Utilization of Non-Invasive Intracranial Pressure Monitoring in Traumatic Brain Injury Patients Treated in Low-resource Settings: The Intrigo Study

Utilization of Non-Invasive Intracranial Pressure Monitoring in Traumatic Brain Injury Patients Treated in Low-resource Settings: The Intrigo Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Utilization of Non-Invasive Intracranial Pressure Monitoring in Traumatic Brain Injury Patients Treated in Low-resource Settings: The Intrigo Study Edoardo Picetti, Fabio Silvio Taccone, Amos O. Adeleye, Sérgio Brasil, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8413090/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Apr, 2026 Read the published version in Neurocritical Care → Version 1 posted 5 You are reading this latest preprint version Abstract Background Invasive intracranial pressure (ICP) monitoring is not universally available in low-resource settings, mainly due to high costs. In this scenario, non-invasive ICP (nICP) estimation could be integrated in therapeutic protocols. The objective of this international survey was to describe the utilization of nICP monitoring in this setting. Methods The survey was composed by 23 items. Target respondents were doctors treating severe traumatic brain injury (TBI) patients in low-resource settings without the availability of invasive ICP monitoring. Results One hundred and twenty-six physicians from 114 centers among 21 countries worldwide responded. The main findings of this study were: a) a predominant use of optic nerve sheath diameter (ONSD) as nICP assessment tool; b) the utilization of at least two methods for nICP estimation in approximately half of the cases; and c) the absence of specific protocol for nICP monitoring. We also reported a certain degree of variability regarding the parameters suggestive of intracranial hypertension for each of the methods used. Conclusions Brain ultrasounds, particularly ONSD assessment, are the most frequently utilized tools for nICP estimation in TBI patients managed in low-resource settings worldwide. Educational efforts linked with protocols development could be a step forward to improve the care of TBI in resource-limited settings. traumatic brain injury monitoring non-invasive intracranial pressure low-resource setting INTRODUCTION Traumatic brain injury (TBI) is a leading cause of mortality and disability worldwide [ 1 – 2 ]. Invasive intracranial pressure (ICP) monitoring plays a fundamental role in the management of severe TBI patients with clinical and/or radiological signs of intracranial hypertension (IH) [ 3 – 5 ]. Standard invasive ICP monitoring is not universally available in low-resource settings, mainly due to high costs [ 6 – 7 ]. In this scenario, non-invasive ICP (nICP) monitoring (e.g., brain ultrasounds, pupillometry, etc.) could be useful in identifying neurological deterioration and managing therapeutic strategies [ 8 – 10 ]. However, few data are available regarding the application of nICP tools in limited-resource settings worldwide [ 11 – 12 ]. Therefore, the objective of this international survey is to describe the utilization of nICP monitoring modalities in this scenario. METHODS This was an international cross-sectional survey comprising 23 items that were developed by three investigators (CR, FST, and EP), following a systematic review of the literature [ 13 – 15 ]. The same was utilized for the Brussels consensus for nICP monitoring when invasive systems are not available in the care of TBI patients (B-ICONIC) [ 10 ]. The initial pool of questions was pilot-tested and critically revised by all authors. The final questionnaire is provided in the electronic supplementary material (Supplemental Additional File 1). From December 1st, 2023, to April 1st, 2024, the study investigators invited eligible participants via email through their professional networks. Respondents were also encouraged to disseminate the survey to additional colleagues. No compensation was provided. All data submitted electronically were stored in a secure, password-protected database accessible only to the principal investigators. Ethical approval was not required because no patient-level data were collected; the survey focused solely on physicians’ practices and attitudes toward nICP monitoring in severe TBI within low-resource environments. The study adhered to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES), which is provided in Supplemental Additional File 2. Statistical Analysis Data were downloaded from the online platform, stored in an Excel file (Microsoft, Redmond, WA), and reviewed for anomalies or entry errors. All questionnaires were complete and free of inconsistencies. Responses that did not match any of the predefined options were categorized under “other.” All variables were categorical, and descriptive statistics were presented as counts and percentages. For questions permitting multiple responses, percentages were calculated for each selected option; consequently, the cumulative percentage exceeded 100%. RESULTS Respondents Characteristics One hundred and twenty-six physicians from 21 countries responded to the survey. Most respondents were from Nepal (n = 32–25.4%), Ecuador (n = 13–10.3%), Brazil (n = 12–9.1%), India (n = 9–7.1%), and Colombia (n = 9–7.1%) (Supplemental Additional File 3). Baseline characteristics of participants are reported in Table 1 ; most respondents were intensivists (n = 82–65.1%), anesthesiologists (n = 30–23.8%), and neurosurgeons (n = 11 − 8.7%). The majority of respondents (n = 123 − 97.6%) worked in hospitals with the availability of brain CT scan. Table 1 – Baseline characteristics of the study population. SPECIALTY n (%) - Intensive care 82 (65.1) - Anesthesia 30 (23.8) - Neurosurgery 11(8.7) - Neurology 1 (0.8) - Other 2 (1.6) YEARS OF PRACTICE - 25 26 (20.6) MEAN ANNUAL NUMBER OF SEVERE TBI PATIENTS ADMISSION - 200 13 (10.3) - not known 12 (9.5) POSSIBILITY TO PERFORM BRAIN CT SCAN IN SEVERE TBI PATIENTS - YES 123 (97.6) - NO 3 (2.4) 24/7 AVAILABILITY OF BRAIN CT SCAN IN SEVERE TBI PATIENTS - YES 121 (98.4) - NO 2 (1.6) Abbreviations: TBI = traumatic brain injury, CT = computed tomography. nICP Tools Optic nerve sheath diameter (ONSD) evaluation was the most utilized tool for nICP (n = 120–95.2%), followed by transcranial Doppler (TCD; n = 76–60.3%) and automated pupillometry (n = 15–11.9%). Seventy-six respondents (60.4%) had more than one tool for nICP evaluation at their disposal (Table 2 ). For nICP estimation, 54% of our respondents relied on at least 2 methods (n = 68). However, no protocol for nICP monitoring was available for most of respondents (n = 74–58.7%). Non-invasive ICP was assessed mainly every 24 (n = 45–35.7%) and 12 (n = 29–23%) hours. The majority of respondents modified their therapeutic strategy according to nICP monitoring (n = 92–73%). A brain CT scan was performed in cases of nICP monitoring suggesting IH for 