• Randall M Chesnut, Sergio Aguilera, Andras Buki, Eileen M Bulger, Giuseppe Citerio, D Jamie Cooper, Ramon Diaz Arrastia, Michael Diringer, Anthony Figaji, Guoyi Gao, Romergryko G Geocadin, Jamshid Ghajar, Odette Harris, HawrylukGregory W JGWJCleveland Clinic Akron General Neurosciences Center, Fairlawn, Ohio, USA.Uniformed Services University, Bethesda, Maryland, USA.Brain Trauma Foundation, New York City, New York, USA., Alan Hoffer, Peter Hutchinson, Mathew Joseph, Ryan Kitagawa, Geoffrey Manley, Stephan Mayer, David K Menon, Geert Meyfroidt, Daniel B Michael, Mauro Oddo, David O Okonkwo, Mayur B Patel, Claudia Robertson, Jeffrey V Rosenfeld, Andres M Rubiano, Juain Sahuquillo, Franco Servadei, Lori Shutter, Deborah M Stein, Nino Stocchetti, Fabio Silvio Taccone, Shelly D Timmons, Eve C Tsai, Jamie S Ullman, Walter Videtta, David W Wright, and Christopher Zammit.
• Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.
• Neurosurgery. 2023 Aug 1; 93 (2): 399408399-408.

BackgroundIntracranial pressure (ICP) monitoring is widely practiced, but the indications are incompletely developed, and guidelines are poorly followed.ObjectiveTo study the monitoring practices of an established expert panel (the clinical working group from the Seattle International Brain Injury Consensus Conference effort) to examine the match between monitoring guidelines and their clinical decision-making and offer guidance for clinicians considering monitor insertion.MethodsWe polled the 42 Seattle International Brain Injury Consensus Conference panel members' ICP monitoring decisions for virtual patients, using matrices of presenting signs (Glasgow Coma Scale [GCS] total or GCS motor, pupillary examination, and computed tomography diagnosis). Monitor insertion decisions were yes, no, or unsure (traffic light approach). We analyzed their responses for weighting of the presenting signs in decision-making using univariate regression.ResultsHeatmaps constructed from the choices of 41 panel members revealed wider ICP monitor use than predicted by guidelines. Clinical examination (GCS) was by far the most important characteristic and differed from guidelines in being nonlinear. The modified Marshall computed tomography classification was second and pupils third. We constructed a heatmap and listed the main clinical determinants representing 80% ICP monitor insertion consensus for our recommendations.ConclusionCandidacy for ICP monitoring exceeds published indicators for monitor insertion, suggesting the clinical perception that the value of ICP data is greater than simply detecting and monitoring severe intracranial hypertension. Monitor insertion heatmaps are offered as potential guidance for ICP monitor insertion and to stimulate research into what actually drives monitor insertion in unconstrained, real-world conditions.Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Congress of Neurological Surgeons.

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