Neurocrit Care

https://doi.org/10.1007/s12028-024-02008-z

ORIGINAL WORK

A Comprehensive Perspective on Intracranial

Pressure Monitoring and Individualized
Management in Neurocritical Care: Results of a
Survey with Global Experts
Sérgio Brasil1* , Daniel Agustín Godoy2, Walter Videtta3, Andrés Mariano Rubiano4, Davi Solla1,
Fabio Silvio Taccone5, Chiara Robba6, Frank Rasulo7, Marcel Aries8,9, Peter Smielewski10, Geert Meyfroidt11,
Denise Battaglini6, Mohammad I. Hirzallah12, Robson Amorim1, Gisele Sampaio13, Fabiano Moulin13,
Cristian Deana14, Edoardo Picetti15, Angelos Kolias16, Peter Hutchinson16, Gregory W. Hawryluk17,18,19,
Marek Czosnyka20, Ronney B. Panerai21, Lori A. Shutter22, Soojin Park23, Carla Rynkowski24, Jorge Paranhos25,
Thiago H. S. Silva26, Luiz M. S. Malbouisson26 and Wellingson S. Paiva1

© 2024 The Author(s)

Abstract
Background: Numerous trials have addressed intracranial pressure (ICP) management in neurocritical care. However,
identifying its harmful thresholds and controlling ICP remain challenging in terms of improving outcomes. Evidence
suggests that an individualized approach is necessary for establishing tolerance limits for ICP, incorporating factors
such as ICP waveform (ICPW) or pulse morphology along with additional data provided by other invasive (e.g., brain
oximetry) and noninvasive monitoring (NIM) methods (e.g., transcranial Doppler, optic nerve sheath diameter ultra-
sound, and pupillometry). This study aims to assess current ICP monitoring practices among experienced clinicians
and explore whether guidelines should incorporate ancillary parameters from NIM and ICPW in future updates.
Methods: We conducted a survey among experienced professionals involved in researching and managing patients
with severe injury across low-middle-income countries (LMICs) and high-income countries (HICs). We sought their
insights on ICP monitoring, particularly focusing on the impact of NIM and ICPW in various clinical scenarios.
Results: From October to December 2023, 109 professionals from the Americas and Europe participated in the
survey, evenly distributed between LMIC and HIC. When ICP ranged from 22 to 25 mm Hg, 62.3% of respondents were
open to considering additional information, such as ICPW and other monitoring techniques, before adjusting therapy
intensity levels. Moreover, 77% of respondents were inclined to reassess patients with ICP in the 18–22 mm Hg range,
potentially escalating therapy intensity levels with the support of ICPW and NIM. Differences emerged between LMIC
and HIC participants, with more LMIC respondents preferring arterial blood pressure transducer leveling at the heart
and endorsing the use of NIM techniques and ICPW as ancillary information.