117 (92.9%) of respondents. Table 2 – Non-invasive ICP monitoring tools and values. nICP TOOLS n (%) ONSD 120 (95.2) TCD 76 (60.3) AP 15 (11.9) OTHER: B4C 11 (8.7) 6 (4.8) nICP TOOLS COMBINATION AT DISPOSAL n (%) TCD + ONSD 62 (49.2) AP + ONSD + TCD 9 (7.1) AP + ONSD 3 (2.4) AP + TCD 1 (1.2) AP + ONSD 1 (1.2) ONSD ONLY 45 (35.7) TCD ONLY 4 (3.2) AP ONLY 1 (1.2) ONSD VALUES SUGGESTIVE OF IH n (%) > 2 mm 0 (0) > 3 mm 0 (0) > 4 mm 0(0) > 5 mm 3 (2.5) > 6 mm 115 (95.8) > 7 mm 2 (1.7) > 8 mm 0 (0) other 0 (0) TCD PARAMETERS AND VALUES SUGGESTIVE OF IH n (%) - PI: > 0.8 > 0.9 > 1 > 1.1 > 1.2 > 1.3 > 1.4 > 1.5 > 1.6 other 74 (97.4) 1 (1.4) 0 (0) 6 (8) 9 (12.2) 36 (48.6) 9 (12.2) 10 (13.5) 0 (0) 3 (4.1) 0 (0) - FVd: < 10 cm/sec < 15 cm/sec < 20 cm/sec < 25 cm/sec < 30 cm/sec other 46 (60.5) 3 (6.5) 3 (6.5) 25 (54.3) 6 (13.1) 9 (19.6) 0 (0) niCPP 41 (53.9) AP PARAMETERS AND VALUES SUGGESTIVE OF IH n (%) - NPi: < 1 < 2 < 3 < 4 < 5 other 13 (86.7) 0 (0) 0 (0) 12 (92.3) 1 (7.7) 0 (0) 0 (0) - Constriction velocity: < 0.6 mm/sec < 0,7 mm/sec < 0.8 mm/sec < 0.9 mm/sec < 1 mm/sec other 10 (66.7) 4 (40) 1 (10) 4 (40) 0 (0) 1 (10) 0 (0) - Dilation velocity: < 0.6 mm/sec < 0,7 mm/sec < 0.8 mm/sec < 0.9 mm/sec < 1 mm/sec other 7 (46.7) 3 (42.9) 0 (0) 3 (42.9) 0 (0) 1 (14.2) 0 (0) Abbreviations: nICP = non-invasive intracranial pressure, ONSD = optic nerve sheath diamter, TCD = transcranial Doppler, AP = automated pupillometry, B4C = brain for care, IH = intracranial hypertension, PI = pulsatility index, FVd = diastolic flow velocity, niCPP = non-invasive cerebral perfusion pressure, NPi = neurological pupil index. Derived Variables and Thresholds Optic nerve sheath diameter evaluation was the most utilized tool for nICP estimation in our study (n = 120 − 95.2%). A value greater than 6 mm was the most suggestive threshold used for detecting IH (n = 115 − 95.8%) (Table 2 ). Transcranial Doppler was used by 76 (60.3%) respondents; in particular, the pulsatility index (PI, n = 74–97.4%), the diastolic flow velocity (FVd, n = 46–60.5%), and the formula to calculate non-invasively ICP (n = 41–53.9%) were used when TCD was available (Table 2 ). A PI > 1.2 (n = 36–48.6%) and a FVd below 20 cm/sec (n = 25–54.3%) were the most frequently thresholds suggestive of IH. Automated pupillometry was used by 15 (11.9%) respondents; the Neurological pupil index (NPi) was the most used variable to detect the presence of IH (n = 13–86.7%), followed by constriction (n = 10–66.7%) or dilation (n = 7–46.7%) velocities. The most used NPi threshold suggestive of IH was < 3 (n = 12–92.3%). DISCUSSION This international survey provided for the first time information regarding the utilization of nICP in TBI patients treated in low-resource settings worldwide. The main findings of this study were: a) the predominant use of ONSD as nICP assessment tool; b) the use of at least two nICP estimation methods in approximately half of the cases; and c) the absence of a dedicated protocol for nICP monitoring. We also observed significant variability in the thresholds and parameters used to define IH across modalities, although they are increasingly being adopted by clinicians in resource-limited areas [ 12 ]. Brain ultrasounds (i.e., ONSD and TCD) are the most utilized nICP methods in our study population. This can be explained by the fact that ultrasound machines are not so expensive, and so are generally available even in low resource settings worldwide because they are used for different clinical purposes (e.g., obstetrics, etc.) [ 16 ]. The ONSD evaluation was the most utilized tool in our study. This method requires a linear probe (without adjunctive software installation) which is generally easy to find worldwide. However, this tool presents several challenges such as eyes accessibility (not always feasible after TBI), the lack of a standardized clinical protocol accepted worldwide (e.g., report of “internal” or “external” ONSD, influence of head position, etc.), and a longer learning curve respect to TCD [ 17 ]. Transcranial Doppler is the second most utilized tool for nICP monitoring in our cohort. This method requires the use of specific software with additional costs. Moreover, some patients may have a poor or absent acoustic window at the temporal bone level, limiting their use [ 18 ]. The automated pupillometer is the least used method by our participants. This instrument, unlike the ultrasound scanner, cannot be used for other clinical purposes and has to be purchased specifically for this task representing an additional cost [ 19 ]. Moreover, it requires the absence of traumatic ocular pathology [ 17 ]. Although an abnormal NPi could indicate brainstem dysfunction, a recent study showed that, overall, NPi values were not significantly associated with invasive ICP values in acute brain injury patients (i.e., TBI, spontaneous subarachnoid and intracerebral hemorrhage) [ 20 ]. About half of our participants use at least two methods for nICP estimation. This is in accordance with what will be subsequently recommended by the B-ICONIC consensus [ 10 ]. In this way (i.e. by using the two methods) diagnostic accuracy in nICP estimation could be improved. However, the approach proposed by the B-ICONIC consensus requires validation in future studies. In our opinion, the scarce availability of protocol for nICP estimation is an important aspect to be highlighted. The burden of TBI is high in low-income and middle-income countries (LMICs), mainly due to an increase in traffic accidents linked to poor compliance with rules, safety measures and road-network quality [ 1 – 2 , 21 ]. Severe TBI is a complex neurological emergency requiring an advanced-care system, assuring continuity of care, from the prehospital phase to rehabilitation [ 22 ]. Limited resources in LMICs generally limit the capacity to successfully treat severely head injured patients [ 20 ]. One possible proposed solution is the creation of protocols to optimize care of TBI patients with locally available critical care resources [ 18 , 23 ]. Protocols for nICP assessment could not only improve patient care but also optimize resource utilization (e.g., reduction of brain CT scans, exploiting the use of ultrasound machines already in use for extracranial pathologies, etc.). Regarding parameters utilized as marker of IH with different nICP tools, the responses of our participants are generally aligned with the available literature (e.g., ONSD > 6 mm, PI > 1.2, etc.) [ 10 , 13 – 15 ]. However, values ​​different from those recommended are also reported. This is another very important aspect to emphasize. In addition to promoting protocols, it would be very important to support educational initiatives such as basic courses dedicated to nICP assessment. This would be a way to adapt tools and methodologies used in developed countries to low resource settings. At the same time, these initiatives can act as a driving force for creating