Intracranial pressure monitoring in central nervous system infective process
Date First Published:
October 29, 2009
Last Updated:
October 29, 2009
Report by:
Deepak Doshi, Specialist Registrar (Manchester Royal Infirmary)
Three-Part Question:
In patients with [central nervous system infection] does [intracranial pressure monitoring] improve [overall survival]?
Clinical Scenario:
A 15 year old boy was admitted to paediatric intensive care unit, with bilateral otitis, mastoiditis and clinical features of meningitis. He was bradycardic And hypertensive. He had nausea, photophobia and neck stiffness. He went to operating theatre for bilateral tube myringotomy. He had a bolt inserted to monitor his intracranial pressure. You wonder whether intracranial pressure monitoring improves outcome in central nervous system infective process.
Search Strategy:
Athens login search: Medline 1966 to 2nd week August 2009
Search Details:
[exp meningitis OR menigism OR encephalitis OR cranial infection OR central nervous system infection AND intracranial pressure$ or ICP]
Outcome:
142 papers identified of which 7 were relevant. One was in French and one in Japanese; and due to lack of translation facility these were excluded.
Remaining five papers are described here.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Variation in the use of intracranial-pressure monitoring and mortality in critically ill children with meningitis in the united states. Odetola F, Tilford J, Davis M. 2006 USA | Children 0-17 years 157 children with ICP monitoring |
Retrospective cohort study | In hospital mortality | 34.3% (CI 0.46 - 2.18, p 0.99) | Retrospecive analysis from data base No control group comparison, only multivariate statiscal analysis Selection of patients for ICP monitoring - unknown |
| Hospital length of stay | 1.43 (CI 1.10-1.86, p 0.01) | ||||
| Cost analysis | 0.41 (CI 0.08-0.74, p 0.02) | ||||
| Multimodal cerebral monitoring and decompressive surgery for the treatment of severe bacterial meningitis with increased intracranial pressure. Baussart B, Cheisson G, Compain M et al. 2006 France | Once case – Neisseria meningitidis – 28 year old adult patient | Case report | ICP 60 mm Hg treated with large hemicraniectomy and ventriculostomy | Favourable long term neurological outcome | One case only |
| Reducing intracranial pressure may increase survival among patients with bacterial meningitis. Lindvall P, Ahlm C, Ericsson M et al. 2004 Sweden | 15 patients in ICU | Series of case reports | 5/15(33%) died | Non survivors: ICP : 46.4 +/- 8.6, CPP: 21.0+/-7.4 | Small number Retrospective data |
| 10/15 (67%) survived | Survivors: ICP: 20.3+/-4.6, CPP: 62.1 +/-7.3 | ||||
| Intraoperative intracranial pressure monitoring in pneumococcal meningitis. Vavivala M, Lam A. 2000 India | Adult patient | Case report | Lowered ICP from 59 to 20 before surgery for myringotomy- using hyperventilation and mannitol | Cerebral perfusion pressure improved to 70 mm Hg, Left sided hemiparesis | Cause of hemiparesis unknown, Single case |
| Intracranial pressure monitoring in tuberculous meningitis: clinical and computerized tomographic correlation Schoeman J, le Roux D, Bezuidenhout P et al. 1985 South Africa | 24 chidren with tuberculous meningitis | Series of case studies | Neurologically normal or slightly handicapped | Sep-24 | Small number, no power calculation No homogeneity in patients for intervention Stastical calculations not given |
| Neurologivally severely abnormal | Jun-24 | ||||
| Dead | Sep-24 | ||||
| No statistically significant relationship between raised ICP and outcome (p=0.79) |
Author Commentary:
Intracranial pressure monitoring for traumatic brain injury is in use for more than five decades. However, ICP is rarely used to monitor central nervous system infective process. Cerebral herniation is reported in 30% of cases who die of bacterial meningitis(8).
There is lack of evidence to support routine use of intracranial pressure monitoring in central nervous system infective process. In the USA and Sweden intensive care units, ICP monitor is occasionally used for infective conditions(1 and 3). There are only two reported small series of cases, where the author did not find any difference in mortality compared to non-monitored group.
There is lack of evidence to support routine use of intracranial pressure monitoring in central nervous system infective process. In the USA and Sweden intensive care units, ICP monitor is occasionally used for infective conditions(1 and 3). There are only two reported small series of cases, where the author did not find any difference in mortality compared to non-monitored group.
Bottom Line:
There are no higher evidence level studies in the literature and therefore these studies can not be used to definitively recommend for or against the use of ICP monitors in infective central nervous system conditions.
Level of evidence: 3 and 4
Grade of recommendation: C
Level of evidence: 3 and 4
Grade of recommendation: C
References:
- Odetola F, Tilford J, Davis M. . Variation in the use of intracranial-pressure monitoring and mortality in critically ill children with meningitis in the united states.
- Baussart B, Cheisson G, Compain M et al. . Multimodal cerebral monitoring and decompressive surgery for the treatment of severe bacterial meningitis with increased intracranial pressure.
- Lindvall P, Ahlm C, Ericsson M et al. . Reducing intracranial pressure may increase survival among patients with bacterial meningitis.
- Vavivala M, Lam A. . Intraoperative intracranial pressure monitoring in pneumococcal meningitis.
- Schoeman J, le Roux D, Bezuidenhout P et al. . Intracranial pressure monitoring in tuberculous meningitis: clinical and computerized tomographic correlation