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Godoy DA, Rubiano AM, Aguilera S, Jibaja M, Videtta W, Rovegno M, Paranhos J, Paranhos E, de Amorim RLO, Castro Monteiro da Silva Filho R, Paiva W, Flecha J, Faleiro RM, Almanza D, Rodriguez E, Carrizosa J, Hawryluk GWJ, Rabinstein AA. Moderate Traumatic Brain Injury in Adult Population: The Latin American Brain Injury Consortium Consensus for Definition and Categorization. Neurosurgery 2024; 95:e57-e70. [PMID: 38529956 DOI: 10.1227/neu.0000000000002912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 01/30/2024] [Indexed: 03/27/2024] Open
Abstract
Moderate traumatic brain injury (TBI) is a diagnosis that describes diverse patients with heterogeneity of primary injuries. Defined by a Glasgow Coma Scale between 9 and 12, this category includes patients who may neurologically worsen and require increasing intensive care resources and/or emergency neurosurgery. Despite the unique characteristics of these patients, there have not been specific guidelines published before this effort to support decision-making in these patients. A Delphi consensus group from the Latin American Brain Injury Consortium was established to generate recommendations related to the definition and categorization of moderate TBI. Before an in-person meeting, a systematic review of the literature was performed identifying evidence relevant to planned topics. Blinded voting assessed support for each recommendation. A priori the threshold for consensus was set at 80% agreement. Nine PICOT questions were generated by the panel, including definition, categorization, grouping, and diagnosis of moderate TBI. Here, we report the results of our work including relevant consensus statements and discussion for each question. Moderate TBI is an entity for which there is little published evidence available supporting definition, diagnosis, and management. Recommendations based on experts' opinion were informed by available evidence and aim to refine the definition and categorization of moderate TBI. Further studies evaluating the impact of these recommendations will be required.
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Affiliation(s)
| | - Andres M Rubiano
- Universidad El Bosque, Bogota , Colombia
- MEDITECH Foundation, Cali , Colombia
| | - Sergio Aguilera
- Department Neurosurgery, Herminda Martín Hospital, Chillan , Chile
| | - Manuel Jibaja
- School of Medicine, San Francisco University, Quito , Ecuador
- Intensive Care Unit, Eugenio Espejo Hospital, Quito , Ecuador
| | - Walter Videtta
- Intensive Care Unit, Hospital Posadas, Buenos Aires , Argentina
| | - Maximiliano Rovegno
- Department Critical Care, Pontificia Universidad Católica de Chile, Santiago , Chile
| | - Jorge Paranhos
- Department of Neurosurgery and Critical Care, Santa Casa da Misericordia, Sao Joao del Rei , Minas Gerais , Brazil
| | - Eduardo Paranhos
- Intensive Care Unit, HEMORIO and Santa Barbara Hospitals, Rio de Janeiro , Brazil
| | | | | | - Wellingson Paiva
- Experimental Surgery Laboratory and Division of Neurological Surgery, University of São Paulo Medical School, Sao Paulo , Brazil
| | - Jorge Flecha
- Intensive Care Unit, Trauma Hospital, Asuncion , Paraguay
- Social Security Institute Central Hospital, Asuncion , Paraguay
| | - Rodrigo Moreira Faleiro
- Department of Neurosurgery, João XXIII Hospital and Felício Rocho Hospital, Faculdade de Ciencias Médicas de MG, Belo Horizonte , Brazil
| | - David Almanza
- Critical and Intensive Care Medicine Department, University Hospital, Fundación Santa Fe de Bogotá, Bogotá , Colombia
- Universidad del Rosario, School of Medicine and Health Sciences, Bogotá , Colombia
| | - Eliana Rodriguez
- Critical and Intensive Care Medicine Department, University Hospital, Fundación Santa Fe de Bogotá, Bogotá , Colombia
- Universidad del Rosario, School of Medicine and Health Sciences, Bogotá , Colombia
| | - Jorge Carrizosa
- Universidad del Rosario, School of Medicine and Health Sciences, Bogotá , Colombia
- Neurointensive Care Unit, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá , Colombia
| | - Gregory W J Hawryluk
- Cleveland Clinic Akron General Hospital, Neurological Institute, Akron , Ohio , USA
| | - Alejandro A Rabinstein
- Neurocritical Care and Hospital Neurology Division, Mayo Clinic, Rochester , Minnesota , USA
