Intracranial Pressure Treatment Thresholds in Pediatric Traumatic Brain Injury

Importance: Intracranial pressure (ICP) is the management focus for improving outcomes after moderate to severe pediatric traumatic brain injury (pTBI). However, contemporary treatment thresholds have limited pediatric specific evidence. Objectives: To explore ICP thresholds associated with improved functional outcomes in pTBI. Design, Setting, and Participants: This study is a secondary analysis from Studying Trends of AutoRegulation in Severe Head Injury in Pediatrics (STARSHIP) research database, a prospective, multicenter, observational study that enrolled children 16 years and younger requiring invasive arterial and intracranial pressure (ICP) monitoring for clinical management of pTBI between July 1, 2018, to March 30, 2023, from 10 pediatric intensive care units (PICUs) in the UK and completed data in June 2024. Exposure: Continuous invasive ICP data during a PICU stay. Main Outcomes and Measures: The primary outcome was 12-month Glasgow Outcome Scale Extended for Pediatrics score. ICP dynamics were explored using minute-level ICP calculated from 10-second averages and thresholds tested across 5 to 20 mm Hg. Confounding was addressed using prognostic sliding dichotomy (baseline injury severity) and Pediatric Intensity Level of Therapy score-stratified analyses (treatment intensity). Sensitivity analyses were performed for robustness using propensity score matching, multivariable mixed-effects logistic regression, and marginal structural models. Results: Among the 135 patients included, the median (IQR) age was 96 (26-152) months, and 105 (78%) patients were male. A median (IQR) of 153 (88-275) hours of ICP data were available per patient for 135 patients. Mean (SD) ICP was higher in patients with poor outcome (nonsurvivors vs survivors: 44 [23] mm Hg vs 17 [6] mm Hg; unfavorable vs favorable: 24 [16] mm Hg vs 17 [6] mm Hg). Thresholds of 14 to 15 mm Hg of ICP were identified as most discriminatory for outcome, with an increase in the odds of poor functional outcome at elevations above these levels, using both the static (odds ratio [OR], 6.1; 95% CI, 2.4-15.5; P < .001) and dynamic (dose: OR, 3.7; 95% CI, 1.5-9.3; P = .004; duration: OR, 3.5; 95% CI, 1.5-8.3; P = .007) analyses. Though treatment intensity was not independently associated with outcome or complications, effective ICP control across treatment levels was associated with more favorable prognosis. Sustained ICP greater than 15 mm Hg remained a prognostic factor for poor functional outcome at 12 months, a finding complemented by propensity score matching and causal modeling. Conclusion and Relevance: In this study, sustained ICP elevations above 14 to 15 mm Hg were associated with poor long-term functional outcomes in pTBI warranting prospective evaluation. These findings suggest that the current treatment threshold of 20 mm Hg maybe too high for pTBI.