. 2026 Apr 12;6:106046. doi: 10.1016/j.bas.2026.106046

Table 13.

Invasive neuromonitoring goals and recommended interventions for abnormal values.

Invasive Neuromonitoring Goals	Recommended Interventions for Abnormal Values
● ICP must be maintained at <22 mmHg. Additionally, the ICP waveform morphology should be evaluated as a complementary tool: a waveform is considered normal when P1 amplitude exceeds P2. When P2 ≥ P1, impaired intracranial compliance is indicated and escalation of ICP management should be initiated (analyzed in conjunction with the absolute ICP threshold). Waveform analysis supplements the 22-mmHg treatment threshold (Chesnut et al., 2020a; Hawryluk et al., 2019; Brasil et al., 2021). ● Maintain PbtO₂ > 20 mmHg whenever monitoring is available. ● Evaluate cerebral autoregulation using the MAP Challenge (Rosenthal et al., as incorporated in the SIBICC consensus) (Chesnut et al., 2020a; Rosenthal et al., 2011): using vasoactive medications, transiently increasing the MAP by 10 mmHg and observe the ICP response over 20 min. An increase in ICP of ≥2 mmHg suggests impaired cerebral autoregulation; in this scenario, CPP targets should be individualized, and a lower MAP target may be preferred.	● If the ICP waveform is abnormal (P2 greater than or equal to P1), consider ventricular drainage if available. ● If PbtO₂ falls below the target, perform a hyperoxia test to assess the underlying cause. If the patient responds to hyperoxia, adjust the FiO₂ to achieve the PbtO₂ target. If there is no response to the hyperoxia test, investigate other potential causes of low PbtO₂ (e.g., elevated ICP, low Hb, abnormal P₅₀, etc) and address them accordingly. ● In cases of sustained loss of cerebral autoregulation, consider more invasive strategies to maintain cerebral perfusion pressure.

Invasive Neuromonitoring Goals

Recommended Interventions for Abnormal Values

●
ICP must be maintained at <22 mmHg. Additionally, the ICP waveform morphology should be evaluated as a complementary tool: a waveform is considered normal when P1 amplitude exceeds P2. When P2 ≥ P1, impaired intracranial compliance is indicated and escalation of ICP management should be initiated (analyzed in conjunction with the absolute ICP threshold). Waveform analysis supplements the 22-mmHg treatment threshold (Chesnut et al., 2020a; Hawryluk et al., 2019; Brasil et al., 2021).
●
Maintain PbtO₂ > 20 mmHg whenever monitoring is available.
●
Evaluate cerebral autoregulation using the MAP Challenge (Rosenthal et al., as incorporated in the SIBICC consensus) (Chesnut et al., 2020a; Rosenthal et al., 2011): using vasoactive medications, transiently increasing the MAP by 10 mmHg and observe the ICP response over 20 min. An increase in ICP of ≥2 mmHg suggests impaired cerebral autoregulation; in this scenario, CPP targets should be individualized, and a lower MAP target may be preferred.

●
If the ICP waveform is abnormal (P2 greater than or equal to P1), consider ventricular drainage if available.
●
If PbtO₂ falls below the target, perform a hyperoxia test to assess the underlying cause. If the patient responds to hyperoxia, adjust the FiO₂ to achieve the PbtO₂ target. If there is no response to the hyperoxia test, investigate other potential causes of low PbtO₂ (e.g., elevated ICP, low Hb, abnormal P₅₀, etc) and address them accordingly.
●
In cases of sustained loss of cerebral autoregulation, consider more invasive strategies to maintain cerebral perfusion pressure.