Impact of intracranial pressure monitoring on 30-day mortality in severe traumatic brain injury: a retrospective cohort study in Kenya

OBJECTIVE: The objective of this study was to evaluate 15-year trends in epidemiology, baseline severity, management, and outcomes of severe traumatic brain injury (sTBI) at a Kenyan tertiary center, and to determine the impact of invasive intracranial pressure (ICP) monitoring on 30-day mortality in a low- and middle-income country (LMIC) context. METHODS: A retrospective quasi-experimental cohort analysis of consecutive sTBI admissions (postresuscitation Glasgow Coma Scale [GCS] score ≤ 8, age ≥ 13 years) from January 1, 2010, to December 31, 2024, was conducted. This time period was divided into two eras: era 1 (2010-2014), premonitoring, and era 2 (2015-2024), routine monitoring. Patient demographics, injury severity (Injury Severity Score [ISS], pupillary response, and Marshall CT class), physiology, therapies utilized (hyperosmolar agents, CSF drainage, barbiturates, and decompressive craniectomy [DC]) and outcomes were collected. Propensity score analysis with 1:1 nearest-neighbor matching for age, sex, ISS, GCS score, pupillary response, hypotension, hypoxemia, time to admission, and Marshall CT class was applied. The primary outcome was 30-day mortality. RESULTS: Among 126 sTBI patients (median age 32 years, 80% male), 52 (41%) received ICP monitoring (56% parenchymal, 44% external ventricular drain). In the unmatched analysis, the mortality rate was 27% with monitoring versus 54% without (risk ratio [RR] 0.50, p = 0.002). In the matched analysis (41 pairs), the mortality rate was 29% with monitoring versus 51% without (RR 0.57, OR 0.39, p = 0.043). Era 2 showed a higher use of hypertonic saline (62% vs 35%, p = 0.003), CSF drainage (37% vs 1.4%, p < 0.001), and DC (22% vs 2.4%, p = 0.011). Complication rates from use of the monitoring device were low (infection 7.7%, hemorrhage 7.7%). CONCLUSIONS: Over the 15-year period, sTBI admissions rose while early mortality declined following the adoption of ICP monitoring and protocol-based care. In this LMIC setting, ICP monitoring was independently associated with lower 30-day mortality, supporting the use of guideline-concordant neuromonitoring and scalable multimodality bundles.