• 
• 

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


[exp meningitis OR menigism OR encephalitis OR cranial infection OR central nervous system infection AND intracranial pressure$ or ICP]

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Odetola F et al 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)
Baussart B 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
Lindvall P 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
Vavivala Met al 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
Schoeman J, le Roux D, Bezuidenhout P 1985 South Africa	24 chidren with tuberculous meningitis	Series of case studies	Neurologically normal or slightly handicapped	9/24	Small number, no power calculation No homogeneity in patients for intervention Stastical calculations not given
			Neurologivally severely abnormal	6/24
			Dead	9/24
				No statistically significant relationship between raised ICP and outcome (p=0.79)

Comment(s)

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.

Clinical 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

References

1. 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. Paediatrics 2006;117:1893-1900
2. 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. Acta anaesthes scand 2006;50(6):762-5
3. Lindvall P, Ahlm C, Ericsson M et al. Reducing intracranial pressure may increase survival among patients with bacterial meningitis. Clin Infect Dis 2004;38:384-390.
4. Vavivala M, Lam A. Intraoperative intracranial pressure monitoring in pneumococcal meningitis. Anesth Analg 2000;90:107-8
5. Schoeman J, le Roux D, Bezuidenhout P et al. Intracranial pressure monitoring in tuberculous meningitis: clinical and computerized tomographic correlation Develop med and child neurol 1985