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Letter: Is Intracranial Pressure Monitoring of Patients With Diffuse Traumatic Brain Injury Valuable? An Observational Multicenter Study.

To the Editor: I read with keen interest the article by Yuan et al regarding the effects of intracranial pressure (ICP) monitoring on the mortality of and functional outcomes in patients with severe diffuse traumatic brain injury (TBI). I commend the authors for their contribution to this hotly debated aspect of ICP monitoring in severe diffuse TBI. The authors concluded after this multicenter study that ICP monitoring was associated with a significant decrease in 6-month mortality after adjustment for the baseline risk profile and the monitoring propensity of patients with diffuse severe TBI, especially those with Glasgow Coma Scale (GCS) scores of 3 to 5 or of Marshall computed tomography (CT) classification IV. The readers would be interested to know whether cerebrospinal fluid diversion was done in all patients or selectively in patients in whom ICP monitoring was done and an increased ICP was obtained. Considering that such patients with severe head injury have effaced ventricle and midline shift, it would be interesting to know what the difficulties were, as well as the principal trajectory for inserting an intraventricular catheter in such patients (the authors describe 162 patients with intraventricular ICP monitoring, which is a sizable number of patients). The authors describe ICP monitoring in Marshall classification IV in 27.5%of patients. It would be interesting to know the time interval between the arrival of the patient in the emergency department and ICPmonitor insertion, considering that thepatientswithMarshallCT classification IV aremore likely to have elevated ICP. A comparison of patients of Marshall classification IV who were treated with ICP monitoring with those who were treated without ICP monitoring would be interesting andwould shed light on themanagement of such patients. The authors report that ICP monitoring had significant 6month favorable outcome in patients with the lowest level of consciousness (GCS scores of 3-5). Chestnut et al, in their study, had considered patients with a GCS score of 3 and fixed dilated pupils to be nonsalvageable and excluded them from their study. This is in sharp contrast to the findings of the current study. The authors report that patients with ICP monitoring had a significantly longer intensive care unit stay and hospital stay, although neither the duration of mechanical ventilation nor the duration of osmotherapy differed in the 2 groups. The authors do not give any reason for this important finding. It could either be because of known complications of ICPmonitor insertion, such as meningitis, hematoma, and catheter breakage, or it could be an inherent bias in the study. This very well might have affected outcome and needs to be clarified by the authors. The authors describe in the patientmanagement protocol section that clinical examination was done hourly in both groups, and a CT scan was done at admission, before the operation, immediately after the operation, and at 1, 2, 5, and 7 days after the operation, but they go on to contradict this under in the limitations section of their article, mentioning that the frequency of neurological examinations and the number of CT scans performed during admission were not collected, and so it was not possible to assess the adequacy of alternative monitoring methods. The above statements are contradictory and, frankly, confusing. Itwould be really great if the authors could clarify this very important aspect.