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Intensive Care Medicine

, Volume 34, Issue 3, pp 461–467 | Cite as

Refractory intracranial hypertension and “second-tier” therapies in traumatic brain injury

  • Nino StocchettiEmail author
  • Clelia Zanaboni
  • Angelo Colombo
  • Giuseppe Citerio
  • Luigi Beretta
  • Laura Ghisoni
  • Elisa Roncati Zanier
  • Katia Canavesi
Original

Abstract

Objective

To quantify the occurrence of high intracranial pressure (HICP) refractory to conventional medical therapy after traumatic brain injury (TBI) and to describe the use of more aggressive therapies (profound hyperventilation, barbiturates, decompressive craniectomy).

Design

Prospective study of 407 consecutive TBI patients

Setting

Three neurosurgical intensive care units (ICU).

Measurements and results

Intracranial pressure (ICP) was studied during the first week after TBI; 153 patients had at least 1 day of ICP > 20 mmHg. Early surgery was necessary for 221 cases, and standard medical therapy [sedation, mannitol, cerebrospinal fluid (CSF) withdrawal, PaCO2 30–35 mmHg] was used in 135 patients. Reinforced treatment (PaCO2 25–29 mmHg, induced arterial hypertension, muscle relaxants) was used in 179 cases (44%), and second-tier therapies in 80 (20%). Surgical decompression and/or barbiturates were used in 28 of 407 cases (7%). Six-month outcome was recorded in 367 cases using the Glasgow outcome scale (GOS). The outcome was favorable (good recovery or moderate disability) in 195 cases (53%) and unfavorable (all the other categories) in 172 (47%). HICP was associated with worse outcome. Outcome for cases who had received second-tier therapies was significantly worse (43% favorable at 6 months, p = 0.03).

Conclusions

HICP is frequent and is associated with worse outcome. ICP was controlled by early surgery and first-tier therapies in the majority of cases. Profound hyperventilation, surgical decompression and barbiturates were used in various combinations in a minority of cases. The indications for surgical decompression and/or barbiturates seem restricted to less than 10% of severe TBI.

Keywords

Intracranial pressure Surgical decompression Barbiturates Hyperventilation Outcome Traumatic brain injury 

Notes

Acknowledgements

We gratefully acknowledge the contribution of Manuela Cormio MD to the development of the first version of the database and the assistance of Emiliana Calappi MD, Cristina Mattioli MD and Sara Cazzaniga BD in data collection.