local protocols tailored as much as possible to the available resources [ 19 ]. This study presents several limitations, including the relatively low number of respondents and the inability to calculate response rates based on the survey design. Moreover, we have few responses from doctors working in Africa limiting the generalizability of our findings. However, we recorded responses from 126 physicians representing 114 centers in 21 countries. CONCLUSIONS Brain ultrasounds, especially ONSD evaluation, are the main tools for nICP monitoring in head injury patients in low-resource settings worldwide. Educational initiatives associated with protocol development may represent an important step toward improving the care of TBI patients in resource-limited settings. Declarations We confirm that manuscript complies with all instructions to authors. Authors contributions: All authors contributed to the study conception, design and data interpretation. EP, CR, and FST performed data collection. EP, CR, and FST performed data processing and statistical analysis. All authors critically reviewed the article. All authors had full access to data, participated in data interpretation, revised the article, and approved the final version of the manuscript. All authors meet requirements for authorship. We confirm that this manuscript has not been published elsewhere and is not under consideration by another journal. We confirm adherence to ethical guidelines and indicate ethical approvals. Use of informed consent: not applicable. Conflicts of Interest: none to disclose for all authors. Use of reporting checklist: CHERRIES. Funding for the study: none. References GBD 2016 Traumatic Brain Injury and Spinal Cord Injury Collaborators. Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019; 18(1): 56-87. Dewan MC, Rattani A, Gupta S, et al. Estimating the global incidence of traumatic brain injury. J Neurosurg. 2018; 130(4): 1080-1097. Hawryluk GWJ, Citerio G, Hutchinson P, et al. Intracranial pressure: current perspectives on physiology and monitoring. Intensive Care Med. 2022; 48(10): 1471-1481. Stocchetti N, Picetti E, Berardino M, et al. Clinical applications of intracranial pressure monitoring in traumatic brain injury: report of the Milan consensus conference. Acta Neurochir (Wien). 2014; 156(8): 1615-22. Robba C, Graziano F, Rebora P, et al. Intracranial pressure monitoring in patients with acute brain injury in the intensive care unit (SYNAPSE-ICU): an international, prospective observational cohort study. Lancet Neurol. 2021; 20(7): 548-558. Godoy DA, Carrizosa J, Aguilera S, Videtta W, Jibaja M; Latin America Brain Injury Consortium (LABIC) Members. Current Practices for Intracranial Pressure and Cerebral Oxygenation Monitoring in Severe Traumatic Brain Injury: A Latin American Survey. Neurocrit Care. 2023; 38(1): 171-177. Rubiano AM, Carney N, Chesnut R, Puyana JC. Global neurotrauma research challenges and opportunities. Nature. 2015; 527(7578): S193-7. Rajajee V. Noninvasive Intracranial Pressure Monitoring: Are We There Yet? Neurocrit Care. 2024; 41(2): 332-338. Brasil S, Chesnut R, Robba C. Noninvasive neuromonitoring in acute brain injured patients. Intensive Care Med. 2024; 50(6): 960-963. Robba C, Picetti E, Vásquez-García S, et al. The Brussels consensus for non-invasive ICP monitoring when invasive systems are not available in the care of TBI patients (the B-ICONIC consensus, recommendations, and management algorithm). Intensive Care Med. 2025; 51(1): 4-20. Mahajan C, Prabhakar H, Rass V, et al. A National Survey on Coma Epidemiology, Evaluation, and Therapy in India: Revisiting the Curing Coma Campaign Come Together Survey. Neurocrit Care. 2024; 40(3): 941-952. Brasil S, Godoy DA, Videtta W, et al. A Comprehensive Perspective on Intracranial Pressure Monitoring and Individualized Management in Neurocritical Care: Results of a Survey with Global Experts. Neurocrit Care. 2024; 41(3): 880-892. Martínez-Palacios K, Vásquez-García S, Fariyike OA, Robba C, Rubiano AM. Non-Invasive Methods for Intracranial Pressure Monitoring in Traumatic Brain Injury Using Transcranial Doppler: A Scoping Review. J Neurotrauma. 2024; 41(11-12):1282-1298. Martínez-Palacios K, Vásquez-García S, Fariyike OA, Robba C, Rubiano AM; noninvasive ICP monitoring international consensus group. Using Optic Nerve Sheath Diameter for Intracranial Pressure (ICP) Monitoring in Traumatic Brain Injury: A Scoping Review. Neurocrit Care. 2024; 40(3): 1193-1212. Martínez-Palacios K, Vásquez-García S, Fariyike OA, Robba C, Rubiano AM; noninvasive intracranial pressure monitoring international consensus group. Quantitative Pupillometry for Intracranial Pressure (ICP) Monitoring in Traumatic Brain Injury: A Scoping Review. Neurocrit Care. 2024; 41(1): 255-271. Stewart KA, Navarro SM, Kambala S, et al. Trends in Ultrasound Use in Low and Middle Income Countries: A Systematic Review. Int J MCH AIDS. 2020; 9(1): 103-120. Kishna YS, Robba C, van der Horst ICC, et al. Practicalities of noninvasive neuromonitoring in intensive care. Neurocrit Care. 2025 Nov 14. Epub ahead of print. Robba C, Goffi A, Geeraerts T, et al. Brain ultrasonography: methodology, basic and advanced principles and clinical applications. A narrative review. Intensive Care Med. 2019; 45(7): 913-927. Shrestha GS, Nepal G, Brasil S. Low-Cost Strategies for the Development of Neurocritical Care in Resource-Limited Settings. Neurocrit Care. 2025; 42(3): 1087-1098. Petrosino M, Gouvêa Bogossian E, Rebora P, et al. Neurological Pupil Index and Intracranial Hypertension in Patients With Acute Brain Injury: A Secondary Analysis of the ORANGE Study. JAMA Neurol. 2025; 82(2): 176-184. Prust ML, Mbonde A, Rubinos C, et al. S Providing Neurocritical Care in Resource-Limited Settings: Challenges and Opportunities. Neurocrit Care. 2022; 37(2): 583-592. Maas AIR, Menon DK, Manley GT, et al. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol. 2022; 21(11): 1004-1060. Shrestha GS, Nepal G, Prabhakar H, Prust ML. Cost-effectiveness of neurocritical care in settings with limited resources. Lancet Glob Health. 2023; 11(9): e1343. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8413090","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":570640937,"identity":"b045155e-60a7-4972-a55c-e60a1061a636","order_by":0,"name":"Edoardo Picetti","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAElEQVRIiWNgGAWjYFCCBCBmAyMgMLBJgAgWEKeFseGAQVoCWHOCARFaGMBaGA5DtDDg0cLPnnzwc0WZTR4f++Hjjz8UnM/jl+9O/PDAgEGeX+wAVi2SPc+SJc+cSytm40lLBDrsdrFkG+9mCaDDDGfOTsCqxeBGjoFkY9vhxDYJHkOQlsQNx3g3gLQkGNzGrsX+Ro7xT4gW/o9ALedAWjb/wKfFQCLHDGYLKMQOgLRsw2uLxJlnaZYNEL8YzjhjkJw4sy13m0WCgQROv/C3Jx++2QAMMfn2ww8+VPyxS+xnPrv55o8KG3l+aexaYABDVgKvcqxaRsEoGAWjYBTAAQBzTWL97gzTBgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-0316-1451","institution":"Azienda Ospedaliero-Universitaria di Parma","correspondingAuthor":true,"prefix":"","firstName":"Edoardo","middleName":"","lastName":"Picetti","suffix":""},{"id":570640938,"identity":"a359fed3-f589-452b-8cb8-6e7d0fbc0b7c","order_by":1,"name":"Fabio Silvio Taccone","email":"","orcid":"","institution":"Centre Universitair Bruxelles Hôpital Erasme: Hopital Erasme","correspondingAuthor":false,"prefix":"","firstName":"Fabio","middleName":"Silvio","lastName":"Taccone","suffix":""},{"id":570640939,"identity":"e12feb68-81ec-47b9-bbb3-943dcd8de332","order_by":2,"name":"Amos O. 