Non-use of intracranial pressure monitoring does not elevate ICH risk in ALF patients

The use of invasive intracranial pressure monitoring (IICPM) in three high-volume liver transplant centres has declined over 10 years with no associated worsening of outcomes among patients with acute liver failure (ALF), according to a study.

“These findings suggest that a management strategy focused on early preventive measures without IICPM is a rational approach and does not increase the risk of intracranial hypertension (ICH), cerebral death, or mortality,” the researchers said.

In this retrospective cohort study, researchers obtained data on consecutive patients with ALF, admitted to liver transplant centres in the UK from 2009 to 2018 from prospective audits. They collected data on the incidence of ICH, cerebral death, the use of IICPM, liver transplantation, and hospital survival. Factors associated with ICH and cerebral death were examined.

The incidence of ICH decreased from 13 percent in 2009 to 3 percent in 2018 (p<0.001), as did the use of IICPM from 20.6 percent of patients admitted in 2009 (n=13) to 1.4 percent (n=1) in 2018 (p<0.001). During this period, no significant changes were observed in hospital survival, liver transplantation, and cerebral death.

Notably, peak arterial ammonia concentration showed a robust association with both ICH and cerebral death.

“With advances in intensive care supportive management, the incidence of intracranial hypertension as a complication of acute liver failure has declined,” the researchers said. “Serum ammonia levels remain central to its pathogenesis and risk stratification.”