References

  1. 1.
    Marmarou A, Anderson RL, Ward JD, Choi SC, Young HF (1991) Impact of ICP instability and hypotension on outcome in patients with severe head trauma. J Neurosurg 75:s59–66Google Scholar
  2. 2.
    Yoo DS, Kim DS, Cho KS, Huh PW, Park CK, Kang JK (1999) Ventricular pressure monitoring during bilateral decompression with dural expansion. J Neurosurg 91:953–959PubMedGoogle Scholar
  3. 3.
    Kunze E, Meixensberger J, Janka M, Sorensen N, Roosen K (1998) Decompressive craniectomy in patients with uncontrollable intracranial hypertension. Acta Neurochir Suppl 71:16–18PubMedGoogle Scholar
  4. 4.
    Guerra WK, Gaab MR, Dietz H, Mueller JU, Piek J, Fritsch MJ (1999) Surgical decompression for traumatic brain swelling: indications and results. J Neurosurg 90:187–196PubMedGoogle Scholar
  5. 5.
    No authors (1988) Cranial decompression. Lancet 1:1204Google Scholar
  6. 6.
    Gower DJ, Lee KS, McWhorter JM (1988) Role of subtemporal decompression in severe closed head injury. Neurosurgery 23:417–422PubMedCrossRefGoogle Scholar
  7. 7.
    The Brain Trauma Foundation, The American Association of Neurological Surgeons, The Joint Section on Neurotrauma and Critical Care (2000) Critical pathway for the treatment of established intracranial hypertension. J Neurotrauma 17:537–538CrossRefGoogle Scholar
  8. 8.
    Citerio G, Stocchetti N, Cormio M, Beretta L (2000) Neuro-Link, a computer-assisted database for head injury in intensive care. Acta Neurochir 142:769–776CrossRefGoogle Scholar
  9. 9.
    Stocchetti N, Rossi S, Buzzi F, Mattioli C, Paparella A, Colombo A (1999) Intracranial hypertension in head injury patients. management and results. Intensive Care Med 25:371–376PubMedCrossRefGoogle Scholar
  10. 10.
    Jennett B, Bond M (1975) Assessment of outcome after severe brain damage. Lancet 1:480–484PubMedCrossRefGoogle Scholar
  11. 11.
    Wilson JT, Pettigrew LE, Teasdale GM (1998) Structured interviews for the Glasgow Outcome Scale and the Extended Glasgow Outcome Scale: guidelines for their use. J Neurotrauma 15:573–585PubMedGoogle Scholar
  12. 12.
    Robertson C, Valadka A, Hannay HJ, Contant CF, Gopinath SP, Cormio M, Uzura M, Grossman RG (1999) Prevention of secondary ischemic insult after severe head injury. Crit Care Med 27:2086–2095PubMedCrossRefGoogle Scholar
  13. 13.
    Hukkelhoven CW, Steyerberg GW, Farace E, Marshall LF (2000) Regional differences in patient characteristics, case management, and outcomes in traumatic brain injury: experience from the tirilazad trials. J Neurosurg 97:549–557Google Scholar
  14. 14.
    Murray GD, Butcher I, McHugh GS, Lu J, Mushkudiani NA, Maas AI, Marmarou A, Steyerberg EW (2007) Multivariable prognostic analysis in traumatic brain injury: results from the IMPACT study. J Neurotrauma 24:329–337PubMedCrossRefGoogle Scholar
  15. 15.
    Muizelaar JP, Marmarou A, Ward JD, Kontos HA, Choi SC, Becker DP, Gruemer H, Young HF (1991) Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial. J Neurosurg 75:731–739PubMedCrossRefGoogle Scholar
  16. 16.
    Roberts I, Schierhout G (2004) Hyperventilation therapy for acute traumatic brain injury (Cochrane Review). In: The Cochrane Library issue 1, Wiley, Chichester, UKGoogle Scholar
  17. 17.
    Stocchetti N, Maas AI, Chieregato A, Van der Plas AA (2005) Hyperventilation in head injury: a review. Chest 127:1812–1827PubMedCrossRefGoogle Scholar
  18. 18.
    Coles JP, Minhas PS, Fryer TD, Smielewski P, Aigbirihio F, Donovan T, Downey SP, Williams G, Chatfield D, Matthews JC, Gupta AK, Carpenter TA, Clark JC, Pickard JD, Menon DK (2002) Effect of hyperventilation on cerebral blood flow in traumatic head injury: clinical relevance and monitoring correlates. Crit Care Med 30:1950–1959PubMedCrossRefGoogle Scholar
  19. 19.
    Eisenberg HM, Frankowski RF, Contant CF, Marshall LF, Walker MD (1988) High-dose barbiturate control of elevated intracranial pressure in patients with severe head injury. J Neurosurg 69:15–23PubMedGoogle Scholar
