Lower ICP Goal May Improve Long-term Outcomes After Pediatric TBI

Source: Agrawal S, Bögli SY, O’Donnell R, et al. Intracranial pressure treatment thresholds in pediatric traumatic brain injury. JAMA Pediatr. 2026;180(6):650-658; doi: 10.1001/jamapediatrics.2026.0197.Investigators from multiple institutions conducted a study to evaluate the impact of increased intracranial pressure (ICP) on 12-month outcome in children with severe traumatic brain injury (TBI). Study participants were patients ≤16 years old with TBI and a post-resuscitation Glasgow Coma Score (GCS) ≤8, admitted to 10 pediatrics ICUs in the UK between July 2018 and March 2023, who had minute-by-minute monitoring of ICP. For the study, ICP data were characterized by mean values while monitored, proportion of monitoring time above a specific threshold (Ptime), and pressure-time dose (PTD), defined as the area under the curve for ICP by time above a specific threshold. The primary outcome was the Glasgow Outcome Scale Extended for Pediatrics (GOSEP) at 12 months post-injury. GOSEP assesses functional recovery, with scores ranging from 1 (death) to 8 (full recovery). A favorable outcome was defined as a 12-month GOSEP score of 5–8, and unfavorable outcomes were scores of 1–4. In general, an ICP threshold of 20 mmHg was used to initiate treatment in study participants. For the analysis, the proportion of children with favorable vs unfavorable outcomes were compared at ICP thresholds ranging from 5–20 mmHg. Outcomes also were assessed in logistic regression models using Ptime and PTD at different ICP thresholds as predictors of an unfavorable outcome.A total of 135 children with TBI were included in the study analyses. The median age of study patients was 96 months, and median GCS was 6. The primary outcome (GOSEP) was determined for 129 participants, including 10 who died and 119 with functional outcomes assessed at 12 months. Mean ICP was significantly lower in children who survived than in those who died (17 ±6 mm Hg vs. 44 ±23 mmHg; P <0.001), and among survivors, mean ICP was lower in those with favorable vs unfavorable outcomes (17 ±6 and 24 ±16 mmHg, respectively; P = 0.004). ICP thresholds about 14–15 mmHg were associated with an increased risk of unfavorable outcomes compared to ICPs <14 (odds ratio [OR], 6.1; 95% confidence interval [CI], 2.4, 15.5). Using an ICP threshold of 14 mmHg, both Ptime and PTD were associated with a significantly increased risk of an unfavorable outcome (OR, 3.5; 95% CI, 1.5, 8.3, and OR, 3.7; 95% CI, 1.5, 9.3, respectively).The authors conclude that in children with severe TBI, sustained ICP values >14–15 mmHg were associated with unfavorable outcomes at 12 months.Dr Miller-Smith has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Following severe TBI, prevention of secondary insult is essential to prevent death and optimize neurological outcomes. Secondary injury occurs hours to days after primary injury and is caused by altered perfusion, inflammation, and other biomechanical and molecular changes.1 Active critical care treatments can mitigate secondary injury. This management requires placement of an ICP monitor to treat intracranial hypertension and assure adequate cerebral perfusion pressure.2 Recommendations for ICP-targeted management in children are largely extrapolated from adult studies recommending a target ICP of less than 20 mmHg.2 Due to significant physiological differences between young children and adults, some have appropriately questioned whether they should share the same target,3 but pediatric data are lacking. Regardless of the exact target, adherence with the Pediatric TBI Guidelines has improved survival GOSEP (see AAP Grand Rounds. 2014;32[5]:51)4 without clear evidence that an ICP <20 mmHg is the ideal goal.The current authors studied participants 16 years and younger with ICP monitors following severe TBI and found sustained ICP >14–15 mmHg was associated with unfavorable outcomes at 12 months. The limitations are well described in the editorial by Simon et al.5 This includes challenges of using binning or converting continuous data into discrete categories, which may not be physiologically consequential. Additionally, the database overrepresents younger children (median age 96 months). Nevertheless, the robust data and strong methodology nudge clinicians to tighten ICP management while assuring this does not increase unintended consequences from treatment side effects, and while we await much-needed research studies specific to pediatric patients.In pediatric patients with severe TBI, there is increasing evidence that sustained ICP >15 mmHg may be associated with worse long-term outcomes.