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16:11:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":610437,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8413090/v1/5cccbcea-5ed1-4afc-bd7c-3b24696cc7d6.pdf"},{"id":100356906,"identity":"34856409-fa1b-4c5d-83c8-1ed84ebef0a9","added_by":"auto","created_at":"2026-01-16 07:17:56","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19936,"visible":true,"origin":"","legend":"","description":"","filename":"cherries.docx","url":"https://assets-eu.researchsquare.com/files/rs-8413090/v1/23734a5fe60c9410eebfe826.docx"},{"id":100356925,"identity":"3140d3e2-b67a-4ff1-bf68-7b618e8109c3","added_by":"auto","created_at":"2026-01-16 07:18:00","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":19431,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8413090/v1/3e7f8439babaf2541ad3c883.docx"},{"id":99836518,"identity":"2356cc3e-cf5f-401d-b28c-f051d92939ac","added_by":"auto","created_at":"2026-01-08 19:11:38","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":19936,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8413090/v1/4a4db84b537d9bd0c7319bb0.docx"},{"id":100356876,"identity":"ffbcbde3-a51a-45a8-bbb2-ab6d8945c06c","added_by":"auto","created_at":"2026-01-16 07:17:53","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":15645,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-8413090/v1/01b2328ed15ac9d3362a73e3.docx"}],"financialInterests":"","formattedTitle":"\u003cp\u003eUtilization of Non-Invasive Intracranial Pressure Monitoring in Traumatic Brain Injury Patients Treated in Low-resource Settings: The Intrigo Study\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eTraumatic brain injury (TBI) is a leading cause of mortality and disability worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Invasive intracranial pressure (ICP) monitoring plays a fundamental role in the management of severe TBI patients with clinical and/or radiological signs of intracranial hypertension (IH) [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Standard invasive ICP monitoring is not universally available in low-resource settings, mainly due to high costs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In this scenario, non-invasive ICP (nICP) monitoring (e.g., brain ultrasounds, pupillometry, etc.) could be useful in identifying neurological deterioration and managing therapeutic strategies [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, few data are available regarding the application of nICP tools in limited-resource settings worldwide [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Therefore, the objective of this international survey is to describe the utilization of nICP monitoring modalities in this scenario.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis was an international cross-sectional survey comprising 23 items that were developed by three investigators (CR, FST, and EP), following a systematic review of the literature [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The same was utilized for the Brussels consensus for nICP monitoring when invasive systems are not available in the care of TBI patients (B-ICONIC) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The initial pool of questions was pilot-tested and critically revised by all authors. The final questionnaire is provided in the electronic supplementary material (Supplemental Additional File 1). From December 1st, 2023, to April 1st, 2024, the study investigators invited eligible participants via email through their professional networks. Respondents were also encouraged to disseminate the survey to additional colleagues. No compensation was provided. All data submitted electronically were stored in a secure, password-protected database accessible only to the principal investigators. Ethical approval was not required because no patient-level data were collected; the survey focused solely on physicians\u0026rsquo; practices and attitudes toward nICP monitoring in severe TBI within low-resource environments. The study adhered to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES), which is provided in Supplemental Additional File 2.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData were downloaded from the online platform, stored in an Excel file (Microsoft, Redmond, WA), and reviewed for anomalies or entry errors. All questionnaires were complete and free of inconsistencies. Responses that did not match any of the predefined options were categorized under \u0026ldquo;other.\u0026rdquo; All variables were categorical, and descriptive statistics were presented as counts and percentages. For questions permitting multiple responses, percentages were calculated for each selected option; consequently, the cumulative percentage exceeded 100%.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eRespondents Characteristics\u003c/h2\u003e \u003cp\u003eOne hundred and twenty-six physicians from 21 countries responded to the survey. Most respondents were from Nepal (n\u0026thinsp;=\u0026thinsp;32\u0026ndash;25.4%), Ecuador (n\u0026thinsp;=\u0026thinsp;13\u0026ndash;10.3%), Brazil (n\u0026thinsp;=\u0026thinsp;12\u0026ndash;9.1%), India (n\u0026thinsp;=\u0026thinsp;9\u0026ndash;7.1%), and Colombia (n\u0026thinsp;=\u0026thinsp;9\u0026ndash;7.1%) (Supplemental Additional File 3). Baseline characteristics of participants are reported in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; most respondents were intensivists (n\u0026thinsp;=\u0026thinsp;82\u0026ndash;65.1%), anesthesiologists (n\u0026thinsp;=\u0026thinsp;30\u0026ndash;23.8%), and neurosurgeons (n\u0026thinsp;=\u0026thinsp;11\u0026thinsp;\u0026minus;\u0026thinsp;8.7%). The majority of respondents (n\u0026thinsp;=\u0026thinsp;123\u0026thinsp;\u0026minus;\u0026thinsp;97.6%) worked in hospitals with the availability of brain CT scan.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003e\u0026ndash;\u003c/b\u003e Baseline characteristics of the study population.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSPECIALTY\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Intensive care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82 (65.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Anesthesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (23.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Neurosurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(8.