  20. 20.
    Roberts I (2000) Barbiturates for acute traumatic brain injury. Cochrane Database Syst Rev(2):CD000033Google Scholar
  21. 21.
    Schalen W, Messeter K, Nordstrom CH (1992) Complications and side effects during thiopentone therapy in patients with severe head injury. Acta Anaesthesiol Scan 36:369–377Google Scholar
  22. 22.
    Munch E, Horn P, Schurer L, Piepgras A, Paul T, Schmiedek P (2000) Management of severe traumatic brain injury by decompressive craniectomy. Neurosurgery 47:315–323PubMedCrossRefGoogle Scholar
  23. 23.
    Schneider GH, Bardt T, Lanksch WR, Unterberg A (2002) Decompressive craniectomy following traumatic brain injury: ICP, CPP and neurological outcome. Acta Neurochir Suppl 81:77–79PubMedGoogle Scholar
  24. 24.
    Stiefel MF, Heuer GG, Smith MJ, Bloom S, Maloney-Wilensky E, Gracias VH, Grady MS, LeRoux PD (2004) Cerebral oxygenation following decompressive hemicraniectomy for the treatment of refractory intracranial hypertension. J Neurosurg 101:241–247PubMedGoogle Scholar
  25. 25.
    Sahuquillo J, Arikan F (2006) Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury. Cochrane Database Syst Rev (1):CD003983Google Scholar
  26. 26.
    Compagnone C, Murray GD, Teasdale GM, Maas AI, Esposito D, Princi P, D'Avella D, Servadei F (2005) The management of patients with intradural post-traumatic mass lesions: a multicenter survey of current approaches to surgical management in 729 patients, coordinated by the European Brain Injury Consortium. Neurosurgery 57:1183–1192PubMedCrossRefGoogle Scholar
  27. 27.
    Aarabi B, Hesdorffer DC, Ahn ES, Aresco C, Scalea TM, Eisenberg HM (2006) Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg 104:469–479PubMedCrossRefGoogle Scholar
  28. 28.
    Polin RS, Shaffrey ME, Bogaev CA, Tisdale N, Germanson T, Bocchicchio B, Jane JA (1997) Decompressive bifrontal craniectomy in the treatment of severe refractory posttraumatic cerebral edema. Neurosurgery 41:84–92PubMedCrossRefGoogle Scholar
  29. 29.
    Skoglund TS, Eriksson-Ritzen C, Jensen C, Rydenhag B (2006) Aspects on decompressive craniectomy in patients with traumatic head injuries. J Neurotrauma 23:1502–1509PubMedCrossRefGoogle Scholar
  30. 30.
    Winkler PA, Stummer W, Linke R, Krishnan KG, Tatsch K (2000) Influence of cranioplasty on postural blood flow regulation, cerebrovascular reserve capacity, and cerebral glucose metabolism. J Neurosurg 93:53–61PubMedGoogle Scholar
  31. 31.
    Unterberg A, Kiening K, Schmiedek P, Lanksch W (1993) Long-term observations of intracranial pressure after severe head injury. The phenomenon of secondary rise of intracranial pressure. Neurosurgery 32:17–24PubMedCrossRefGoogle Scholar
  32. 32.
    Citerio G, Andrews PJ (2007) Refractory elevated intracranial pressure: intensivist's role in solving the dilemma of decompressive craniectomy. Intensive Care Med 33:45–48PubMedCrossRefGoogle Scholar
  33. 33.
    Department of Human Services, Victoria, Australia. Trauma treatment trial for new research center [updated Nov 2003]. Available from: http://www.dhs.vic.gov.au/humanservicesnews/nov03/trauma.html
  34. 34.
    The RESCUEicp study. University of Cambridge Departments of Neurosurgery / Neuro-intensive Care and the European Brain Injury Consortium. Available from: http://www.rescueicp.com/contacts.html

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Nino Stocchetti
    • 1
    Email author
  • Clelia Zanaboni
    • 1
  • Angelo Colombo
    • 1
  • Giuseppe Citerio
    • 2
  • Luigi Beretta
    • 3
  • Laura Ghisoni
    • 1
  • Elisa Roncati Zanier
    • 1
  • Katia Canavesi
    • 1
  1. 1.Neuroscience Intensive Care UnitOspedale Maggiore Policlinico, Mangiagalli, e Regina Elena, Fondazione IRCCSMilanItaly
  2. 2.Terapia Intensiva Neurochirurgica Ospedale S. GerardoMonzaItaly
  3. 3.Terapia Intensiva Neurochirurgica Ospedale S. RaffaeleMilanItaly

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