Time-burden insults of neuromonitoring signals: practical implications for the management of acute brain injury.

Purpose of review: To explore recent insights into measures of time-burden insults in intracranial pressure (ICP) monitoring, and potential implications for clinical management.

Recent findings: The ICP is an important therapeutic target in patients with traumatic brain injury (TBI) and some other brain injuries. Current clinical guidelines in TBI recommend starting treatment above a fixed ICP threshold of 22 mmHg. The concept of ICP burden was introduced recently, which takes both intensity and duration of an episode of elevated ICP into account. This burden of ICP is visualized in a colour-coded plot. In different cohorts of brain injured patients, prolonged ICP elevations, even at values below 20 or 22 mmHg, are associated with worse outcomes, and higher ICPs can only be tolerated briefly. The ICP burden plots are influenced by age, cerebral perfusion pressure, and cerebrovascular autoregulation, illustrating the complexity and dynamic aspect of secondary insults of elevated ICP events, and the need for personalization. Two clinical trials are currently investigating the impact of presenting this information at the bedside to clinicians.

Summary: The implementation of information on ICP burden at the patient's bedside could assist clinicians in recognizing secondary brain injury and result in more personalized ICP management.