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Neurology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYEARS OF PRACTICE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- \u0026lt; 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (25.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;5\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (19.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;10\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (15.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;15\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (11.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;20\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (7.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- \u0026gt; 25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (20.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMEAN ANNUAL NUMBER OF\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eSEVERE TBI PATIENTS\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eADMISSION\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- \u0026lt; 50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (31)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;50\u0026ndash;100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (27.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;100\u0026ndash;150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (15.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;150\u0026ndash;200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (5.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- \u0026gt; 200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (10.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- not known\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (9.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePOSSIBILITY TO PERFORM BRAIN CT SCAN IN SEVERE TBI PATIENTS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- YES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e123 (97.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- NO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e24/7 AVAILABILITY OF BRAIN CT SCAN IN SEVERE TBI PATIENTS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- YES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e121 (98.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- NO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\u003cp\u003eAbbreviations: TBI = traumatic brain injury, CT = computed tomography.\u003c/p\u003e\n\u003ch3\u003enICP Tools\u003c/h3\u003e\n\u003cp\u003eOptic nerve sheath diameter (ONSD) evaluation was the most utilized tool for nICP (n\u0026thinsp;=\u0026thinsp;120\u0026ndash;95.2%), followed by transcranial Doppler (TCD; n\u0026thinsp;=\u0026thinsp;76\u0026ndash;60.3%) and automated pupillometry (n\u0026thinsp;=\u0026thinsp;15\u0026ndash;11.9%). Seventy-six respondents (60.4%) had more than one tool for nICP evaluation at their disposal (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). For nICP estimation, 54% of our respondents relied on at least 2 methods (n\u0026thinsp;=\u0026thinsp;68). However, no protocol for nICP monitoring was available for most of respondents (n\u0026thinsp;=\u0026thinsp;74\u0026ndash;58.7%). Non-invasive ICP was assessed mainly every 24 (n\u0026thinsp;=\u0026thinsp;45\u0026ndash;35.7%) and 12 (n\u0026thinsp;=\u0026thinsp;29\u0026ndash;23%) hours. The majority of respondents modified their therapeutic strategy according to nICP monitoring (n\u0026thinsp;=\u0026thinsp;92\u0026ndash;73%). A brain CT scan was performed in cases of nICP monitoring suggesting IH for 117 (92.9%) of respondents.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003e\u0026ndash;\u003c/b\u003e Non-invasive ICP monitoring tools and values.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003enICP TOOLS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eONSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120 (95.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTCD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (60.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (11.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOTHER:\u003c/p\u003e \u003cp\u003eB4C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (8.7)\u003c/p\u003e \u003cp\u003e6 (4.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003enICP TOOLS COMBINATION AT DISPOSAL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTCD\u0026thinsp;+\u0026thinsp;ONSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (49.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAP\u0026thinsp;+\u0026thinsp;ONSD\u0026thinsp;+\u0026thinsp;TCD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAP\u0026thinsp;+\u0026thinsp;ONSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAP\u0026thinsp;+\u0026thinsp;TCD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAP\u0026thinsp;+\u0026thinsp;ONSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eONSD ONLY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (35.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTCD ONLY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAP ONLY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eONSD VALUES SUGGESTIVE\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eOF IH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;3 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;4 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;6 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115 (95.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;7 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;8 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTCD PARAMETERS AND VALUES SUGGESTIVE OF IH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- PI:\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.8\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.9\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1.1\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1.2\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1.3\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1.4\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1.5\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1.6\u003c/p\u003e \u003cp\u003eother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (97.4)\u003c/p\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003cp\u003e6 (8)\u003c/p\u003e \u003cp\u003e9 (12.2)\u003c/p\u003e \u003cp\u003e36 (48.6)\u003c/p\u003e \u003cp\u003e9 (12.2)\u003c/p\u003e \u003cp\u003e10 (13.5)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003cp\u003e3 (4.1)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- FVd:\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10 cm/sec\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;15 cm/sec\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20 cm/sec\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;25 cm/sec\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;30 cm/sec\u003c/p\u003e \u003cp\u003eother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (60.5)\u003c/p\u003e \u003cp\u003e3 (6.5)\u003c/p\u003e \u003cp\u003e3 (6.5)\u003c/p\u003e \u003cp\u003e25 (54.3)\u003c/p\u003e \u003cp\u003e6 (13.1)\u003c/p\u003e \u003cp\u003e9 (19.6)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eniCPP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (53.