Intensive Care Medicine: Published: 29 July 2026
Abstract
Acute brain injury (ABI), including traumatic brain injury,
ischemic and hemorrhagic stroke, is associated with high morbidity and
mortality, which is driven not only by the primary brain injury, but also by
the development of secondary cerebral insults. Among these, raised intracranial
pressure (ICP) plays a central pathophysiological role, acting both as a
consequence and a driver of ongoing brain injury through mechanical deformation
and cerebral ischemia. Although invasive intracranial pressure (ICP) monitoring
has a longstanding and ongoing role in neurocritical care management, the
interpretation and clinical use of ICP remain controversial. Traditional
management strategies rely on fixed ICP thresholds (e.g., > 22 mmHg) to trigger a standardized stepwise
escalation of therapy; however, growing clinical evidence indicates that
tolerance to ICP elevation varies widely across patients, disease entities, and
physiological contexts. This review summarizes the physiological determinants
of ICP, including intracranial compliance, cerebrospinal fluid dynamics,
cerebral blood volume, and systemic factors, and describes the mechanisms
underlying intracranial hypertension. We discuss limitations of using fixed ICP
thresholds and highlight emerging concepts, such as ICP burden, waveform
morphology, cerebral autoregulation, and functional brain monitoring, as tools
to individualize ICP interpretation. The role of invasive and noninvasive ICP
monitoring (nICP) modalities is reviewed, emphasizing the complementary value
of nICP in guiding decision-making when invasive monitoring is unavailable or
contraindicated. Particular attention is given to the integration of ICP within
multimodal neuromonitoring frameworks assessing cerebral perfusion,
oxygenation, and metabolism. Finally, we explore future perspectives, including
the potential of artificial intelligence–based approaches to analyse complex
neuromonitoring data, predict secondary insults, and move toward actionable,
patientspecific therapeutic strategies. Collectively, these advances support a
shift from a uniform, threshold-driven approach toward individualized,
physiology-informed management of intracranial hypertension.
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