Intracranial Pressure Monitoring in Patients With Spontaneous Intracerebral Hemorrhage: Insights From the SYNAPSE-ICU Study

Background: Uncertainties remain regarding the indications, management, and effect of intracranial pressure (ICP) monitoring and treatment on outcome in spontaneous intracranial hemorrhage (ICH) patients. Methods: Analysisof spontaneous ICH patients enrolled in the SYNAPSE-ICU study an international prospective observational study on the use of ICP monitoring. This study aimed to describe, in a large cohort of patients with spontaneous ICH admitted to ICU, the clinical practice of ICP monitoring, the occurrence of intracranial hypertension and its therapeutic management. We further assessed in-hospital mortality and the association between ICP monitoring and 6-months mortality and outcome by a propensity score approach with inverse probability weighting. Results: 587 ICH patients were included in this study; 281 (47.9%) received ICP monitoring. ICP-monitored patients, compared to non-monitored, were younger (61 vs 67 years, p<0.001), presented more frequently with both reactive pupils (67.2%, vs 55.2%, p=0.008), with better neurological status at admission (GCS≤ 8, 82.3% vs 88.8%, p=0.038) and received higher therapy intensity level during ICU stay. In 70.5% (170 out of 241) of ICP monitored patients the ICH score was equal to 3 or 4. Nearly half of monitored patients (46.6%) had at least one episode of ICP ≥ 20 mmHg during the first week. An intraventricular catheter (53.6%) was the most frequently used device and had fewer episodes of intracranial hypertension compared to the other monitoring devices (43.7% vs 64.9%, respectively). At weighted Cox regression model, ICP monitoring was associated with a significant reduction of 6-month mortality (Hazard Ratio, HR= 0.49 (95% Confidence Intervals CI=0.35-0.71, p=0.001), but not with neurological outcome (OR=0.83, 95%CI= 0.41-1.68, p=0.6077). Conclusions: ICP monitoring in ICH was utilized mainly in moderately severe cases. ICP monitoring was associated with a reduction of in-hospital and 6-month mortality but did not improve 6-months functional outcomes. Further research and randomized controlled trials to generate higher-level medical evidence to support guidelines regarding ICP use and treatment in patients with ICH are needed.