Non-invasive ICP monitoring when invasive systems are available in the care of acute brain injured patients: a clinical approach

Invasive intracranial pressure (ICP) monitoring is considered the gold standard for the management of patients with an acute brain injury and at risk of developing intracranial hypertension (IH). However, invasive devices (e.g., intraparenchymal probe or external ventricular drain) are expensive, not available worldwide, and might be associated with some risks. Recently, a consensus for the monitoring and management of traumatic brain injury (TBI) patients when invasive ICP is not available (B-ICONIC) was developed. This approach is based on repeated neurological evaluation, neuroimaging, and the use of non-invasive ICP monitoring tools, such as transcranial Doppler, automated pupillometry, and ultrasound optic nerve sheath diameter measurement, to titrate interventions aiming at controlling ICP. Despite this clinical algorithm was mainly proposed for low and middle-income countries where invasive ICP is not widely implemented, a potential application of this approach may exist even in healthcare facilities where direct ICP monitoring is available. This includes patients who may have contraindications to invasive monitoring, such as coagulopathy, as well as those in whom ICP monitoring is not routinely implemented, such as individuals with post-anoxic brain injury or acute liver failure, for the reported occurrence of cerebral edema and potential risk of IH in these cases. Therefore, the aim of this manuscript is to propose the extension of the B-ICONIC algorithm to a wider population, regardless of the decision to insert an ICP sensor, and to guide their management using this multimodal approach.