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Intracranial pressure (ICP) monitoring is considered the standard of care for severe traumatic brain injury (sTBI) and its use is suggested by guidelines [1]. The efficacy of treatment based on monitoring in improving outcome had not been rigorously assessed, however, until the recently published BEST TRIP study [2]. This was a multicenter, controlled trial in Bolivia and Ecuador in which 324 patients with sTBI were randomly assigned to one of two specific protocols: guideline-based management based on monitored ICP versus treatment based on imaging and clinical examination. The primary outcome was a composite of survival time, impaired consciousness, and functional status at 3 months and 6 months and neuropsychological status at 6 months. The trial found that care focused on maintaining monitored ICP at 20 mmHg or less was not superior to care based on imaging and clinical examination. A major concern of the authors was that misinterpretation of these results might lead to abandoning ICP monitoring in managing sTBI.

Intracranial pressure monitoring: headstone or a new head start. The BEST TRIP trial in perspective