What the BEST TRIP study means to me as the Principal Investigator.

Randall M Chesnut MD FCCM FACS

As someone who has never treated an sTBI patient without an ICP monitor, this study warranted serious personal concern as the primary author. Although it questions how we currently interpret the ICP values, it does not question their importance. Non-monitored (ICE) treatment was guided by imaging and clinical examination, which are, at best, semi-quantitative. Cisternal compression is subjective and the clinical exam is often pharmacologically obscured and provides relatively late signs. In my practice, the use of a safe and accurate quantitative index of ICP, the ICP course, and its response to treatment is much preferable to treating semi-empirically and waiting for pupillary changes to tell me that I am not being successful. It should also be noted that, within this investigation, ICP-based-management was more efficient in terms of shorter ICU treatment course and fewer interventions to achieve the same outcome. On the other hand, in my practice, we have followed a targeted therapy approach for many years, wherein the interpretation of the ICP treatment threshold is based on multimodality monitoring (which includes CT imaging and the neurological examination), which is not the course of ICP-monitor-based treatment studied in this paper. I believe that the proper interpretation of this study by centres with adequate resources, mandates refinement of our use of ICP monitoring in guiding treatment (such as in determining the ICP treatment threshold in individual cases). For centres with limited resources, it provides a treatment algorithm that appears to produce acceptable outcomes in the absence of monitoring. For all centres, it solidly supports that sTBI patients require aggressive treatment of intracranial pressure by whatever means is available.