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Yang F, Peng C, Peng L, Wang P, Cheng C, Zuo W, Zhao L, Jin Z, Li W. Group-based trajectory modeling of intracranial pressure in patients with acute brain injury: Results from multi-center ICUs, 2008-2019. CNS Neurosci Ther 2022; 28:1218-1228. [PMID: 35611794 PMCID: PMC9253780 DOI: 10.1111/cns.13854] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/16/2022] [Accepted: 04/22/2022] [Indexed: 11/30/2022] Open
Abstract
Objective The objective of the study was to characterize the longitudinal, dynamic intracranial pressure (ICP) trajectory in acute brain injury (ABI) patients admitted to intensive care unit (ICU) and explore whether it added sights over traditional thresholds in predicting outcomes. Methods ABI patients with ICP monitoring were identified from two public databases named Medical Information Mart for the Intensive Care (MIMIC)‐IV and eICU Collaborative Research Database (eICU‐CRD). Group‐based trajectory modeling (GBTM) was employed to identify 4‐h ICP trajectories in days 0–5 post‐ICU admission. Then, logistic regression was used to compare clinical outcomes across distinct groups. To further validate previously reported thresholds, we created the receiver operating characteristic (ROC) curve in our dataset. Results A total of 810 eligible patients were ultimately enrolled in the study. GBTM analyses generated 6 distinct ICP trajectories, differing in the initial ICP, evolution pattern, and number/proportion of spikes >20/22 mmHg. Compared with patients in “the highest, declined then rose” trajectory, those belonging to the “lowest, stable,” “low, stable,” and “medium, stable” ICP trajectories were at lower risks of 30‐day mortality (odds ratio [OR] 0.04; 95% confidence interval [CI] 0.01, 0.21), (OR 0.04; 95% CI 0.01, 0.19), (OR 0.08; 95% CI 0.01, 0.42), respectively. ROC analysis demonstrated an unfavorable result, for example, 30‐day mortality in total cohort: an area under the curve (AUC): 0.528, sensitivity: 0.11, and specificity: 0.94. Conclusions This study identified three ICP trajectories associated with elevated risk, three with reduced risks for mortality during ICU hospitalization. Notably, a fixed ICP threshold should not be applied to all kinds of patients. GBTM, a granular method for describing ICP evolution and their association with clinical outcomes, may add to the current knowledge in intracranial hypertension treatment.
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Affiliation(s)
- Fan Yang
- Department of Plastic Surgery and Burns, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Chi Peng
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Liwei Peng
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Peng Wang
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Chao Cheng
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Wei Zuo
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Lei Zhao
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Zhichao Jin
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Weixin Li
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
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Abstract
PURPOSE OF REVIEW Severe traumatic brain injury (TBI) is an extremely serious health problem, especially in low-middle income countries (LMICs). The prevalence of severe TBI continues to increase in LMICs. Major limitations in the chain of care for TBI patients are common in LMICs including suboptimal or nonexistent prehospital care, overburdened emergency services, lack of trained human resources and limited availability of ICUs. Basic neuromonitoring, such as intracranial pressure, are unavailable or underutilized and advanced techniques are not available. RECENT FINDINGS Attention to fundamental principles of TBI care in LMICs, including early categorization, prevention and treatment of secondary insults, use of low-cost technology for evaluation of intracranial bleeding and neuromonitoring, and emphasis on education of human resources and multidisciplinary work, are particularly important in LMICs. Institutional collaborations between high-income and LMICs have developed evidence focused on available resources. Accordingly, an expert group have proposed consensus recommendations for centers without availability of invasive brain monitoring. SUMMARY Severe TBI is very prevalent in LMIC and neuromonitoring is often not available in these environments. When intracranial pressure monitors are not available, careful attention to changes on clinical examination, serial imaging and noninvasive monitoring techniques can help recognize intracranial hypertension and effectively guide treatment decisions.