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAP PARAMETERS AND VALUES SUGGESTIVE OF IH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- NPi:\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;3\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;4\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5\u003c/p\u003e \u003cp\u003eother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (86.7)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003cp\u003e12 (92.3)\u003c/p\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Constriction velocity:\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.6 mm/sec\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,7 mm/sec\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.8 mm/sec\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.9 mm/sec\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1 mm/sec\u003c/p\u003e \u003cp\u003eother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (66.7)\u003c/p\u003e \u003cp\u003e4 (40)\u003c/p\u003e \u003cp\u003e1 (10)\u003c/p\u003e \u003cp\u003e4 (40)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003cp\u003e1 (10)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Dilation velocity:\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.6 mm/sec\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,7 mm/sec\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.8 mm/sec\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.9 mm/sec\u003c/p\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1 mm/sec\u003c/p\u003e \u003cp\u003eother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (46.7)\u003c/p\u003e \u003cp\u003e3 (42.9)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003cp\u003e3 (42.9)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003cp\u003e1 (14.2)\u003c/p\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eAbbreviations: nICP\u0026thinsp;=\u0026thinsp;non-invasive intracranial pressure, ONSD\u0026thinsp;=\u0026thinsp;optic nerve sheath diamter, TCD\u0026thinsp;=\u0026thinsp;transcranial Doppler, AP\u0026thinsp;=\u0026thinsp;automated pupillometry, B4C\u0026thinsp;=\u0026thinsp;brain for care, IH\u0026thinsp;=\u0026thinsp;intracranial hypertension, PI\u0026thinsp;=\u0026thinsp;pulsatility index, FVd\u0026thinsp;=\u0026thinsp;diastolic flow velocity, niCPP\u0026thinsp;=\u0026thinsp;non-invasive cerebral perfusion pressure, NPi\u0026thinsp;=\u0026thinsp;neurological pupil index.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eDerived Variables and Thresholds\u003c/h3\u003e\n\u003cp\u003eOptic nerve sheath diameter evaluation was the most utilized tool for nICP estimation in our study (n\u0026thinsp;=\u0026thinsp;120\u0026thinsp;\u0026minus;\u0026thinsp;95.2%). A value greater than 6 mm was the most suggestive threshold used for detecting IH (n\u0026thinsp;=\u0026thinsp;115\u0026thinsp;\u0026minus;\u0026thinsp;95.8%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTranscranial Doppler was used by 76 (60.3%) respondents; in particular, the pulsatility index (PI, n\u0026thinsp;=\u0026thinsp;74\u0026ndash;97.4%), the diastolic flow velocity (FVd, n\u0026thinsp;=\u0026thinsp;46\u0026ndash;60.5%), and the formula to calculate non-invasively ICP (n\u0026thinsp;=\u0026thinsp;41\u0026ndash;53.9%) were used when TCD was available (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A PI\u0026thinsp;\u0026gt;\u0026thinsp;1.2 (n\u0026thinsp;=\u0026thinsp;36\u0026ndash;48.6%) and a FVd below 20 cm/sec (n\u0026thinsp;=\u0026thinsp;25\u0026ndash;54.3%) were the most frequently thresholds suggestive of IH.\u003c/p\u003e \u003cp\u003eAutomated pupillometry was used by 15 (11.9%) respondents; the Neurological pupil index (NPi) was the most used variable to detect the presence of IH (n\u0026thinsp;=\u0026thinsp;13\u0026ndash;86.7%), followed by constriction (n\u0026thinsp;=\u0026thinsp;10\u0026ndash;66.7%) or dilation (n\u0026thinsp;=\u0026thinsp;7\u0026ndash;46.7%) velocities. The most used NPi threshold suggestive of IH was \u0026lt;\u0026thinsp;3 (n\u0026thinsp;=\u0026thinsp;12\u0026ndash;92.3%).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis international survey provided for the first time information regarding the utilization of nICP in TBI patients treated in low-resource settings worldwide. The main findings of this study were: a) the predominant use of ONSD as nICP assessment tool; b) the use of at least two nICP estimation methods in approximately half of the cases; and c) the absence of a dedicated protocol for nICP monitoring. We also observed significant variability in the thresholds and parameters used to define IH across modalities, although they are increasingly being adopted by clinicians in resource-limited areas [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBrain ultrasounds (i.e., ONSD and TCD) are the most utilized nICP methods in our study population. This can be explained by the fact that ultrasound machines are not so expensive, and so are generally available even in low resource settings worldwide because they are used for different clinical purposes (e.g., obstetrics, etc.) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The ONSD evaluation was the most utilized tool in our study. This method requires a linear probe (without adjunctive software installation) which is generally easy to find worldwide. However, this tool presents several challenges such as eyes accessibility (not always feasible after TBI), the lack of a standardized clinical protocol accepted worldwide (e.g., report of \u0026ldquo;internal\u0026rdquo; or \u0026ldquo;external\u0026rdquo; ONSD, influence of head position, etc.), and a longer learning curve respect to TCD [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Transcranial Doppler is the second most utilized tool for nICP monitoring in our cohort. This method requires the use of specific software with additional costs. Moreover, some patients may have a poor or absent acoustic window at the temporal bone level, limiting their use [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The automated pupillometer is the least used method by our participants. This instrument, unlike the ultrasound scanner, cannot be used for other clinical purposes and has to be purchased specifically for this task representing an additional cost [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Moreover, it requires the absence of traumatic ocular pathology [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Although an abnormal NPi could indicate brainstem dysfunction, a recent study showed that, overall, NPi values were not significantly associated with invasive ICP values in acute brain injury patients (i.e., TBI, spontaneous subarachnoid and intracerebral hemorrhage) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAbout half of our participants use at least two methods for nICP estimation. This is in accordance with what will be subsequently recommended by the B-ICONIC consensus [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In this way (i.e. by using the two methods) diagnostic accuracy in nICP estimation could be improved. However, the approach proposed by the B-ICONIC consensus requires validation in future studies.