Transcranial Doppler as a screening test to exclude intracranial hypertension in brain-injured patients: the IMPRESSIT-2 prospective multicenter international study

• DOI: 10.1186/s13054-022-03978-2
• Publication Date: 2022-04-15T17:09:23Z
• Authors: Frank A. Rasulo; Stefano Calza; Chiara Robba; Fabio Silvio Taccone; Daniele G. Biasucci; Rafael Badenes; Simone Piva; Davide Savo; Giuseppe Citerio; Jamil R. Dibu; Francesco Curto; Martina Merciadri; Paolo Gritti; Paola Fassini; Soojin Park; Massimo Lamperti; Pierre Bouzat; Paolo Malacarne; Arturo Chieregato; Rita Bertuetti; Raffaele Aspide; Alfredo Cantoni; Victoria McCredie; Lucrezia Guadrini; Nicola Latronico
• Keywords: Soins intensifs réanimation; Intracranial Pressure; Intracranial pressure; Ultrasonography, Doppler, Transcranial; 610; Brain--Wounds and injuries; Intracranial hypertension; 03 medical and health sciences; 0302 clinical medicine; Settore MED/41 - ANESTESIOLOGIA; 616; Humans; Prospective Studies; Brain injury; RC86-88.9; Research; Brain; Medical emergencies. Critical care. Intensive care. First aid; Brain injury; Intracranial hypertension; Intracranial pressure; Noninvasive monitoring;; 3. Good health; Intracranial Hypertension; Brain injury; Intracranial hypertension; Intracranial pressure; Noninvasive monitoring; Brain; Humans; Intracranial Pressure; Prospective Studies; Ultrasonography, Doppler, Transcranial; Intracranial Hypertension; Noninvasive monitoring; Transcranial Doppler ultrasonography; [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology

Abstract Background Alternative noninvasive methods capable of excluding intracranial hypertension through use of transcranial Doppler (ICPtcd) in situations where invasive methods cannot be used or are not available would be useful during the management of acutely brain-injured patients. The objective of this study was to determine whether ICPtcd can be considered a reliable screening test compared to the reference standard method, invasive ICP monitoring (ICPi), in excluding the presence of intracranial hypertension.

Methods This was a prospective, international, multicenter, unblinded, diagnostic accuracy study comparing the index test (ICPtcd) with a reference standard (ICPi), defined as the best available method for establishing the presence or absence of the condition of interest (i.e., intracranial hypertension). Acute brain-injured patients pertaining to one of four categories: traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) or ischemic stroke (IS) requiring ICPi monitoring, were enrolled in 16 international intensive care units. ICPi measurements (reference test) were compared to simultaneous ICPtcd measurements (index test) at three different timepoints: before, immediately after and 2 to 3 h following ICPi catheter insertion. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated at three different ICPi thresholds (> 20, > 22 and > 25 mmHg) to assess ICPtcd as a bedside real-practice screening method. A receiver operating characteristic (ROC) curve analysis with the area under the curve (AUC) was used to evaluate the discriminative accuracy and predictive capability of ICPtcd.

Results Two hundred and sixty-two patients were recruited for final analysis. Intracranial hypertension (> 22 mmHg) occurred in 87 patients (33.2%). The total number of paired comparisons between ICPtcd and ICPi was 687. The NPV was elevated (ICP > 20 mmHg = 91.3%, > 22 mmHg = 95.6%, > 25 mmHg = 98.6%), indicating high discriminant accuracy of ICPtcd in excluding intracranial hypertension. Concordance correlation between ICPtcd and ICPi was 33.3% (95% CI 25.6–40.5%), and Bland–Altman showed a mean bias of -3.3 mmHg. The optimal ICPtcd threshold for ruling out intracranial hypertension was 20.5 mmHg, corresponding to a sensitivity of 70% (95% CI 40.7–92.6%) and a specificity of 72% (95% CI 51.9–94.0%) with an AUC of 76% (95% CI 65.6–85.5%).

Conclusions and relevance ICPtcd has a high NPV in ruling out intracranial hypertension and may be useful to clinicians in situations where invasive methods cannot be used or not available. Trial registration: NCT02322970.