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Godoy DA, Murillo-Cabezas F. Evolutionary conceptualization of the injury mechanisms intraumatic brain injury. Med Intensiva 2021; 46:90-93. [PMID: 34887231 DOI: 10.1016/j.medine.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/28/2020] [Accepted: 02/08/2020] [Indexed: 10/19/2022]
Affiliation(s)
- D A Godoy
- Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, San Fernando del Valle de Catamarca, Argentina; Unidad de Terapia Intensiva, Hospital San Juan Bautista, San Fernando del Valle de Catamarca, Argentina
| | - F Murillo-Cabezas
- Grupo de Neurocríticos, Instituto de Biomedicina de Sevilla/Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain.
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Doron O, Hemphill JC, Manley G, Rosenthal G. Improved Pressure Equalization Ratio Following Mannitol Administration in Patients With Severe TBI: A Preliminary Study of a Potential Bedside Marker for Response to Therapy. Neurocrit Care 2021; 36:519-526. [PMID: 34498204 PMCID: PMC8425582 DOI: 10.1007/s12028-021-01332-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/13/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Performing a cerebrospinal fluid (CSF) drainage challenge can be used to measure the pressure equalization (PE) ratio, which describes the extent to which CSF drainage can equalize pressure to the height of the external ventricular drain and may serve as a correlate of cerebral edema. We sought to assess whether treatment with mannitol improves PE ratio in patients with severe traumatic brain injury (TBI) with elevated intracranial pressure (ICP). METHODS We studied consecutive patients with TBI and brain edema on computed tomography scan and an external ventricular drain (EVD), admitted to the neurointensive care unit. PE ratio, defined as ICP prior to CSF drainage minus ICP after CSF drainage divided by ICP prior to CSF drainage minus EVD height, was measured as previously described. Patients were treated with mannitol for raised ICP based on clinical indication and PE ratio measured before and after mannitol administration. RESULTS We studied 20 patients with severe TBI with raised ICP. Mean ICP prior to mannitol treatment was 29 ± 7 mm Hg. PE ratio rose substantially after mannitol treatment (0.62 ± 0.24 vs. 0.29 ± 0.20, p < 0.0001), indicating an improved ability to drain CSF and equalize ICP with the preset height of the EVD. The combination of mannitol and CSF drainage led to an improved reduction in ICP compared with that seen before mannitol therapy (11 ± 2 mm Hg vs. 6 ± 2 mm Hg, p < 0.01), and led to a decrease in ICP below the 20 mm Hg threshold in 77% of cases. CONCLUSIONS Treatment with mannitol leads to a substantial improvement in PE ratio that reflects the ability to achieve a greater decrease in ICP when CSF drainage is performed after mannitol administration. This preliminary study raises the possibility that PE ratio may be useful to follow response to therapy in patients with cerebral edema and raised ICP. Further studies to determine whether PE ratio may serve as an easily obtained and clinically useful surrogate marker for the extent of brain edema are warranted.
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Affiliation(s)
- Omer Doron
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Engineering, Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Geoffrey Manley
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Guy Rosenthal
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Doron O, Barnea O, Stocchetti N, Or T, Nossek E, Rosenthal G. Cardiac-gated intracranial elastance in a swine model of raised intracranial pressure: a novel method to assess intracranial pressure-volume dynamics. J Neurosurg 2021; 134:1650-1657. [PMID: 32503002 DOI: 10.3171/2020.3.jns193262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/31/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Previous studies have demonstrated the importance of intracranial elastance; however, methodological difficulties have limited widespread clinical use. Measuring elastance may offer potential benefit in helping to identify patients at risk for untoward intracranial pressure (ICP) elevation from small rises in intracranial volume. The authors sought to develop an easily used method that accounts for the changing ICP that occurs over a cardiac cycle and to assess this method in a large-animal model over a broad range of ICPs. METHODS The authors used their previously described cardiac-gated intracranial balloon pump and swine model of cerebral edema. In the present experiment they measured elastance at 4 points along the cardiac cycle-early systole, peak systole, mid-diastole, and end diastole-by using rapid balloon inflation to 1 ml over an ICP range of 10-30 mm Hg. RESULTS The authors studied 7 swine with increasing cerebral edema. Intracranial elastance rose progressively with increasing ICP. Peak-systolic and end-diastolic elastance demonstrated the most consistent rise in elastance as ICP increased. Cardiac-gated elastance measurements had markedly lower variance within swine compared with non-cardiac-gated measures. The slope of the ICP-elastance curve differed between swine. At ICP between 20 and 25 mm Hg, elastance varied between 8.7 and 15.8 mm Hg/ml, indicating that ICP alone cannot accurately predict intracranial elastance. CONCLUSIONS Measuring intracranial elastance in a cardiac-gated manner is feasible and may offer an improved precision of measure. The authors' preliminary data suggest that because elastance values may vary at similar ICP levels, ICP alone may not necessarily best reflect the state of intracranial volume reserve capacity. Paired ICP-elastance measurements may offer benefit as an adjunct "early warning monitor" alerting to the risk of untoward ICP elevation in brain-injured patients that is induced by small increases in intracranial volume.