\u003c/p\u003e \u003cp\u003eIn our opinion, the scarce availability of protocol for nICP estimation is an important aspect to be highlighted. The burden of TBI is high in low-income and middle-income countries (LMICs), mainly due to an increase in traffic accidents linked to poor compliance with rules, safety measures and road-network quality [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Severe TBI is a complex neurological emergency requiring an advanced-care system, assuring continuity of care, from the prehospital phase to rehabilitation [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Limited resources in LMICs generally limit the capacity to successfully treat severely head injured patients [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. One possible proposed solution is the creation of protocols to optimize care of TBI patients with locally available critical care resources [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Protocols for nICP assessment could not only improve patient care but also optimize resource utilization (e.g., reduction of brain CT scans, exploiting the use of ultrasound machines already in use for extracranial pathologies, etc.).\u003c/p\u003e \u003cp\u003eRegarding parameters utilized as marker of IH with different nICP tools, the responses of our participants are generally aligned with the available literature (e.g., ONSD\u0026thinsp;\u0026gt;\u0026thinsp;6 mm, PI\u0026thinsp;\u0026gt;\u0026thinsp;1.2, etc.) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, values ​​different from those recommended are also reported. This is another very important aspect to emphasize. In addition to promoting protocols, it would be very important to support educational initiatives such as basic courses dedicated to nICP assessment. This would be a way to adapt tools and methodologies used in developed countries to low resource settings. At the same time, these initiatives can act as a driving force for creating local protocols tailored as much as possible to the available resources [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study presents several limitations, including the relatively low number of respondents and the inability to calculate response rates based on the survey design.\u003c/p\u003e \u003cp\u003eMoreover, we have few responses from doctors working in Africa limiting the generalizability of our findings. However, we recorded responses from 126 physicians representing 114 centers in 21 countries.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eBrain ultrasounds, especially ONSD evaluation, are the main tools for nICP monitoring in head injury patients in low-resource settings worldwide. Educational initiatives associated with protocol development may represent an important step toward improving the care of TBI patients in resource-limited settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eWe confirm that manuscript complies with all instructions to authors.\u003c/p\u003e\n\n\u003cp\u003eAuthors contributions: All authors contributed to the study conception, design and data\u003c/p\u003e\n\u003cp\u003einterpretation. EP, CR, and FST performed data collection. EP, CR, and FST performed data processing and statistical analysis. All authors critically reviewed the article. All authors had full access to data, participated in data interpretation, revised the article, and approved the final version of the manuscript. All authors meet requirements for authorship.\u003c/p\u003e\n\n\u003cp\u003eWe confirm that this manuscript has not been published elsewhere and is not under consideration by another journal.\u003c/p\u003e\n\n\u003cp\u003eWe confirm adherence to ethical guidelines and indicate ethical approvals.\u003c/p\u003e\n\n\u003cp\u003eUse of informed consent: not applicable.\u003c/p\u003e\n\n\u003cp\u003eConflicts of Interest: none to disclose for all authors.\u003c/p\u003e\n\n\u003cp\u003eUse of reporting checklist: CHERRIES.\u003c/p\u003e\n\n\u003cp\u003eFunding for the study: none.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGBD 2016 Traumatic Brain Injury and Spinal Cord Injury Collaborators. Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019; 18(1): 56-87. \u003c/li\u003e\n \u003cli\u003eDewan MC, Rattani A, Gupta S, et al. Estimating the global incidence of traumatic brain injury. J Neurosurg. 2018; 130(4): 1080-1097. \u003c/li\u003e\n \u003cli\u003eHawryluk GWJ, Citerio G, Hutchinson P, et al. Intracranial pressure: current perspectives on physiology and monitoring. Intensive Care Med. 2022; 48(10): 1471-1481. \u003c/li\u003e\n \u003cli\u003eStocchetti N, Picetti E, Berardino M, et al. Clinical applications of intracranial pressure monitoring in traumatic brain injury: report of the Milan consensus conference. Acta Neurochir (Wien). 2014; 156(8): 1615-22. \u003c/li\u003e\n \u003cli\u003eRobba C, Graziano F, Rebora P, et al. Intracranial pressure monitoring in patients with acute brain injury in the intensive care unit (SYNAPSE-ICU): an international, prospective observational cohort study. Lancet Neurol. 2021; 20(7): 548-558. \u003c/li\u003e\n \u003cli\u003eGodoy DA, Carrizosa J, Aguilera S, Videtta W, Jibaja M; Latin America Brain Injury Consortium (LABIC) Members. Current Practices for Intracranial Pressure and Cerebral Oxygenation Monitoring in Severe Traumatic Brain Injury: A Latin American Survey. Neurocrit Care. 2023; 38(1): 171-177. \u003c/li\u003e\n \u003cli\u003eRubiano AM, Carney N, Chesnut R, Puyana JC. Global neurotrauma research challenges and opportunities. Nature. 2015; 527(7578): S193-7. \u003c/li\u003e\n \u003cli\u003eRajajee V. Noninvasive Intracranial Pressure Monitoring: Are We There Yet? Neurocrit Care. 2024; 41(2): 332-338. \u003c/li\u003e\n \u003cli\u003eBrasil S, Chesnut R, Robba C. Noninvasive neuromonitoring in acute brain injured patients. Intensive Care Med. 2024; 50(6): 960-963. \u003c/li\u003e\n \u003cli\u003eRobba C, Picetti E, Vásquez-García S, et al. The Brussels consensus for non-invasive ICP monitoring when invasive systems are not available in the care of TBI patients (the B-ICONIC consensus, recommendations, and management algorithm). Intensive Care Med. 2025; 51(1): 4-20. \u003c/li\u003e\n \u003cli\u003eMahajan C, Prabhakar H, Rass V, et al. A National Survey on Coma Epidemiology, Evaluation, and Therapy in India: Revisiting the Curing Coma Campaign Come Together Survey. Neurocrit Care. 2024; 40(3): 941-952. \u003c/li\u003e\n \u003cli\u003eBrasil S, Godoy DA, Videtta W, et al. A Comprehensive Perspective on Intracranial Pressure Monitoring and Individualized Management in Neurocritical Care: Results of a Survey with Global Experts. Neurocrit Care. 2024; 41(3): 880-892. \u003c/li\u003e\n \u003cli\u003eMartínez-Palacios K, Vásquez-García S, Fariyike OA, Robba C, Rubiano AM. Non-Invasive Methods for Intracranial Pressure Monitoring in Traumatic Brain Injury Using Transcranial Doppler: A Scoping Review. J Neurotrauma. 