[Intracranial pressure monitoring in France, and French-speaking Belgium and Switzerland. Retrospective and prospective survey]

Escalation therapy in severe traumatic brain injury: how long is intracranial pressure monitoring necessary?

Traumatic brain injury frequently causes an elevation of intracranial pressure (ICP) that could lead to reduction of cerebral perfusion pressure and cause brain ischemia. Invasive ICP monitoring is recommended by international guidelines, in order to reduce the incidence of secondary brain injury; although rare, the complications related to ICP probes could be dependent on the duration of monitoring. The aim of this manuscript is to clarify the appropriate timing for removal and management of invasive ICP monitoring, in order to reduce the risk of related complications and guarantee adequate cerebral autoregulatory control. There is no universal consensus concerning the duration of invasive ICP monitoring and its related complications, although the pertinent literature seems to show that the longer is the monitoring maintenance, the higher is the risk of technical issues. Besides, upon 72 h of normal ICP values or less than 72 h if the first computed tomography scan is normal (none or minimal signs of injury) and the neurological exam is available (allowing to observe variations and possible occurrence of new-onset pathological response), the removal of invasive ICP monitoring can be justified. The availability of non-invasive monitoring systems should be considered to follow up patients' clinical course after invasive ICP probe removal or for substituting the invasive monitoring in case of contraindication to its placement. Recently, optic nerve sheath diameter and straight sinus systolic flow velocity evaluation through ultrasound methods showed a good correlation with ICP values, demonstrating their potential role in place of invasive monitoring or in the early weaning phase from the invasive ICP monitoring.

Training Protocol for Intracranial Pressure Monitor Placement by Nonneurosurgeons: 5-Year Experience

BACKGROUND

This report evaluates a protocol for training nonneurosurgeon medical staff to perform ventricular catheter placement for ICP monitoring in traumatic brain injury and other appropriate patients under the guidance of neurosurgeons.

METHODS

Eleven neurosurgery house officers were enrolled in the program to be certified for ventricular catheter placement. The training program using the Ghajar Guide is described as well as the preprocedural checklist. The results of these certified house officers were tracked over a 5-year period.

RESULTS

Ten house officers successfully completed the certification process for ventricular catheter placement in a total of 106 patients. The majority of ventricular catheters were placed at the bedside. The reported results and the complication rates of catheter-related infections and intracranial hemorrhage are similar to that of neurosurgeons or neurosurgeons in training.

CONCLUSION

House officers under the guidance of neurosurgeons can be trained to successfully and safely place ventricular catheters for ICP monitoring in patients needing ICP monitoring.

[The impact of a French guideline on the clinical management of severe head injury (SHI) published in 1999]

OBJECTIVE

To evaluate the impact of a French guideline on the clinical management of severe head injury (SHI) published in 1999.

STUDY DESIGN

Nationwide survey.

METHODS

182 medical centres answered the inquiry.

RESULTS

111 centres declared to manage such patients suffering from SHI. 68% of doctors from these clinical departments did report to have read these guidelines. Fifty percent of them found in these guidelines useful data for their clinical practice. Forty four percent of centres could not monitor ICP lacking neurosurgical facility in their hospital. Conversely, all hospitals with neurosurgery available did monitor ICP. Seventy six percent of centres reported difficulties to find a facility, which would take these patients in charge when discharged from ICU. We analysed the main items included in the guidelines and report their impact. Seventy four percent of responders found that clinical management of SHI patients had improved during the last years.

CONCLUSION

The French guidelines had a significant impact and seem to have provided a useful aid to clinical management of SHI patients. ICP monitoring and the shortage in post-ICU facilities are remaining issues.

[Management of severe head injuries during the first 24 hours, in the emergency department, in neurosurgery]

In France, the role of the neurosurgeon in the emergency department depends on local health care policies and geographical constraints. Some departments include a neurosurgical team with a dedicated operating room. In others, a neurosurgeon can be reached by phone, possibly with an image transfer. Whatever the case, it should be possible to remove on site and without delay an intracranial haematoma, which is most often an extradural injury. The management of a haematoma of the posterior fossa or a bleeding dural venous sinus would be difficult for a surgeon not qualified in neurosurgery. The optimal situation is the presence of a neurosurgeon in the medical team admitting patients with a severe head or spine trauma, for assessment of the neurological status, or interpretation of radiological explorations, insertion of an intracranial pressure monitoring device. Besides the extradural haematoma, other injuries such as an acute subdural haematoma, a haematoma associated with a contusion, an acute hydrocephalus, a depressed fracture of the skull, or a craniocerebral wound, also require an emergency decompressive procedure.