Management of intracranial hypertension with and without invasive intracranial pressure monitoring

Table 9 Summary of intracranial pressure managing protocols

	ICE protocol	CREVICE protocol	SIBICC protocol	B-ICONIC protocol
Setting	BEST-TRIP study (Latin America, limited resources)	Post-BEST-TRIP refinement (Latin America, limited resources)	High-resource ICU with access to invasive multimodal monitoring	Low-resource settings without access to invasive monitoring
Type of monitoring	Non-invasive ICP monitoring	Non-invasive ICP monitoring	ICP ± brain oxygen monitoring (PbtO2)	Non-invasive ICP monitoring
Trigger for protocol activation	GCS ≤ 8 with abnormal CT scan	Suspected intracranial hypertension (SICH): 1 major or 2 minor criteria (e.g., imaging, age, motor response, hypotension)	Elevated ICP and/or low PbtO2	SICH plus ≥ 2 abnormal non-invasive findings (see below)
Basis for monitoring	Serial clinical exams and CT scans	Clinical exams and CT; revised with definitions of neuroworsening and structured de-escalation	Continuous ICP and/or PbtO2 values with tiered thresholds	Four non-invasive markers: (1) ONSD; (2) pulsatility index (3) estimated ICP via TCD; and (4) NPi on pupillometry
Threshold for escalation	Clinical or radiological neuroworsening	Neuroworsening or failure of Tier 1 therapy	ICP ≥ 22 mmHg, PbtO2 < 20 mmHg, or clinical deterioration	Two or more non-invasive abnormalities, or clinical worsening
Treatment Strategy (Tiers)	Aggressive from outset; includes hyperosmolar therapy, hyperventilation, barbiturates, decompressive craniectomy	Tiered escalation (Tier 1 to Tier 3); last treatment in should be first out	Tiered algorithm with increasing intensity and risk (Tier 1 to 3), individualized per ICP and PbtO2 status	Uses CREVICE framework with adapted triggers; relies on availability of non-invasive modalities
De-escalation guidance	Not clearly structured; based on improvement or repeat imaging	Defined matrix combining imaging and neuro exam (pupils, motor score); last treatment added is first to be withdrawn	Heatmap and structured matrix based on ICP/PbtO2; includes neuroworsening and “tier zero” baseline care	Structured de-escalation using improvement of non-invasive markers and clinical status
Limitations	Aggressive, CT-dependent, lacks flexibility for mild cases	Still CT-dependent; subjective criteria for SICH; limited data validation	Based on expert consensus (Delphi method), lacks RCT validation	Dependent on accuracy of non-invasive markers; potential for false-positives or over-treatment
Unique features	First consensus protocol for ICP-unmonitored patients; used in RCT	Adds clarity on neuroworsening, introduces structured de-escalation	Integrates ICP and brain oxygenation; includes “MAP challenge” and not recommended interventions list	First consensus using only non-invasive data; bridges evidence gap in LMICs

CT: Computed tomography; GCS: Glasgow Coma scale; ICP: Intracranial pressure; LMICs: Low- and middle-income countries; MAP: Mean arterial pressure; NPi: Neurological pupil index; ONSD: Optic nerve sheath diameter; PbtO₂: Brain tissue oxygen pressure; RCT: Randomized controlled trial; SICH: Suspected intracranial hypertension; TCD: Transcranial doppler; ICU: Intensive care unit.