Functional outcomes in severe traumatic brain injury: A comparative study of intracranial pressure guided therapy vs. conventional management

Purpose The clinical benefit of intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI) remains controversial. This study compared functional outcomes between ICP guided therapy and conventional management in routine trauma practice and explored whether treatment effects differed across clinically relevant patient subgroups. Methods We conducted a retrospective cohort study of 1112 patients with severe TBI (Glasgow coma scale (GCS) score 3 – 8) admitted to a tertiary trauma center between January 1, 2004 and December 31, 2024. Patients were managed either with ICP monitoring and targeted therapy ( n = 408) or conventional management guided by clinical assessment and neuroimaging ( n = 704). Functional outcomes were assessed using the Glasgow outcome scale–extended at 7 days, 3 months, and 6 months. Multivariate logistic regression was used to identify independent predictors of favorable outcome at 6 months. Prespecified subgroup analyses were performed according to injury type, initial GCS score, and neurosurgical emergency status. Results Baseline characteristics differed between groups, with the ICP monitoring group demonstrating a higher frequency of diffuse brain injury (58.8% vs. 27.3%, p < 0.001), chest injury (25.5% vs. 9.1%, p = 0.009), hypoxia at admission (7.8% vs. 0%, p = 0.017), and anemia at admission (7.8% vs. 0%, p = 0.017). Despite receiving more intensive therapies, including sedation, vasopressors, osmotherapy, and induced hypothermia, functional outcomes did not differ significantly between treatment strategies at any time point. At 6 months, favorable outcomes were observed in 78.9% of patients in the ICP monitoring group and 78.7% in the conventional management group ( p = 0.973). In multivariable logistic regression analysis, increasing age (adjusted odds ratio ( OR ): 0.93, 95% confidence interval ( CI ): 0.89 – 0.98, p = 0.010), initial GCS score 6 – 8 (adjusted OR: 10.71, 95% CI : 2.48 – 46.28, p = 0.001), absence of diffuse brain injury (adjusted OR : 11.57, 95% CI : 1.14 – 117.20, p = 0.038), absence of subdural hematoma (adjusted OR : 2.60, 95% CI : 2.74 – 11.29, p = 0.009), and absence of neurosurgical emergency conditions (adjusted OR : 23.65, 95% CI : 1.91 – 292.91, p = 0.014) were independently associated with favorable outcome. ICP monitoring was not independently associated with favorable outcome (adjusted OR : 2.42, 95% CI : 0.40 – 14.49, p = 0.334). No significant interactions were observed in prespecified subgroup analyses. Conclusion In this real-world cohort of patients with severe TBI, ICP-guided therapy was not associated with improved functional outcomes compared with structured conventional management.