*Correspondence: sbrasil@usp.br
1
Division of Neurosurgery, Department of Neurology, School of Medicine
University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo,
Brazil
Full list of author information is available at the end of the article
 Conclusions: Experienced clinicians tend to personalize ICP management, emphasizing the importance of consider-
ing various monitoring techniques. ICPW and noninvasive techniques, particularly in LMIC settings, warrant further
exploration and could potentially enhance individualized patient care. The study suggests updating guidelines to
include these additional components for a more personalized approach to ICP management.
Keywords: Cerebral perfusion pressure, Individualized care, Intracranial pressure, Intracranial pressure waveform,
Intracranial compliance, Neurocritical care
Introduction
Our understanding of intracranial pressure (ICP), a criti-
cal indicator of brain health, is continuously evolving [1],
with satisfactory evidence supporting its monitoring as
a means of outcome improvement [2, 3]. However, both
the safety limits and therapeutic thresholds for manag-
ing and treating ICP are still debatable [4, 5], although
the current recommendation is based on 22 mm Hg [6].
Several notable trials investigating traumatic brain injury
(TBI), whether targeting ICP alone [7] or in combination
with brain oximetry [8], employing various therapy strat-
egies, such as decompressive craniectomy [9, 10], hypo-
thermia [11], and others, have highlighted the ongoing
need for further advancement in outcome improvement.
Possibly, part of this issue may be attributed to attempts
to oversimplify ICP as a binary “yes” or “no” phenome-
non, neglecting to individualize ICP thresholds based on
disease processes or individual variations.
The generation of pressure within the cranium is a
dynamic process involving various anatomical struc-
tures, such as the brain, cerebrospinal fluid, arterial
and venous blood volumes, meninges, and bones. Addi-
tionally, pressure in abdominal, thoracic, and cervical
cavities also influences intracranial space pressure [12].
Following an acute brain injury, inflammatory cascades
and impairment in cerebral physiological components
contribute to brain tissue volume expansion (cerebral
edema) and elevation of ICP [13, 14]. Moreover, fac-
tors such as ventilator-patient desynchrony, improper
patient positioning, sedation use, arterial blood pres-
sure (ABP), and volemic management, as well as com-
plications such as ischemia, vasospasm, infection, and
secondary hemorrhage, may also lead to intracranial
hypertension (IH) development [12].
Among these factors, the intracranial variation of
blood volume during each heartbeat is the primary
determinant of ICP dynamics, at least on a second-by-
second timescale [15]. Beat by beat, ICP pulse slopes
can be observed, showing habitual systolic and dias-
tolic phases in dedicated monitors. This pulse morphol-
ogy can indicate compromised intracranial compliance
(ICC) and may predict IH [16–18]. Therefore, abso-
lute ICP numbers alone may not be precise indicators
because they do not reflect ICC and may not assist in
determining therapy strategy following different IH
syndromes [19] and may lead to imprecise cerebral
perfusion pressure (CPP) calculation [20]. This under-
scores the need for additional parameters for guidance.
In this context, multimodality neuromonitoring and
ICP waveform (ICPW) or pulse morphology emerge as
promising options for better differentiation of patients
at risk of developing IH crisis [21, 22] (Fig. 1).
The present study is a survey on perceptions regard-
ing ICP monitoring among neurocritical care profes-
sionals. The primary objective was to gather opinions
on current ICP monitoring practices from professionals
with diverse backgrounds, for a discussion on individu-
alizing ICP management using additional monitoring
tools, especially ICPW and noninvasive monitoring
(NIM). The study aimed to determine whether, from
an expert standpoint, ICP management guidelines can
consider the inclusion of ancillary physiological param-
eters derived from NIM and ICPW in future updates.
Differences in opinions among professionals from high-
income countries (HICs) and low-middle income coun-
tries (LMICs) were explored.
Methods
A cross-sectional survey was developed to assess profes-
sional practices and knowledge regarding ICP, CPP, and
ICPW. The survey was crafted by a steering committee
following the checklist for reporting of survey studies
(CROSS) recommendations (Supplemental 1) previously
published [23]. A pilot test involving five professionals
was conducted, and based on their feedback, the survey
was refined before dissemination via email, social media,
and medical meetings to eligible participants (details pro-
vided in the following section). The survey was hosted on
Google Forms for broad accessibility and was available
from October 1st to November 30th, 2023. Participa-
tion was voluntary and anonymous, with each partici-
pant permitted to submit only one response. The online
form was designed to automatically conclude once all
questions were answered. Additionally, participants were
encouraged to share the survey link with other profes-
sionals with similar backgrounds who met the participa-
tion criteria.
 Fig. 1 Three different patients with the same ICP value (20 mm Hg) but distinct ICP pulse morphologies (purple waveforms) representing distinct
levels of intracranial compliance. ICP intracranial pressure (Color figure online)
Survey
The survey is shown in Supplemental 2. It pertained to
patients with acute brain injury undergoing invasive
ICP monitoring (regardless of an external drain, paren-
chymal, or other). Other invasive techniques (e.g., brain
oximetry, microdialysis) were not considered as rou-
tine, but participants could discuss these techniques in
the free-text fields. The survey results, which include an
analysis of the divergence in opinions between LMIC
and HIC clinicians, are presented following the assess-
ment of each field, which were as follows: (1) agreement
with the 22 mm Hg threshold to either start or escalate
IH therapy intensity levels (TILs) (based on the Seattle
International Brain Injury Consensus Conference rec-
ommendations [6]), (2) general knowledge on ICPW
and its practical relevance, (3) agreement on using NIM
and ICPW to support the individualization of ICP judg-
ment in selected cases, and (4) agreement with includ-
ing these additional parameters in future guideline
updates.
Participants’ Characteristics
