neuromonitoring Methodshellip
• The NIH-NINDS Trial of ICP Monitoring in BoliviaLABIChellip
• Slide Number 9
• Slide Number 10
• Why the Chesnut Bolivia ICP monitoring trial is not ldquogeneralisablerdquo to rest of the worldhellip
• Slide Number 12
• Slide Number 13
• Neuromonitoring Methodshellip
• Slide Number 15
• Slide Number 16
• Slide Number 17
• Slide Number 18
• Slide Number 19
• Tissue Oxygen Tension in Humans after TBI
• Slide Number 21
• TBI Clinical Trials--ongoinghellip2013 Clinical trials Gov n= 762 (n= 307 in 2010) DOD effecthellip$120M in 2007hellip 80 observationalhellip
• CBF monitoring
• What has been achieved by monitoring the injured Brain
• Slide Number 25
• Slide Number 26
• Jiang et al 2005
• Slide Number 28
• R 21 Grant NIH NINDS RNS069309ACapacity building for Decompressive Craniotomy in Colombiahellip

R 21 Grant NIH NINDS RNS069309ACapacity building for

Decompressive Craniotomy in Colombiahellip

The objective of this proposal is to create a standardized protocol for DC implementation with subsequent implementation of the protocol in three hospitals in Colombia The initial pilot study will accrue 40 adult patients with severe TBI and evaluate outcomes over a 2 year period using the

data registry

• Is Neuromonitoring an expensive waste of time in Severe Traumatic Brain Injury
• Subcellular mechanisms in TBISAH ICH Stroke
• ldquoMonitors alone cannot save patients but wise application of the data from monitoring the injured brain canrdquo
• Severe TBI-- Does it all make a difference
• Ischemic Tissue Damage and Infarction is Dependent on Reduction of Oxygen Delivery and the Duration of the Ischemic Insult
• Why is ICP Monitoring so Important
• Neuromonitoring Methodshellip
• The NIH-NINDS Trial of ICP Monitoring in BoliviaLABIChellip
• Slide Number 9
• Slide Number 10
• Why the Chesnut Bolivia ICP monitoring trial is not ldquogeneralisablerdquo to rest of the worldhellip
• Slide Number 12
• Slide Number 13
• Neuromonitoring Methodshellip
• Slide Number 15
• Slide Number 16
• Slide Number 17
• Slide Number 18
• Slide Number 19
• Tissue Oxygen Tension in Humans after TBI
• Slide Number 21
• TBI Clinical Trials--ongoinghellip2013 Clinical trials Gov n= 762 (n= 307 in 2010) DOD effecthellip$120M in 2007hellip 80 observationalhellip
• CBF monitoring
• What has been achieved by monitoring the injured Brain
• Slide Number 25
• Slide Number 26
• Jiang et al 2005
• Slide Number 28
• R 21 Grant NIH NINDS RNS069309ACapacity building for Decompressive Craniotomy in Colombiahellip