2024; 41(11-12):1282-1298. \u003c/li\u003e\n \u003cli\u003eMartínez-Palacios K, Vásquez-García S, Fariyike OA, Robba C, Rubiano AM; noninvasive ICP monitoring international consensus group. Using Optic Nerve Sheath Diameter for Intracranial Pressure (ICP) Monitoring in Traumatic Brain Injury: A Scoping Review. Neurocrit Care. 2024; 40(3): 1193-1212. \u003c/li\u003e\n \u003cli\u003eMartínez-Palacios K, Vásquez-García S, Fariyike OA, Robba C, Rubiano AM; noninvasive intracranial pressure monitoring international consensus group. Quantitative Pupillometry for Intracranial Pressure (ICP) Monitoring in Traumatic Brain Injury: A Scoping Review. Neurocrit Care. 2024; 41(1): 255-271. \u003c/li\u003e\n \u003cli\u003eStewart KA, Navarro SM, Kambala S, et al. Trends in Ultrasound Use in Low and Middle Income Countries: A Systematic Review. Int J MCH AIDS. 2020; 9(1): 103-120. \u003c/li\u003e\n \u003cli\u003eKishna YS, Robba C, van der Horst ICC, et al. Practicalities of noninvasive neuromonitoring in intensive care. Neurocrit Care. 2025 Nov 14. Epub ahead of print. \u003c/li\u003e\n \u003cli\u003eRobba C, Goffi A, Geeraerts T, et al. Brain ultrasonography: methodology, basic and advanced principles and clinical applications. A narrative review. Intensive Care Med. 2019; 45(7): 913-927. \u003c/li\u003e\n \u003cli\u003eShrestha GS, Nepal G, Brasil S. Low-Cost Strategies for the Development of Neurocritical Care in Resource-Limited Settings. Neurocrit Care. 2025; 42(3): 1087-1098. \u003c/li\u003e\n \u003cli\u003ePetrosino M, Gouvêa Bogossian E, Rebora P, et al. Neurological Pupil Index and Intracranial Hypertension in Patients With Acute Brain Injury: A Secondary Analysis of the ORANGE Study. JAMA Neurol. 2025; 82(2): 176-184. \u003c/li\u003e\n \u003cli\u003ePrust ML, Mbonde A, Rubinos C, et al. S Providing Neurocritical Care in Resource-Limited Settings: Challenges and Opportunities. Neurocrit Care. 2022; 37(2): 583-592. \u003c/li\u003e\n \u003cli\u003eMaas AIR, Menon DK, Manley GT, et al. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol. 2022; 21(11): 1004-1060. \u003c/li\u003e\n \u003cli\u003eShrestha GS, Nepal G, Prabhakar H, Prust ML. Cost-effectiveness of neurocritical care in settings with limited resources. Lancet Glob Health. 2023; 11(9): e1343. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"neurocritical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"neca","sideBox":"Learn more about [Neurocritical Care](http://link.springer.com/journal/12028)","snPcode":"12028","submissionUrl":"https://www.editorialmanager.com/neca/default2.aspx","title":"Neurocritical Care","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"traumatic brain injury, monitoring, non-invasive, intracranial pressure, low-resource setting","lastPublishedDoi":"10.21203/rs.3.rs-8413090/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8413090/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInvasive intracranial pressure (ICP) monitoring is not universally available in low-resource settings, mainly due to high costs. In this scenario, non-invasive ICP (nICP) estimation could be integrated in therapeutic protocols. The objective of this international survey was to describe the utilization of nICP monitoring in this setting.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe survey was composed by 23 items. Target respondents were doctors treating severe traumatic brain injury (TBI) patients in low-resource settings without the availability of invasive ICP monitoring.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOne hundred and twenty-six physicians from 114 centers among 21 countries worldwide responded. The main findings of this study were: a) a predominant use of optic nerve sheath diameter (ONSD) as nICP assessment tool; b) the utilization of at least two methods for nICP estimation in approximately half of the cases; and c) the absence of specific protocol for nICP monitoring. We also reported a certain degree of variability regarding the parameters suggestive of intracranial hypertension for each of the methods used.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eBrain ultrasounds, particularly ONSD assessment, are the most frequently utilized tools for nICP estimation in TBI patients managed in low-resource settings worldwide. Educational efforts linked with protocols development could be a step forward to improve the care of TBI in resource-limited settings.\u003c/p\u003e","manuscriptTitle":"Utilization of Non-Invasive Intracranial Pressure Monitoring in Traumatic Brain Injury Patients Treated in Low-resource Settings: The Intrigo Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-08 19:11:33","doi":"10.21203/rs.3.rs-8413090/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2026-01-08T21:10:42+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-07T07:50:06+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Neurocritical Care","date":"2026-01-03T15:53:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-28T14:25:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"Neurocritical Care","date":"2025-12-28T04:34:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"neurocritical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"neca","sideBox":"Learn more about [Neurocritical Care](http://link.springer.com/journal/12028)","snPcode":"12028","submissionUrl":"https://www.editorialmanager.com/neca/default2.aspx","title":"Neurocritical Care","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"3decb9bf-80f0-4c6b-8c6f-8715908ec6b7","owner":[],"postedDate":"January 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-07T16:07:32+00:00","versionOfRecord":{"articleIdentity":"rs-8413090","link":"https://doi.org/10.1007/s12028-026-02494-3","journal":{"identity":"neurocritical-care","isVorOnly":false,"title":"Neurocritical Care"},"publishedOn":"2026-04-02 15:58:41","publishedOnDateReadable":"April 2nd, 2026"},"versionCreatedAt":"2026-01-08 19:11:33","video":"","vorDoi":"10.1007/s12028-026-02494-3","vorDoiUrl":"https://doi.org/10.1007/s12028-026-02494-3","workflowStages":[]},"version":"v1","identity":"rs-8413090","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8413090","identity":"rs-8413090","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}