Those surveyed should be active practitioners or
researchers with ten or more years of experience in the
management and/or research in neurocritical care pos-
sessing experience in ICP dynamics. Therefore, par-
ticipants also should have participated in academic
production in the scope of the survey. Participants were
not necessarily medical doctors but also nurses and other
professionals associated with this practice. The survey
was composed of 15 questions in English; therefore, Eng-
lish proficiency was an additional prerequisite. The ques-
tions allowed a single response and space for providing
any additional comment. Exclusively in the case of ancil-
lary tools available in each participant’s health facility,
multiple answers were possible.
Statistical Analysis
A standard descriptive analysis was performed. Variables
were presented through absolute and relative frequen-
cies and, when applicable, 95% confidence intervals (CIs)
were calculated with the binomial exact method. Infer-
ential exploratory analyses were conducted and, when
applicable, the groups were compared using the χ2 test.
LMIC and HIC were defined as the World Bank classifi-
cation (available at https://​datah​elpde​sk.​world​bank.​org).
There were no missing data. All tests were two-tailed,
and final p values under 0.05 were considered significant.
The analyses were conducted with the Statistical Pack-
age for Social Sciences software (IBM SPSS Statistics for
Windows, version 24.0; IBM Corp., Armonk, NY).
Results
Participants
This survey recruited 109 participants meeting the inclu-
sion criteria, being evenly distributed between HIC and
LMIC (55 and 54 participants, respectively). Among the
represented institutions, 48 (54%) were from HIC, and 73
(82%) were academic institutions out of a total of 88. The
participants consisted of 6 (5%) nurses, 70 (64%) inten-
sivists, 6 (5%) neurologists, 4 (3%) brain physiologists,
and 23 (21%) neurosurgeons involved with the care of
patients with severe neurological injury.
Guidelines Adherence and CPP Measurement
The survey revealed a common practice of individualiz-
ing target ranges for ICP and CPP, with a frequent reli-
ance on adjunctive NIM techniques to support decisions
in the scenario of a patient with acute brain injury with
invasive ICP monitoring. Only 30 (27.5%) participants
followed 22 mm Hg as the threshold for initiating or
escalating TIL. A total of 68 (62.4%) participants were
more flexible on cutoff choices, and 11 (10.1%) partici-
pants surveyed did not follow the recommended cut-
off. Regarding CPP monitoring thresholds, 39 (35.7%)
participants pursue the 60–70 mm Hg range, whereas 44
(40.3%) rely on this range when it is supported by ancil-
lary means, such as NIM and imaging, and 26 (23.8%) do
not rely on this range. Figure 2 shows the most used NIM
techniques among participants. The level with which
ABP is zeroed and the transducer positioned, which
impacts directly with CPP calculation, is also heterog-
enous; among the respondents, this level was the heart
for 60 (55%) participants, the tragus for 36 (33%) partici-
pants, and both levels for 13 (11.9%) participants.
Relevance of ICPW and NIM
With reference to ICPW monitoring, 71 (65%) partici-
pants surveyed considered ICPW fundamental to individ-
ualize ICP management, whereas 38 (35%) reported using
ICPW in select cases only. The correlation of profession-
als who consider ICPW fundamental to individualize
their patients’ treatment with support to the inclusion of
ICPW analysis in future guidelines update was significant
(p = 0.004). Regarding the use of NIM techniques to sup-
port ICP plus CPP monitoring and management individu-
alization, 82 (75.2%) participants agreed to use both NIM
and ICP, 23 (21.1%) declared to use NIM occasionally,
and only 4 (3.6%) did not see value in using NIM to refine
treatment guidance. Likewise, the position of clinicians on
behalf of NIM parameters inclusion in future guidelines
update was significant (p = 0.019).
NIRS
B4C
Pupillometry
ONSD
TCD/TCCD
Imaging
% 0 10 20
Fig. 2 The most used noninvasive techniques to support ICP monitoring among the participants (in percentages of incidence). Data are presented
in percentages. B4C Brain4Care, ICP intracranial pressure, NIRS near-infrared spectroscopy, ONSD optic nerve sheath diameter, TCCD transcranial
color-coded duplex, TCD transcranial Doppler
Role of ICPW in Different ICP Situations
Table 1 and Fig. 3 show the responses for each of the
survey’s questions. In controversial situations when
ICP is under 22 mm Hg but ICPW presents an abnor-
mal morphology suggestive of poor ICC, 84 (77%) par-
ticipants would review their patients holistically and
consider escalating IH TILs between lower tiers 1 or 2.
A total of 84 (77%) participants also agreed that a use-
ful way to clarify these situations might be using NIM.
The situation of a patient with borderline ICP values
between 18 and 22 mm Hg compels 47 (43%) respond-
ers to continue just observing when ICPW keeps its
normal shape, whereas 62 (57%) would proceed with
reassessing the patient and/or taking additional tests
to consider escalating lower TILs. Finally, for patients
with ICP between 22 and 25 mm Hg but normal ICPW,
33 (30%) participants escalate TILs, 7 (6%) monitor the
ICPW to take actions, and 69 (64%) would still pro-
ceed to guide actions after performing further ancillary
assessments.
Diversity Between LMICs and HICs
Significant differences were observed on ICP manage-
ment perceptions and practices between LMICs and
HICs, as shown in Table 2. Participants from LMICs are
more likely to level ABP at the heart than the tragus and
to use multimodal NIM as ancillary information to ICP
30 40 50 60 70
values. Furthermore, participants from LMICs con-
sider ICPW relevant and are more willing to support
its implementation in the guidelines as an ICP refine-
ment. Participants who supported updating guidelines
toward a personalized ICP management also agreed
with adding NIM in this setting (Table 3). There were
no differences between LMICs and HICs regarding
the use of imaging and transcranial Doppler (TCD) or
transcranial color-coded duplex, and these techniques
were the most used NIM (70% and 65%, respectively).
However, application of optic nerve sheath ultrasound
(ONSUS) is significantly higher in LMICs (80%) than in
HICs (40.7%, p < 0.001). Overall, 71 (65%) participants
supported considering the inclusion of ICPW analy-
sis in future guidelines update, whereas 38 (35%) think
evidence in this regard is still lacking. Support was sig-
nificantly more prevalent among LMIC participants
(p = 0.004).

