n engl j med 368;18 nejm.org may 2, 2013 1748 The new england journal of medicine correspondence Intracranial-Pressure Monitoring in Traumatic Brain Injury To the Editor: In response to the article by Chesnut et al. (Dec. 27 issue) 1 reporting results of the trial on intracranial-pressure monitoring, we want to mention that environment must be taken into consideration to understand the role of in- tracranial-pressure monitoring on outcome. Ap- proximately 80% of severe traumatic brain inju- ries occur in austere environments, 2 defined as regions lacking in prehospital and advanced care in an intensive care unit (ICU). Care within orga- nized trauma systems has been shown to reduce mortality associated with severe traumatic brain injury. 3-5 Studies of traumatic brain injury in aus- tere environments have shown rates of death that are 2 to 3 times as high as those in environments where advanced care is available. 6 As the authors mention, several patients in this study arrived after 1 hour without appropri- ate prehospital care. In this real scenario, ICU monitoring has very little chance of making a difference by itself. We are currently engaged in a study sponsored by the National Institutes of Health (Capacity Building for Decompressive Craniotomy in Colom- bia) to identify whether early surgical decompres- sion may have an effect on outcome in such en- vironments. The rationale for this approach is to prepare the cranial compartment for the brain response to the injury in cases in which ICU monitoring is not feasible and all we can rely on is the clinical evaluation. Andrés M. Rubiano, M.D. Neiva University Hospital Neiva, Colombia rubianoam@upmc.edu Juan C. Puyana, M.D. University of Pittsburgh Medical Center Pittsburgh, PA No potential conflict of interest relevant to this letter was re- ported. 1. Chesnut RM, Temkin N, Carney N, et al. A trial of intracra- nial-pressure monitoring in traumatic brain injury. N Engl J Med 2012;367:2471-81. 2. Shakur H, Roberts I, Piot P, Horton R, Krug E, Mersch J. A promise to save 100,000 trauma patients. Lancet 2012;380:2062-3. 3. Sánchez AI, Krafty RT, Weiss HB, Rubiano AM, Peitzman AB, Puyana JC. Trends in survival and early functional outcomes from hospitalized severe adult traumatic brain injuries, Pennsyl- vania, 1998 to 2007. J Head Trauma Rehabil 2012;27:159-69. 4. Lu J, Marmarou A, Choi S, Maas A, Murray G, Steyerberg EW. Mortality from traumatic brain injury. Acta Neurochir 2005;95: Suppl:281-5. 5. Narotam PK, Morrison JF, Nathoo N. Brain tissue oxygen monitoring in traumatic brain injury and major trauma: out- come analysis of a brain tissue oxygen-directed therapy. J Neu- rosurg 2009;111:672-82. 6. De Silva MJ, Roberts I, Perel P, et al. Patient outcome after traumatic brain injury in high-, middle- and low-income coun- tries: analysis of data on 8927 patients in 46 countries. Int J Epi- demiol 2009;38:452-8. DOI: 10.1056/NEJMc1301076 To the Editor: Chesnut et al. compare outcomes of intracranial-pressure monitoring with a strat- egy of imaging and clinical examination in pa- tients with traumatic brain injury. Although the authors generally use a reasonable set of inclu- sion criteria, their indications for the placement of intracranial-pressure monitoring unfortunate- ly differ from the recommendations in widely used national guidelines, which advise the use of computed tomography of the head, patient age, systolic blood pressure, and specific neurologic- this week’s letters 1748 Intracranial-Pressure Monitoring in Traumatic Brain Injury 1752 Smoking-Related Mortality in the United States 1754 Proteotoxicity and Cardiac Dysfunction 1756 Hepatocellular Carcinoma after the Fontan Procedure The New England Journal of Medicine Downloaded from nejm.org on January 28, 2015. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved.