Use of intracranial pressure monitoring and risk factors for the development of intracranial hypertension in acute liver failure.
Murphy, Nick El-Dalil, Philip Patel, Sameer Ryan, Jennifer Bangash, Mansoor Agarwal, Banwari Jalan, Rajiv Wendon, Julia Bernal, William
Murphy, Nick
El-Dalil, Philip
Patel, Sameer
Ryan, Jennifer
Bangash, Mansoor
Agarwal, Banwari
Jalan, Rajiv
Wendon, Julia
Bernal, William
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Publication date
2025-12-17
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Abstract
Background & aims: The use of invasive intracranial pressure monitoring (IICPM) in acute liver failure (ALF) is controversial. The incidence of intracranial hypertension (ICH) in ALF appears to have declined since it was first recognised, and the risk-benefit ratio of IICPM has therefore been questioned. Anecdotal reports suggest that the use of IICPM has fallen significantly in the UK. We investigated trends in IICPM use, the incidence of ICH, and factors associated with ICH and cerebral death (CD).
Methods: This retrospective cohort study collected data on consecutive patients with ALF, admitted to three liver transplant centres in the UK from 2009 to 2018 from prospective audits. Data on the incidence of ICH, CD, the use of IICPM, liver transplantation and hospital survival were collected. Factors associated with ICH and CD were investigated.
Results: The incidence of ICH fell over the study period from 13% in 2009 to 3% in 2018 (p <0.001). The use of IICPM fell over the study period from 20.6% of patients admitted in 2009 (n = 13) to 1.4% (n = 1) in 2018 (p <0.001). Hospital survival, liver transplantation and CD did not vary significantly during this period. Peak arterial ammonia concentration was strongly associated with both ICH and CD.
Conclusion: In three high-volume liver transplant centres, the use of IICPM declined markedly over a 10-year period without an associated worsening of clinical outcomes. These findings suggest that a management strategy focused on early preventive measures without invasive ICP monitoring is a rational approach and does not increase the risk of ICH, CD, or mortality.
Impact and implications: With advances in intensive care supportive management, the incidence of intracranial hypertension as a complication of acute liver failure has declined. Serum ammonia levels remain central to its pathogenesis and risk stratification. Although invasive intracranial pressure monitoring is considered the gold standard for detection of intracranial hypertension, concerns regarding availability, clinical utility, and complications have limited its use. Our findings demonstrate that reduced use of invasive intracranial pressure monitoring was not associated with adverse patient-centred outcomes.
Citation
Murphy N, El-Dalil P, Patel S, Ryan J, Bangash M, Agarwal B, Jalan R, Wendon J, Bernal W. Use of intracranial pressure monitoring and risk factors for the development of intracranial hypertension in acute liver failure. J Hepatol. 2025 Dec 17:S0168-8278(25)02725-4. doi: 10.1016/j.jhep.2025.12.007.
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Article