Table 1 Answers for the survey’s questions

Question Frequency Percent (CI 95%)

Adherence to recommendation on escalating ICP interventions when it is ≥ 22 mm Hg

Do not agree at all, this threshold is not accurate to me 11 10.1 (5.2–17.3)
I partially agree, I am more flexible with thresholds 68 62.4 (52.6–71.5)
I strongly agree 30 27.5 (19.4–36.9)
Agreement on keeping CPP range 60–70 mm Hg
Do not agree with this range, I always look for an individualized CPP 26 23.8 (16.2–33.0)
I partially agree. I look for this range but only with ancillary support 44 40.4 (31.1–50.2)
I strongly agree. I look for this range on the bedside monitor 39 35.8 (26.8–45.5)
Use of noninvasive ancillary tests to support ICP assessment
Do not agree at all 4 3.7 (1.0–9.1)
I partially agree. I seldomly check on ancillary tests regarding ICP monitoring 23 21.1 (13.9–30.0)
I strongly agree 82 75.2 (66.0–83.0)
ICPW education during training
I have no knowledge on this subject 2 1.8 (0.2–6.5)
I did not learn about this subject in residency, I did it by myself 48 44.1 (34.5–53.9)
Yes, I have been trained on this subject very well during my specialization 59 54.1 (44.3–63.7)
Confidence on interpreting ICPW
I have little knowledge about this subject 3 2.8 (0.6–7.8)
Not much confident. I need to gain a better understanding of the significance of the distinct peaks in the 23 21.1 (13.9–30.0)
ICP waveform
Very confident. I know the physiology of ICP wave morphology very well 83 76.1 (67.0–83.8)
ICPW relevance
It has some importance to me; I check on this in selected cases only 38 34.9 (26.0–44.6)
It is fundamental to individualize my patients’ management 71 65.1 (55.4–74.0)
Perception of difficulty on applying ICPW in clinical practice
I lack confidence in assessing ICP waveforms visually due to the inherent subjectivity in the process 13 12.0 (6.5–19.5)
I have difficulties identifying the wave components very often 14 12.8 (7.2–20.6)
No, I feel confident about observing and interpreting the ICP slopes 82 75.2 (66.0–83.0)
Familiarity to ICPW parameters (P2/P1 ratio and TTP)
I don’t know these parameters 9 8.2 (3.8–15.1)
I know a little about this 27 24.8 (17.0–34.0)
Yes 73 67.0 (57.3–75.7)
Support the inclusion of ICPW parameters interpretation to refine ICP management
Partially agree. Although it is promising information, there still need for more large-scale studies 38 34.9 (26.0–44.6)
Strongly agree 71 65.1 (55.4–74.0)
CI confidence interval, CPP cerebral perfusion pressure, ICP intracranial pressure, ICPW ICP waveform, P2/P1 quotient between second and first ICP waveform peaks,
TTP time to peak
 Fig. 3 Participants’ answers distributions regarding intracranial pressure waveform (ICPW) relevance according to different intracranial pressure
(ICP) levels
Discussion
The current study compiled insights from numerous
actively engaged academics with more than a decade of
experience in treating neurocritical patients and man-
aging ICP. Participants were divided based on regional
economic conditions, distinguishing between LMICs
and HICs. This differentiation is particularly significant
for assessing the impact of resource availability on medi-
cal practices. The collected opinions revealed that prac-
titioners are becoming less rigid in adhering to ICP and
CPP thresholds, instead using ICPW and NIM as sup-
plementary tools to inform management decisions. There
is a growing confidence in customizing thresholds, such
as “optimal CPP” or “critical ICP,” based on the observed
autoregulatory status [24].
Novel methods for using ICPW and NIM to increase
understanding of cerebrospinal compensatory reserve
or brain compliance are emerging [25]. Furthermore,
interest in NIM is also as a means to reduce the finan-
cial burden related to ICP monitoring, which has grown
exponentially in the last few decades [26]. Understand-
ing of ICPW and its clinical application receives atten-
tion whether professionals are from LMICs or HICs and
its interpretation seems to be determinant on decisions.
The participants of the present survey agreed with the
addition of these components to be considered in future
guideline revisions.
With reference to the most cited NIM techniques by
the surveyed, TCD has been acknowledged by its capac-
ity of assessing blood velocities and observe CPP reduc-
tion by means of the pulsatility index [27] or even the
ICP/CPP estimation [28, 29]. Furthermore, TCD is highly
sensitive to cerebrovascular dynamics, allowing clini-
cians to assess immediate responses at the bedside in the
case of changes in ABP and ­pCO2, hydrocephalus, mid-
line shift, and brain death (e.g., see [30]). The ONSUS has
been extensively studied in the last years, with a threshold
of ~ 5.8 mm currently adopted as a suitable cutoff for ele-
vated ICP [31]. Among ONSUS advantages are low costs,
short learning curve, and readiness. The pupil-reactivity
index (NPi), derived from automated pupillometry, has
been the most studied parameter of this technique for
its correlation with ICP, understanding NPi decrease as a
potential indicator of ICP elevation [32], while one mul-
ticentric trial observed significant correlation between
persistent NPi < 3 and poorer outcomes in neurocritical
care [33]. One emerging technique cited by 27.5% of the
surveyed (Table 2) reproduces ICPW following pulsatile
Table 2 LMIC and HIC participants responses on ICP/CPP practices
Question Total Country p value
LMIC HIC

