The crisis of the third day in intracranial pressure dynamics following traumatic brain injury, fact or fiction?

In 1960, Lazorthes and Campman introduced the concept of a ‘crisis of the third day’, which gained prominence in the field of traumatic brain injury (TBI), where it relates to neurological deterioration on the third day after injury. However, evidence regarding this phenomenon remains scarce. This study aimed to analyze posttraumatic intracranial pressure (ICP) patterns in a large European cohort to investigate the existence of a third-day crisis and its impact on 12-month functional outcomes. Data were analyzed from the prospective Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Patients with TBI admitted to ICUs in 65 European centers who received ICP monitoring were included. ICP measurements, averaged per day, were analyzed using mixed models. The association between ICP peak timing and functional outcome was examined with multivariable logistic regression. The study included 886 patients. Average ICP trajectories showed no significant changes over the first seven days post-injury, without elevation around the third day. Among 563 patients with ICP >20 during the first week, 45% reached their highest ICP after the third day. Elevated ICP (>20 mmHg) during the first week was associated with unfavorable 12-month outcomes, but the timing of ICP peak was not linked to functional outcomes. This multicenter study challenges the ‘crisis of the third day’ concept. No distinct ICP or TIL elevations were observed around the third day. Elevated ICP remains a prognostic indicator, but ICP peak timing does not correlate with functional outcomes. •Average ICP and TIL values did not show significant changes or peaks around the third day post-TBI.•The timing of peak ICP was not linked to functional outcomes at 12 months.•A substantial share of patients had their ICP peak level after the third day, stressing the importance of continued monitoring.