Milan Consensus

Milan Consensus Conference on Intracranial Pressure Monitoring in Traumatic Brain Injury

Objective

The Milan Consensus Conference aimed to provide consensus on the practical applications of intracranial pressure (ICP) monitoring in severe adult traumatic brain injury (TBI) by discussing its indications and effectiveness.

Methods

A consensus conference was held on October 5, 2013, in Milan, bringing together neurosurgeons and intensivists with recognized expertise in TBI treatment. Four key topics were addressed through presentations and discussions: diffuse brain injury, cerebral contusions, secondary decompressive craniectomy (DC), and post-evacuation of intracranial traumatic hematomas. Participants reviewed existing evidence and shared their clinical experiences to draft recommendations.

Results and Recommendations

ICP Monitoring in Diffuse Brain Injury

• Indications: ICP monitoring is recommended for comatose TBI patients with brain swelling seen on initial or subsequent CT scans. It is also advised for patients who exhibit further neurological deterioration after an initial normal CT scan.
• When Not to Monitor: ICP monitoring is generally not recommended for comatose TBI patients with a normal initial CT scan if no further neurological deterioration occurs.

ICP Monitoring in Traumatic Brain Contusions (TBCs)

• Indications: ICP monitoring is recommended for comatose patients with TBCs when interruption of sedation is dangerous or clinical examination is unreliable. It is also indicated for patients with large bifrontal TBCs or hemorrhagic lesions near the brainstem.
• When Not to Monitor: ICP monitoring may not be necessary for patients with small, stable TBCs who are neurologically stable and can be reliably monitored clinically.

ICP Monitoring Following Secondary Decompressive Craniectomy

• Indications: ICP monitoring is recommended after secondary DC to assess the effectiveness of the procedure in controlling ICP and guiding further therapy.
• When Not to Monitor: If the patient has no signs of ICP elevation post-surgery and can be reliably monitored clinically, ICP monitoring may not be required.

ICP Monitoring After Evacuation of Intracranial Traumatic Hematomas

• Indications: ICP monitoring should be considered for salvageable patients with increased risk factors for HICP, including specific pre-operative clinical and imaging findings.
• When Not to Monitor: Patients with minimal risk factors for ICP elevation post-evacuation and who can be monitored reliably clinically may not need ICP monitoring.

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Summary of Recommendations

Condition	When ICP Monitoring is Indicated	When ICP Monitoring Can Be Deferred
Diffuse Brain Injury	Comatose patients with brain swelling on CT or further neurological deterioration	Normal initial CT scan without further neurological deterioration
Traumatic Brain Contusions (TBCs)	Comatose patients when sedation interruption is dangerous or clinical exams are unreliable; large bifrontal contusions or hemorrhages near the brainstem	Small, stable contusions with reliable clinical monitoring
Secondary Decompressive Craniectomy	Post-surgery to assess effectiveness and guide further therapy	No signs of elevated ICP post-surgery with reliable clinical monitoring
Post-Evacuation of Intracranial Hematomas	Patients with risk factors for elevated ICP post-evacuation	Minimal risk factors for ICP elevation post-evacuation with reliable clinical monitoring

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Conclusion

The Milan Consensus Conference provided detailed recommendations for the use of ICP monitoring in various TBI scenarios. The consensus emphasized the need for further research to optimize patient outcomes and highlighted specific scenarios where ICP monitoring is and is not recommended.

Reference

Stocchetti N, Picetti E, Berardino M, et al. Clinical applications of intracranial pressure monitoring in traumatic brain injury: Report of the Milan consensus conference. Acta Neurochir. 2014; DOI:10.1007/s00701-014-2127-4. File:MilanConsensus.pdf