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Affiliation(s)
- Omer Doron
- 1Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem
- 2Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Ofer Barnea
- 2Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Nino Stocchetti
- 3Department of Physiopathology and Transplantation, Milan University and Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; and
| | - Tal Or
- 2Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Erez Nossek
- 4Department of Neurosurgery, New York University Medical Center, New York, New York
| | - Guy Rosenthal
- 1Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem
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Chesnut RM, Videtta W. Situational Intracranial Pressure Management: An Argument Against a Fixed Treatment Threshold. Crit Care Med 2020; 48:1214-1216. [PMID: 32697494 DOI: 10.1097/ccm.0000000000004395] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Randall M Chesnut
- Department of Neurological Surgery, University of Washington, Harborview Medical Center, Seattle, WA
| | - Walter Videtta
- Department of Critical Care Medicine, Hospital Nacional Professor Alejandro Posadas, Buenos Aires, Argentina
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8
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Godoy DA, Videtta W, Santa Cruz R, Silva X, Aguilera-Rodríguez S, Carreño-Rodríguez JN, Ciccioli F, Piñero G, Ciro JD, da Re-Gutiérrez S, Domeniconi G, Fischer D, Hernández O, Lacerda-Gallardo A, Mejía J, Panhke P, Romero C, Lora FS, Soler-Morejón C, Sufan JL, Montes JM, Fuenzalida LC, Parahnos JL, Jibaja M. General care in the management of severe traumatic brain injury: Latin American consensus. Med Intensiva 2020; 44:500-508. [PMID: 32376092 DOI: 10.1016/j.medin.2020.01.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/16/2019] [Accepted: 01/26/2020] [Indexed: 01/08/2023]
Abstract
Severe traumatic brain injury (sTBI) remains prevalent in the young adult population. Indeed, far from descending, the incidence of sTBI remains high. One of the key bases of treatment is to avoid, detect and correct secondary injuries of systemic origin, which aggravate the primary lesion. Much of this can be achieved by maintaining an adequate physiological microenvironment allowing recovery of the damaged brain tissue. General care measures are nonspecific actions designed to meet that objective. The available guidelines on the management of sTBI have not included the topics contemplated in this consensus. In this regard, a group of members of the Latin American Brain Injury Consortium (LABIC), involved in the different aspects of the acute management of sTBI (neurosurgeons, intensivists, anesthesiologists, neurologists, nurses and physiotherapists) were gathered. An exhaustive literature search was made of selected topics in the LILACS, PubMed, Embase, Scopus, Cochrane Controlled Register of Trials and Web of Science databases. To establish recommendations or suggestions with their respective strength or weakness, the GRADE methodology (Grading of Recommendations, Assessment, Development and Evaluation) was applied. Additionally, certain recommendations (included in complementary material) were not assessed by GRADE, because they constitute a set of therapeutic actions of effective compliance, in which it was not possible to apply the said methodology. Thirty-two recommendations were established, 16 strong and 16 weak, with their respective levels of evidence. This consensus attempts to standardize and establish basic general care measures in this particular patient population.