Level of ABP measurement 0.003

Heart 60 (55,0) 38 (69,1) 22 (40,7)
Tragus 36 (33,0) 10 (18,2) 26 (48,1)
Both 13 (11,9) 7 (12,7) 6 (11,1)
Agreement to use noninvasive ancillary tests to enhance clinical judgment 0.041
Do not agree at all 4 (3,7) 1 (1,8) 3 (5,6)
Partially agree 23 (21,1) 8 (14,5) 15 (27,8)
Strongly agree 82 (75,2) 46 (83,6) 36 (66,7)
Noninvasive ancillary tests
Imaging 77 (70,6) 43 (78,2) 34 (63,0) 0.081
TCD 72 (66,1) 39 (70,9) 33 (61,1) 0.280
ONSD 66 (60,6) 44 (80,0) 22 (40,7) < 0.001
Pupillometry 45 (41,3) 23 (41,8) 22 (40,7) 0.909
Noninvasive ICPW (B4C) 30 (27,5) 25 (45,5) 5 (9,3) < 0.001
ICPW education during training 0.030
No knowledge on this subject 2 (1,8) 2 (3,6) 0 (0,0)
Self-taught 48 (44,0) 18 (32,7) 30 (55,6)
Trained during residency 59 (54,1) 35 (63,6) 24 (44,4)
Confidence on interpreting ICPW 0.006
Little knowledge/Not much confident 26 (23,9) 7 (12,7) 19 (35,2)
Very confident 83 (76,1) 48 (87,3) 35 (64,8)
ICPW morphology relevance < 0.001
Some importance (selected cases) 38 (34,9) 10 (18,2) 28 (51,9)
Fundamental to individualize management 71 (65,1) 45 (81,8) 26 (48,1)
Familiarity to ICPW parameters (P2/P1 ratio and TTP) 0.021
Do not know 9 (8,3) 3 (5,5) 6 (11,1)
Little knowledge 27 (24,8) 9 (16,4) 18 (33,3)
Familiar 73 (67,0) 43 (78,2) 30 (55,6)
Support the inclusion of ICPW parameters interpretation to refine ICP management 0.004
Partially agree 38 (34,9) 12 (21,8) 26 (48,1)
Strongly agree 71 (65,1) 43 (78,2) 28 (51,9)
ABP arterial blood pressure, B4C Brain4Care, CPP cerebral perfusion pressure, HIC high-income country, ICP intracranial pressure, ICPW ICP waveform, LMIC low/middle-
income country, NIM noninvasive monitoring, P2/P1 quotient between second and first ICP waveform peaks, TCD transcranial Doppler, TTP time-to-peak

