LETTER TO THE EDITOR - BRAIN TRAUMA Intracranial pressure (ICP) monitoring in diffuse brain injury: to do or not to do? Ravi Sharma 1 & Vivek Tandon 1 & Dattaraj Sawarkar 1 & Manoj Phalak 1 & Amol Raheja 1 & Shashank S. Kale 1 Received: 19 May 2018 /Accepted: 25 June 2018 # Springer-Verlag GmbH Austria, part of Springer Nature 2018 Abbreviations ICP Intracranial pressure RESCUE ICP Randomized evaluation of surgery with craniectomy for uncontrollable elevation of intracranial pressure DECRA Decompressive craniectomy trial TBI Traumatic brain injury Dear Sir, We read with great interest the article in your journal by Vora et al. regarding the role of intracranial pressure (ICP) moni- toring in diffuse brain injury titled “Intracranial pressure mon- itoring in diffuse brain injury-why the developing world needs it more?” [4]. We commend the authors for evaluating the role of ICP monitoring in long-term outcomes of patients with diffuse brain injury. It was indeed interesting to note that they found statistically significant improvement in the extended Glasgow outcome scale (GOS-E) at 1 month in the ICP monitoring group. Moreover, a better 2 weeks and 6 months mortality rates in the ICP-monitored group were observed, though it was not statistically significant. However, we would like to discuss a few shortcomings of the article as below: 1. Need for brain-specific treatment and number of CT scans required were assessed as a secondary outcome according to the authors in this study. However, in the non ICP monitoring group, the authors have given brain-specific treatment (mannitol and furosemide) to all the patients as a part of protocol. Further, the CT scan has been done at fixed regular intervals or done when there was clinical worsening. These management steps were taken not only when required but as part of protocol. Hence, we feel it is not quite right to express them as a requirement of the said procedure/treatment. For the same reason, their compari- son with the ICP-monitored group hardly yields any clin- ically relevant information. In our opinion evaluating a protocolled intervention to be an outcome must be con- sidered a methodological fallacy. 2. It is elaborated by the authors that criteria for decom- pressive craniectomy and for CT scan were a raised ICP reading (> 20 mm/hg). However, the duration and the fre- quency of the ICP readings have not been stated. For instance, out of the 67 patients in ICP group, 15 patients have received mannitol, 12 received hypertonic saline, and 13 received loop diuretics, and in 1 patient, ventriculostomy was done. The total number of patients receiving brain-specific treatment, whether mannitol and hypertonic saline were given to separate patients or there was some overlap is not mentioned. This further questions the rationale in giving mannitol to some patients and hy- pertonic saline to others. 3. There is no mention in the methodology section regarding the protocol for choosing the specific single or multiple drug brain-specific medical therapy. 4. There was no statistically significant difference in the in- fectious complications like incidence of respiratory infec- tions, septicemia, and meningitis between two groups. This article is part of the Topical Collection on Brain trauma * Vivek Tandon drtandonvivek@gmail.com Ravi Sharma aiims.ravisharma@gmail.com Dattaraj Sawarkar dattaraja@gmail.com Manoj Phalak manojphalak@yahoo.com Amol Raheja dramolraheja@gmail.com Shashank S. Kale Skale67@gmail.com 1 Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India Acta Neurochirurgica https://doi.org/10.1007/s00701-018-3610-0