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Affiliation(s)
- D A Godoy
- Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, San Fernando del Valle de Catamarca, Catamarca, Argentina; Unidad de Cuidados Intensivos, Hospital San Juan Bautista, San Fernando del Valle de Catamarca, Catamarca, Argentina.
| | - W Videtta
- Unidad de Cuidados Intensivos, Hospital Nacional Alejandro Posadas, Unidad de Cuidados Intensivos Hospital Eva Perón, Merlo, Buenos Aires, Argentina
| | - R Santa Cruz
- Unidad de Terapia Intensiva, Hospital Regional Río Gallegos, Río Gallegos, Santa Cruz, Argentina
| | - X Silva
- Escuela de Medicina, Universidad de Magallanes, Punta Arenas, Magallanes, Chile
| | - S Aguilera-Rodríguez
- Servicio Neurocirugía, Hospital Naval Almirante Nef. Viña del Mar, Universidad de Valparaíso, Chile
| | - J N Carreño-Rodríguez
- Unidad de Cuidados Intensivos y Servicio Neurocirugía, Fundación Santa Fe de Bogotá, Universidad del Rosario, Bogotá, Colombia
| | - F Ciccioli
- Unidad Terapia Intensiva, Hospital Municipal de Agudos «Dr. Leónidas Lucero», Universidad Nacional del Sur, Bahía Blanca, Buenos Aires, Argentina
| | - G Piñero
- Unidad Terapia Intensiva, Hospital Municipal de Agudos «Dr. Leónidas Lucero», Universidad Nacional del Sur, Bahía Blanca, Buenos Aires, Argentina
| | - J D Ciro
- Anestesia y Cuidados Intensivos, Clínica Las Américas Auna, Medellín, Antioquia, Colombia
| | - S da Re-Gutiérrez
- Unidad de Terapia Intensiva Adultos, Hospital Materno Infantil C.N.S0, La Paz, Bolivia
| | - G Domeniconi
- Unidad de Cuidados Intensivos, Sanatorio de la Trinidad San Isidro, San Isidro, Buenos Aires, Argentina
| | - D Fischer
- Unidad de Paciente Critico Adulto, Clínica Universidad de los Andes, Santiago de Chile, Chile
| | - O Hernández
- Unidad de Cuidados Intensivos, Clínica Medellín, Medellín, Antioquia, Colombia
| | - A Lacerda-Gallardo
- Departamento de Neurocirugía, Hospital General Docente «Roberto Rodríguez», Morón, Ciego de Ávila, Cuba
| | - J Mejía
- Unidad de Cuidados Neurointensivos, Fundación Valle del Lili, Cali, Valle del Cauca, Colombia
| | - P Panhke
- Shock Room, Hospital Municipal de Urgencias, Córdoba, Argentina
| | - C Romero
- Departamento de Medicina, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, Santiago de Chile, Chile
| | - F S Lora
- Universidad Mayor de San Andrés, La Paz, Bolivia
| | - C Soler-Morejón
- Hospital Clínico Quirúrgico «Hermanos Ameijeiras», La Habana, Cuba
| | - J L Sufan
- Unidad de Paciente Neurocrítico, Clínica Indisa, Escuela de Kinesiología, Facultad de Ciencias de la Rehabilitación, Universidad Andres Bello, Santiago, Chile
| | - J M Montes
- Unidad de Paciente Crítico, Clínica Alemana, Santiago de Chile, Chile
| | - L C Fuenzalida
- Departamento Medicina, Pontificia Universidad Católica de Chile, Centro de Pacientes Críticos, Complejo Hospitalario Barros Luco Trudeau, Santiago de Chile, Chile
| | - J L Parahnos
- Unidad de Terapia Intensiva y Servicio de Neurocirugía, Hospital de la Santa Casa, São João del-Rei, Minas Gerais, Brasil
| | - M Jibaja
- Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Escuela de Medicina, Universidad Internacional del Ecuador, Quito, Ecuador
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Godoy DA, Murillo-Cabezas F. Evolutionary conceptualization of the injury mechanisms intraumatic brain injury. Med Intensiva 2020; 46:S0210-5691(20)30055-3. [PMID: 32192779 DOI: 10.1016/j.medin.2020.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/28/2020] [Accepted: 02/08/2020] [Indexed: 11/22/2022]
Affiliation(s)
- D A Godoy
- Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, San Fernando del Valle de Catamarca, Argentina; Unidad de Terapia Intensiva, Hospital San Juan Bautista, San Fernando del Valle de Catamarca, Argentina
| | - F Murillo-Cabezas
- Grupo de Neurocríticos, Instituto de Biomedicina de Sevilla/Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, España.