Table 3 Agreement perception on using NIM and ICP micrometric dilations of the skull at each heartbeat. Its
guidelines update generated waveforms undergo automated analysis and
Agreement to use NIM Agreement level with guidelines Total numerical ratios as the quotient between second and first
tests to enhance clinical updating using ICP plus addi- ICP waveform peaks (P2/P1) and time to peak may aid
discernment tional NIM information physicians detecting poor ICC [34]. Figure 4 summarizes
Partially agree Strongly agree this combination of NIM with their respective indicators.
Studying such a model and how it can aid in improving
Do not agree at all 3 (7,9) 1 (1,4) 4 (3,7)
ICP judgment warrants prospective validation.
I partially agree. I 11 (28,9) 12 (16,9) 23 (21,1)
seldomly check on
ancillary tests regarding CPP
ICP monitoring Cerebral perfusion pressure is the force with which blood
I strongly agree 24 (63,2) 58 (81,7) 82 (75,2) penetrates brain tissue and its adequacy is fundamen-
ICP intracranial pressure, NIM noninvasive monitoring tal to meet the brain’s metabolic demand [20]. It was
p value = 0.019
described more than 60 years ago by Lassen [35], who
hypothesized that CPP would be the difference between
the input (mean ABP [MAP]) and the intracranial resist-
ance provided by the brain tissue and the venous outflow,
or ICP. These concepts were proven to be true among
healthy individuals, and the formula CPP = MAP − ICP is
currently adopted in clinical practice and widely present
in neurocritical care literature [36]. The Brain Trauma
Foundation recommend the 60–70 mm Hg range [37],
whereas the Lund recommendations are to keep CPP
near 50 mm Hg in severe TBI [38]. However, once either
chronic or acute situations that impair cerebral autoregu-
lation are present [39, 40], CPP manipulation strictly by
means of changes in ABP just to compensate ICP may be
iatrogenic [41].
The extremely rich branching of cerebral vessels creates
a progressive reduction in the actual ABP in intracra-
nial vessels from the circle of Willis to the cerebral small
vessels [42]. This lower ABP, associated with absence of
muscular wall in the final arterial line make these vessels
much more sensitive to higher ICP and easily collapsible
after acute brain injuries, expanding hypoperfusion to its
surrounding areas [43]. Therefore, cerebral blood flow
(CBF) stops in the small vessels even with ABP being far
from zero, the so-called critical closing pressure which
changes in strict adherence with ICP fluctuations [44].
Furthermore, it was demonstrated that the counterforces
between MAP and ICP do not behave as balanced as the
formula preconizes, being the cerebrovascular capacity
to compensate CPP in face of ICP elevations much more
mitigated when compared to cerebrovascular response to
ABP changes [45, 46].
With all the above, it may be concluded that assessing
CPP as the difference between MAP and ICP may not
be accurate. Several efforts are being made to provide
an accurate estimation and optimization of CPP [47,
48]. Unfortunately, optimal CPP is still under develop-
ment [49, 50] and needs dedicated systems that are not
widely available especially in LMICs. To estimate CPP
properly, it is recommended to monitor ABP with the
transducer leveled at the tragus [36, 51, 52], but our
result in this regard indicate that this is not always the
case, which is consistent with a previous survey among
the Brain Trauma Foundation authors [53]. An ABP
leveled at the heart may overestimate CPP between
10 to 20 mm Hg [36, 54] (Fig. 5). However, even with
ABP leveled at the tragus, the resultant CPP may
not represent the whole brain CPP. When available,
TCD [29] and brain oximetry [55] provide adjunctive
information.
Adherence to ICP Management Guidelines
The Seattle International Severe Brain Injury Consensus
Conference recommended that physicians use their clini-
cal judgment and adapt the guidelines as best possible
[6]. In the present survey, 70% of participants described
their practice as flexible with thresholds; this was inde-
pendent of being based in a LMIC or HIC. LMIC partici-
pants were more favorable in considering the inclusion
of additional information such as ICPW parameters and

• Escalate ancillary neuromonitoring to close following

Transitory ICP • Revise paent (TIL 1)
>15 mmHg

• TCD PI >1.4, eCPP <45 mmHg, NPI <3, ONSU >5mm, P2/P1 rao >1.2, TTP
>0.22
Persistent ICP • Consider escalang TIL 2-3?
15-25 mmHg

• TCD PI >1.4, eCPP <45 mmHg, NPI <3, ONSU >5mm, P2/P1 rao >1.2, TTP
>0.22
Persistent ICP • Consider escalang TIL 2-4?
>25 mmHg

