1. Secondary Brain Injury Processes:
   • Secondary brain injury processes contribute to additional brain damage in acute brain injury patients.
   • Monitoring and detecting these insults is crucial for a more informed and individualized approach to treatment.
2. Neurologic Status Monitoring:
   • Daily evaluation of neurologic and mental status is important.
   • Assessment tools like the Glasgow Coma Scale (GCS) and Full Outline of UnResponsiveness (FOUR) score can be used.
   • Both the GCS and FOUR score provide useful measures of neurologic state.
3. Pupillary Evaluation and Pain Assessment:
   • Pupillary evaluation is a strong predictor of outcome and should be integrated into neurologic evaluations.
   • Handheld pupillometers provide objective measurement, but further clinical experience is needed.
   • Validated pain assessment scales like the Sedation-Agitation Scale (SAS) and Richmond Agitation-Sedation Scale (RASS) should be used.
4. Wake-Up Tests and Outcome Tools:
   • Wake-up tests in patients with intracranial hypertension pose risks and show no proven benefits.
   • Outcome tools like the Glasgow Outcome Scale (GOS) and Neurological Outcome Scale for TBI (NOS-TBI) can be used for assessment.
5. Intracranial Pressure and Cerebral Perfusion Pressure:
   • Normal resting ICP is <15 mm Hg, and sustained ICP >20 mm Hg is considered pathologic.
   • ICP monitoring is recommended for severe TBI patients to reduce mortality.
   • Maintaining an adequate CPP (70-85 mm Hg) is important to prevent cerebral ischemia and hypoperfusion.
6. Intracranial Pressure Monitoring Devices:
   • The ventriculostomy catheter is the gold standard for ICP monitoring.
   • Microtransducer-tipped ICP monitors and noninvasive devices have advantages and disadvantages.
   • Invasive monitors remain more accurate and reliable.
   • Noninvasive devices still require further development for sufficient accuracy.
7. ICP Waveforms:
   • The normal ICP waveform consists of three arterial components superimposed on the respiratory rhythm.
   • Percussion wave, tidal wave, and dicrotic wave can be seen.
   • Understanding ICP waveforms can provide valuable information for diagnosis and management.
8. ICP Monitoring:
   • ICP monitoring involves measuring the pressure inside the skull.
   • Complications of ICP monitoring include intracranial hemorrhage, infections, malfunction, malposition, and obstruction.
9. Intracranial Hemorrhage and Infections:
   • Intracranial hemorrhage and infections are the most common complications of ICP monitoring.
   • Infection rates range from 0% to 22% depending on the type of device.
   • Prophylactic antibiotics and sterile placement can help reduce the risk of infection.
10. Jugular Venous Oxygen Saturation:
    • Jugular venous oxygen saturation (SjvO) monitors global oxygenation in the brain.
    • Placement of a catheter for SjvO monitoring should be done above the C1-C2 vertebral bodies.
    • Normal SjvO values range from 55% to 75%.
11. Side of Jugular Catheterization:
    • The dominant jugular vein is recommended for catheter placement if using SjvO as a monitor of global oxygenation.
    • Ultrasound imaging can be used to determine the size of the dominant internal jugular vein.
12. Transcranial Doppler Flow Velocity:
    • Transcranial Doppler (TCD) ultrasonography measures blood flow velocity in major arteries of the brain.
    • TCD monitoring can help detect cerebral vasospasm after SAH or TBI.
    • Velocities above 200 cm/sec may indicate posttraumatic vasospasm.
13. Brain Tissue Oxygen Partial Pressure:
    • Brain tissue oxygen partial pressure (PbtO) measures local brain oxygen levels.
    • PbtO values below 20 mm Hg indicate compromised brain oxygen.
    • Proper probe placement and interpretation of PbtO values are essential for accurate monitoring.
14. Monitoring Strategies:
    • ICP monitoring and PbtO assessment are important for managing severe TBI.
    • PbtO values can guide pharmacologic, hemodynamic, or respiratory therapy.
15. ICP + PbtO-guided management in severe TBI:
    • Associated with reduced mortality and improved outcomes 6 months postinjury
    • Laying the foundation for BOOST-3 phase III trial
16. Treatment for reduced PbtO:
    • First directed at underlying causes of inadequate cerebral oxygen delivery
    • Includes increasing CPP, improving arterial oxygenation, reducing fever, etc.
17. Near-infrared spectroscopy (NIRS):
    • Noninvasive method for estimating regional changes in cerebral oxygenation
    • Limited clinical use due to inability to differentiate intracranial and extracranial changes in blood flow and oxygenation
18. Electroencephalogram (EEG):
    • Detects clinical and subclinical seizures
    • Predicts outcome after coma in ICU setting
19. Continuous EEG (cEEG):
    • Recommended in comatose TBI patients to monitor subclinical seizures
    • Urgently needed in patients with convulsive status epilepticus
20. Intracranial EEG:
    • Superior at identifying certain forms of seizures not detected by standard scalp EEG
    • Associated with cortical spreading depolarizations and worsened outcomes