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Management of Head Trauma in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Godoy DA, Lubillo S, Rabinstein AA. Pathophysiology and Management of Intracranial Hypertension and Tissular Brain Hypoxia After Severe Traumatic Brain Injury: An Integrative Approach. Neurosurg Clin N Am 2018; 29:195-212. [PMID: 29502711 DOI: 10.1016/j.nec.2017.12.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Monitoring intracranial pressure in comatose patients with severe traumatic brain injury (TBI) is considered necessary by most experts. Acute intracranial hypertension (IHT), when severe and sustained, is a life-threatening complication that demands emergency treatment. Yet, secondary anoxic-ischemic injury after brain trauma can occur in the absence of IHT. In such cases, adding other monitoring modalities can alert clinicians when the patient is in a state of energy failure. This article reviews the mechanisms, diagnosis, and treatment of IHT and brain hypoxia after TBI, emphasizing the need to develop a physiologically integrative approach to the management of these complex situations.
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Affiliation(s)
- Daniel Agustín Godoy
- Intensive Care Unit, San Juan Bautista Hospital, Catamarca, Argentina; Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina.
| | - Santiago Lubillo
- Intensive Care Unit, Hospital Universitario NS de Candelaria, Tenerife, Spain
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12
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Prophylactic and Therapeutic Hypothermia in Severe Traumatic Brain Injury. CURRENT TRAUMA REPORTS 2018. [DOI: 10.1007/s40719-018-0121-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Godoy DA, Videtta W, Di Napoli M. Practical Approach to Posttraumatic Intracranial Hypertension According to Pathophysiologic Reasoning. Neurol Clin 2017; 35:613-640. [DOI: 10.1016/j.ncl.2017.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Intracranial pressure monitoring after primary decompressive craniectomy in traumatic brain injury: a clinical study. Acta Neurochir (Wien) 2017; 159:615-622. [PMID: 28236181 DOI: 10.1007/s00701-017-3118-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 02/14/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Intracranial pressure (ICP) monitoring represents an important tool in the management of traumatic brain injury (TBI). Although current information exists regarding ICP monitoring in secondary decompressive craniectomy (DC), little is known after primary DC following emergency hematoma evacuation. METHODS Retrospective analysis of prospectively collected data. Inclusion criteria were age ≥18 years and admission to the intensive care unit (ICU) for TBI and ICP monitoring after primary DC. Exclusion criteria were ICU length of stay (LOS) <1 day and pregnancy. Major objectives were: (1) to analyze changes in ICP/cerebral perfusion pressure (CPP) after primary DC, (2) to evaluate the relationship between ICP/CPP and neurological outcome and (3) to characterize and evaluate ICP-driven therapies after DC. RESULTS A total of 34 patients were enrolled. Over 308 days of ICP/CPP monitoring, 130 days with at least one episode of intracranial hypertension (26 patients, 76.5%) and 57 days with at least one episode of CPP <60 mmHg (22 patients, 64.7%) were recorded. A statistically significant relationship was discovered between the Glasgow Outcome Scale (GOS) scores and mean post-decompression ICP (p < 0.04) and between GOS and CPP minimum (CPPmin) (p < 0.04). After DC, persisting intracranial hypertension was treated with: barbiturate coma (n = 7, 20.6%), external ventricular drain (EVD) (n = 4, 11.8%), DC diameter widening (n = 1, 2.9%) and removal of newly formed hematomas (n = 3, 8.8%). CONCLUSION Intracranial hypertension and/or low CPP occurs frequently after primary DC; their occurence is associated with an unfavorable neurological outcome. ICP monitoring appears useful in guiding therapy after primary DC.
