Further support for the intracranial compartmental syndrome concept

The current approach to severe neuro-injury monitoring, especially traumatic brain injury (TBI), has experienced paradigm shifts that open a broad outlook for the future [1]. On one hand, advances in pathophysiological knowledge have made possible establishing today that intracranial pressure (ICP) control is just one more epiphenomenon within other serious events that occur simultaneously such as tissue hypoxia, metabolic crises and cerebral energy dysfunction [1]. On the other hand, the advent of new monitoring techniques (invasive and noninvasive) have allowed a deeper analysis in real time of what is happening in the injured brain [1]. One of the most important advancements in neuromonitoring was the recent popularization of the analysis of the ICP wave (ICPw) morphology. Current studies pointed the changes in ICPw as reliable markers of cerebrospinal compliance and to be followed in clinical environments. In this regard, ICPw was considered the pillar of the intracranial compartmental syndrome (ICCS) concept [2]. So, “ICCS occurs when the compliance of the intracranial system is compromised as a result of the exhaustion of the compensating mechanisms that try to keep it within normal limits’’. ‘’Perfusion, oxygenation and energy utilization compromise are its consequences’’ [2].

Further enlightenments raised from the recent study of Kazimierska et al., which evaluated a series of 130 patients who were victims of severe TBI from the CENTER-TBI database. Those authors analyzed the relationship between parameters obtained from the neuroimaging Computed Tomography (CT) scan upon admission and variables collected from invasive ICP monitoring [3]. Injury mass volume, degree of midline shift, Marshall’s and Rotterdam classifications were the data provided by the CT scans, while mean ICP values, wave amplitude and indices derived from the analysis of ICP recordings. A neural network model (previously tested with 93% accuracy) was applied in order to automatically group ICP waveforms into 4 classes [3]. As a main finding, the pulse shape index—PSI was strongly correlated with the analyzed tomographic parameters (p = 0.001), while mean ICP was correlated with ICPw amplitude, indicating that the morphology of the ICP pulse wave reflects a decrease in the cerebrospinal compensatory reserve therefore of cerebral compliance [3].

ICP waveform is a result of complex interaction between volumes (blood, brain and cerebrospinal fluid) restrained by meninges and the bony skull box, interacting with dynamic phenomena as blood viscosity, cardiac and respiratory cycles per example [1]. Therefore, several are the ways of exploring and translating ICPw into parameters readable at the bedside to assess compensatory reserve status. Prior to PSI, the compensatory reserve index (RAP) was described by Czosnyka et al. as the moving correlation between ICP values and ICP pulse amplitude variation [4]. Both the PSI and RAP can be assessed imputing ICP and further variables to the ICM + software (Cambridge Enterprise Ltd., Cambridge, UK). More recently, based on ICP waveform peak relationship changes following cerebral compliance status, Brasil et al. observed the P2/P1 ratio (the second peak amplitude elevation) and time-to-peak (the time length from pulse triggering to its highest peak amplitude) variations following an induced mild ICP variation in neurocritical patients, demonstrating that these parameters may also translate the pressure/volume intracranial relationship [5]. The latter parameters acquisition and assessment are available by means of noninvasive hardware, with potential to widening intracranial compliance applications beyond severe acute brain injuries.

With the infinite contribution which newer hardware and software offer in data acquisition and analysis, we reach assessment options to support the ICCS hypothesis, raising the foundations for developing multicenter prospective clinical studies and validate the concept on a large scale.

Not applicable.

TBI:

Traumatic brain injury

ICP:

Intracranial pressure

CT:

Computed tomography

ICCS:

Intracranial compartmental syndrome

PSI:

Pulse shape index

RAP:

Compensatory reserve index

ICM:

Intensive care monitor

1. Lazaridis C, Foreman B. Management strategies based on multi-modality neuromonitoring in severe traumatic brain injury. Neurotherapeutics. 2023;20(6):1457–71. https://doi.org/10.1007/s13311-023-01411-2.

   Article PubMed Google Scholar

2. Godoy DA, Brasil S, Iaccarino C, et al. The intracranial compartmental syndrome: a proposed model for acute brain injury monitoring and management. Crit Care. 2023;27:137. https://doi.org/10.1186/s13054-023-04427-4.

   Article PubMed PubMed Central Google Scholar

3. Kazimierska A, Uryga A, Mataczyński C, et al. Relationship between the shape of intracranial pressure pulse waveform and computed tomography characteristics in patients after traumatic brain injury. Crit Care. 2023;27:447. https://doi.org/10.1186/s13054-023-04731-z.

   Article PubMed PubMed Central Google Scholar

4. Czosnyka M, Smielewski P, Timofeev I, Lavinio A, Guazzo E, Hutchinson P, et al. Intracranial pressure: more than a number. Neurosurg Focus. 2007;22(5):E10. https://doi.org/10.3171/foc.2007.22.5.11.

   Article PubMed Google Scholar

5. Brasil S, Solla DJF, Nogueira RC, Teixeira MJ, Malbouisson LMS, Paiva WDS. A novel noninvasive technique for intracranial pressure waveform monitoring in critical care. J Pers Med. 2021;11(12):1302. https://doi.org/10.3390/jpm11121302.

   Article PubMed PubMed Central Google Scholar

Download references

None.

Not applicable.

Authors and Affiliations

1. Neurointensive Care Unit, Sanatorio Pasteur, Chacabuco 675, 4700, Catamarca, Argentina

   Daniel Agustin Godoy

2. LIM 62, Department of Neurology, University of São Paulo Medical School, Sao Paulo, Brazil

   Sergio Brasil & Andres M. Rubiano

3. Professor of Neurosciences and Neurosurgery, Universidad El Bosque, Bogotá, Colombia

   Andres M. Rubiano

4. Medical and Research Director, MEDITECH Foundation, Cali, Colombia

   Daniel Agustin Godoy, Sergio Brasil & Andres M. Rubiano

Authors

1. Daniel Agustin GodoyView author publications

   You can also search for this author in PubMed Google Scholar

2. Sergio BrasilView author publications

   You can also search for this author in PubMed Google Scholar

3. Andres M. RubianoView author publications

   You can also search for this author in PubMed Google Scholar

Contributions

All author's contribute equally

Corresponding author

Correspondence to Daniel Agustin Godoy.

Ethics approval and consent to participate

Not applicable.

Consent for publication

All authors give the consent to publish.

Competing interests

DAG and AMR claim no competing interest or conflict of interest. SB serves as a scientific advisor for brain4care.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

Cite this article

Godoy, D.A., Brasil, S. & Rubiano, A.M. Further support for the intracranial compartmental syndrome concept. Crit Care 28, 311 (2024). https://doi.org/10.1186/s13054-024-04974-4

Download citation

• Received: 11 March 2024

• Accepted: 27 May 2024

• Published: 18 September 2024

• DOI: https://doi.org/10.1186/s13054-024-04974-4

Share this article

Anyone you share the following link with will be able to read this content:

Get shareable link

Sorry, a shareable link is not currently available for this article.

Copy to clipboard

Provided by the Springer Nature SharedIt content-sharing initiative