Fig. 4 A flowchart proposal (still to be prospectively validated) for ICP management, considering evidence-based ancillary noninvasive neuromoni-
toring. Techniques may include transcranial Doppler, pupillometry, ICP waveform, and ONSUS. eCPP estimated cerebral perfusion pressure, ICP
intracranial pressure, NPI neuropupillary index, ONSUS optic nerve sheath ultrasound, P2/P1 quotient between second and first ICP waveform peaks,
TIL therapy intensity level, TTP time to peak
NIM in determining IH actions. Probably the most suita-
ble explanation for this finding is the lack of invasive ICP
for all patients in need in LMIC areas, compelling these
physicians to build up experience using NIM.
In healthy adults, ICP values remain under 15 mm Hg
[51, 56]. In face of a sustained range of 22–25 mm Hg,
30% of this survey’s participants opt to escalate IH TILs
regardless of any further information. For borderline
ICP values like 18–22 mm Hg (and possibly lower values
in selected cases) the need for additional data becomes
evident, since allowing ICP to remain beyond individual
safety thresholds may carry inadvertent consequences
[56]. This is supported by the recent work from Riparbelli
et al. [4], in which a cohort of more than 300 patients
found 18 mm Hg as a threshold associated with mortality
and unfavorable outcomes.
ICPW
Intracranial pressure pulse morphology carries useful
information [15, 21], ancillary to the mean ICP typically
shown on bedside monitors (which is measured by aver-
ages of time intervals) [57]. The changes in beat-by-beat
ICPW have been extensively studied, especially the cor-
relation between its different peak amplitudes (P1, P2,