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Lund SB, Gjeilo KH, Moen KG, Schirmer-Mikalsen K, Skandsen T, Vik A. Moderate traumatic brain injury, acute phase course and deviations in physiological variables: an observational study. Scand J Trauma Resusc Emerg Med 2016; 24:77. [PMID: 27216804 PMCID: PMC4878035 DOI: 10.1186/s13049-016-0269-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 05/13/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with moderate traumatic brain injury (TBI) are a heterogeneous group with great variability in clinical course. Guidelines for monitoring and level of care in the acute phase are lacking. The main aim of this observational study was to describe injury severity and the acute phase course during the first three days post-injury in a cohort of patients with moderate TBI. Deviations from defined parameters in selected physiological variables were also studied, based on guidelines for severe TBI during the same period. METHODS During a 5-year period (2004-2009), 119 patients ≥16 years (median age 47 years, range 16-92) with moderate TBI according to the Head Injury Severity Scale were admitted to a Norwegian level 1 trauma centre. Injury-related and acute phase data were collected prospectively. Deviations in six physiological variables were collected retrospectively. RESULTS Eighty-six percent of the patients had intracranial pathology on CT scan and 61 % had extracranial injuries. Eighty-four percent of all patients were admitted to intensive care units (ICUs) the first day, and 51 % stayed in ICUs ≥3 days. Patients staying in ICUs ≥3 days had lower median Glasgow Coma Scale score; 12 (range 9-15) versus 13 (range 9-15, P = 0.003) and more often extracranial injuries (77 % versus 42 %, P = 0.001) than patients staying in ICU 0-2 days. Most patients staying in ICUs ≥3 days had at least one episode of hypotension (53 %), hypoxia (57 %), hyperthermia (59 %), anaemia (56 %) and hyperglycaemia (65 %), and the proportion of anaemia related to number of measurements was high (33 %). CONCLUSION Most of the moderate TBI patients stayed in an ICU the first day, and half of them stayed in ICUs ≥3 days due to not only intracranial, but also extracranial injuries. Deviations in physiological variables were often seen in this latter group of patients. Lack of guidelines for patients with moderate TBI may leave these deviations uncorrected. We propose that in future research of moderate TBI, patients might be differentiated with regard to their need for monitoring and level of care the first few days post-injury. This could contribute to improvement of acute phase management.
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Affiliation(s)
- Stine B Lund
- Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
- Department of Neuroscience, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 3250 Sluppen, N-7006, Trondheim, Norway.
- Department of Nursing Science, Faculty of Health and Social Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Kari H Gjeilo
- Department of Cardiothoracic Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kent G Moen
- Department of Medical Imaging, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuroscience, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 3250 Sluppen, N-7006, Trondheim, Norway
| | - Kari Schirmer-Mikalsen
- Department of Anaesthesia and Intensive care Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Toril Skandsen
- Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuroscience, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 3250 Sluppen, N-7006, Trondheim, Norway
| | - Anne Vik
- Department of Neurosurgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Neuroscience, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, 3250 Sluppen, N-7006, Trondheim, Norway
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Chesnut RM. What is wrong with the tenets underpinning current management of severe traumatic brain injury? Ann N Y Acad Sci 2014; 1345:74-82. [PMID: 25048398 DOI: 10.1111/nyas.12482] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The results of a recent randomized controlled trial comparing intracranial pressure (ICP) monitor-based treatment of severe traumatic brain injury (sTBI) to management without ICP monitoring prompt this skeptical reconsideration of the scientific foundation underlying current sTBI management. Much of current practice arises from research performed under conditions that are no longer relevant today. The definition of an episode of intracranial hypertension is incomplete, and the application of a fixed, universal ICP treatment threshold is poorly founded. Although intracranial hypertension is a valid indicator of disease severity, it remains to be demonstrated that lowering ICP improves outcome. Furthermore, sTBI has not been categorized on the basis of underlying pathophysiology despite the current capability to do so. Similar concerns also apply to manipulation of cerebral perfusion with respect to maintaining universal thresholds for contrived variables rather than tailoring treatment to monitored processes. As such, there is a failure to either optimize management approaches or minimize associated treatment risks for individual sTBI patients. The clinical and research TBI communities need to reassess many of the sTBI management concepts that are currently considered well established.
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Affiliation(s)
- Randall M Chesnut
- Departments of Neurological Surgery and Orthopaedics and Sports Medicine, Harborview Medical Center, School of Medicine and School of Global Health, University of Washington, Seattle, Washington
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