Fig. 5 A representation of how changing ABP level from right atrium to tragus may change CPP calculation. Top, CPP is overestimated in 75 mm
Hg, whereas real CPP is 55 mm Hg in the lower picture. It is fundamental to consider patient positioning (bed and head angle) and that these CPP
values differences vary among individuals. ABP arterial blood pressure, CPP cerebral perfusion pressure
 Fig. 6 Parameters extracted and calculated from intracranial pulse slopes. P2/P1 ratio is the ratio between second and first peak amplitudes,
whereas TTP is the time from pulse upstroke to the highest amplitude identified, represented in percentage. Rounded intracranial pressure pulse
shapes indicating reduced intracranial compliance present with higher P2/P1 ratios and TTP
and P3) following changes in the volume/pressure rela-
tionship [58–60]. Inside the bony box of the skull, the
continuously moving interaction between arterial blood
flow with the brain and ventricles filled with cerebrospi-
nal fluid, determines the formation of P1 (upstroke peak),
P2 (tidal wave), which is associated with ICC, and the
buffering reserve. Finally, P3 is associated with the clo-
sure of the aortic valve [58]. Because ICP is correlated
with CBF, other variables that influence CBF may also
influence ICPW, such as the ventilatory status [61], blood
viscosity, temperature, and the cardiac output [62].
ICPW parameters including P2 elevation may precede
an IH crisis by several minutes [17, 18]. This observa-
tion led to an increased interest in exploring the param-
eter P2/P1 ratio, as a descriptor of decreased adaptative
capacity [63, 64]. Brasil et al. [16] found the P2/P1 ratio
to increase around 10% after promoting an ICP increase
of ~ 4 mm Hg from a baseline of ~ 15 mm Hg in a study of
patients with TBI without skull damage. Integrated artifi-
cial intelligence–based pulse shape index tracing contin-
uously P2 to P1 proportions has recently been proven to
associate both with outcome after TBI and CT findings
[65, 66]. The time to peak (TTP) is a normalized param-
eter derived from each pulse triggering up to its highest
amplitude [67, 68]. The pulse slope triggering is time zero
and the end of the pulse is time hundred, therefore TTP
is the percentage representation of the pulse’s length in
which the highest amplitude is identified (Fig. 6). These
parameters, currently available exclusively in a nonin-
vasive device [34] soon will be also included in inva-
sive systems to gather ICP values and ICPW automated
metrics [69], what will aid practitioners on interpreting
ICPW changes instead of making a simple visual assess-
ment. Given the multiple inherent variables included in
this phenomenon [57], distinguishing the distinct ICPW
peaks without the support of a dedicated analytics pro-
cess may become difficult.
In this survey, it was noted that as ICP exceeds 22 mm
Hg, fewer experts rely on ICPW for decision-making.
However, ICPW garners more attention in distinguish-
ing patients below this threshold but at risk of experi-
encing ICC impairment. Therefore, the accurate use of
ICPW hinges on the clinician’s confidence in interpreting
its patterns. The vast majority of participants expressed
confidence in interpreting and applying ICPW in their
clinical practices, citing their understanding of the patho-
physiology of patients with severe neurological injury.
Limitations
Limitations of the present study include relying on the
limited area of survey distribution, which included
primarily professionals from Europe and North, Cen-
tral, and South America, having no participants from
Oceania, Asia, and Africa. Survey responses were kept
anonymous; therefore, the accuracy of the information
provided and fulfillment of prerequisites for participat-
ing was based on good faith. The survey did not embrace
questioning participants on their perceptions regarding
ICP levels more than 25 mm Hg, although it is implicit
that over this level, professionals take their actions to
treat IH independently of any further information. The
survey considered LMICs and HICs exclusively, accord-
ing to the real situation of their health services, and
therefore the results may not represent the actual hetero-
geneity of resources available especially in LMIC.
Conclusions
Experienced professionals are prone to the individualiza-
tion of ICP thresholds, by means of a variety of ancillary
parameters, which can be obtained using other invasive
or noninvasive techniques. Among a majority of these
professionals, ICP pulse morphology and NIM tech-
niques (imaging, TCD, pupillometry, and ONSUS) were
considered valuable options to be included in future
guideline updates. Especially when ICP is below 22 mm
Hg but ICC seems to be compromised, the use of sup-
portive invasive or noninvasive techniques to refine bed-
side judgment increases. Professionals from LMICs are
likely more supportive of these ancillary methods to alter
IH TILs. Nevertheless, prospective studies to create the
ideal ICP monitoring and treatment algorithm are still
needed. These implications are fundamental to assess
CPP, which also currently lacks standardization in its
measurement.
Supplementary Information
The online version contains supplementary material available at https://​doi.​
org/​10.​1007/​s12028-​024-​02008-z.
Author details
1
Division of Neurosurgery, Department of Neurology, School of Medicine
University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo,
Brazil. 2 Neurointensive Care Unit, Sanatório Pasteur, Catamarca, Argentina.
3
Intensive Care Unit, Hospital Posadas, Buenos Aires, Argentina. 4 Neu-
rosciences and Neurosurgery, Universidad El Bosque, Bogotá, Colombia.
5
Department of Intensive Care, Hôpital Universitaire de Bruxelles, Univer-
sité Libre de Bruxelles, Brussels, Belgium. 6 Anesthesia and Intensive Care,
Scientific Institute for Research, Hospitalization and Healthcare, Policlínico San
Martino, Genoa, Italy. 7 Neuroanesthesia, Neurocritical and Postoperative Care,
Spedali Civili University Affiliated Hospital of Brescia, Brescia, Italy. 8 Depart-
ment of Intensive Care, Maastricht University Medical Center, Maastricht, The
Netherlands. 9 School of Mental Health and Neurosciences, University Maas-
tricht, Maastricht, The Netherlands. 10 Department of Clinical Neurosciences,
Addenbrookes Hospital, University of Cambridge, Cambridge, UK. 11 Depart-
ment and Laboratory of Intensive Care Medicine, University Hospitals Leuven,
Leuven, Belgium. 12 Departments of Neurology, Neurosurgery, and Center
for Space Medicine, Baylor College of Medicine, Houston, TX, USA. 13 Neurol-
ogy Department, São Paulo Federal University Medical School, São Paulo, Bra-
zil. 14 Department of Anesthesia and Intensive Care, Health Integrated Agency
of Friuli Centrale, Udine, Italy. 15 Department of Anesthesia and Intensive Care,
Parma University Hospital, Parma, Italy. 16 University of Cambridge, Cambridge,
UK. 17 Cleveland Clinic Neurological Institute, Akron General Hospital, Fairlawn,
OH, USA. 18 Uniformed Services University, Bethesda, USA. 19 Brain Trauma
Foundation, New York, USA. 20 Division of Neurosurgery, Addenbrooke’s Hos-
pital, Cambridge, UK. 21 Cerebral Haemodynamics in Ageing and Stroke Medi-
cine Group, Department of Cardiovascular Sciences, University of Leicester,
Leicester, UK. 22 Departments of Critical Care Medicine, Neurology and Neu-
rosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
23
Departments of Neurology and Biomedical Informatics, Columbia University
Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital,
New York, NY, USA. 24 Department of Urgency and Trauma, Medical Faculty,
Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil.
25
Intensive Care and Neuroemergency, Santa Casa de Misericórdia, São João
del Rei, Brazil. 26 Department of Intensive Care, School of Medicine University
of São Paulo, São Paulo, Brazil.
Acknowledgements
We thank Antônio Estevam dos Santos Filho for the illustration artwork.
Author Contributions
SB: Original idea, wrote survey and manuscript, elaborated figures. DAG:
Piloted survey. WV: Piloted survey. DS: Statistical analysis. All authors: Review,
discussion, critical analysis and edition of the manuscript. The final manuscript
was approved by all authors.
Source of Support
The authors of this article declare they have not received funds or fees for
writing it.
Conflict of interest
SB is scientific advisor for Brain4care. The other authors have no COI related to
the present work.
Ethical Approval/Informed Consent
Not applicable.
Open Access
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License, which permits use, sharing, adaptation, 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
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article are included in the article’s Creative Commons licence, unless indicated
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article’s Creative Commons licence and your intended use is not permitted
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Publisher’s Note
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Received: 23 February 2024 Accepted: 1 May 2024
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