title: Improved outcome after severe head injury with a new therapy based on principles for brain volume regulation and preserved microcirculation.
abstract: OBJECTIVE
  To assess the new "Lund therapy" of posttraumatic brain edema, based on principles for brain-volume regulation and improved microcirculation.
  
  
  METHODS
  A prospective, nonrandomized outcome study over a 5-yr period on severely head-injured patients with increased intracranial pressure, comparing the results with a historical control group with the same selection criteria for patients who were treated according to conventional principles.
  
  
  METHODS
  General intensive care unit of a university hospital.
  
  
  METHODS
  Fifty-three consecutive head-injured patients with a Glasgow Coma Score of <8, and with increased intracranial pressure (>25 mm Hg), despite conventional treatment.
  
  
  METHODS
  Interstitial fluid resorption was obtained by lowering intracapillary hydrostatic pressure, by preserving normal colloid osmotic pressure, and by maintaining a normovolemic (normal albumin/serum and hemoglobin/serum), not overtransfused patient. Intracapillary pressure was reduced by the combination of precapillary vasoconstriction (low-dose thiopental, dihydroergotamine) and reduction of mean arterial pressure, the latter attained with a beta1-antagonist (metoprolol 0.2 to 0.3 mg/kg/24 hrs iv) and an alpha2-agonist (clonidine 0.4 to 0.8 microg/kg x 4 to 6 iv). Clonidine, in combination with normovolemia, also improves microcirculation by reducing catecholamines in plasma. Intracranial blood volume was reduced by arterial (low-dose thiopental sodium and dihydroergotamine) and large-vein (dihydroergotamine) vasoconstriction. The start dose of dihydroergotamine (maximum 0.9 microg/kg/hr) was successively reduced toward discontinuation within 4 to 5 days.
  
  
  RESULTS
  There were 8% of patients who died and the neurologic conditions of 13% remained severely damaged, compared with 47% and 11%, respectively, for the control group.
  
  
  CONCLUSIONS
  The low mortality compared with previous outcome studies strongly indicates that this therapy improves outcome for severe head injuries. However, a randomized, controlled study is needed to reach general acceptance of this new therapy.
authors.affiliation: Department of Rehabilitation, Lund University Hospital, Sweden.
authors.forename: C
authors.initials: C
authors.lastname: Eker
authors.forename: B
authors.initials: B
authors.lastname: Asgeirsson
authors.forename: P O
authors.initials: PO
authors.lastname: Grände
authors.forename: W
authors.initials: W
authors.lastname: Schalén
authors.forename: C H
authors.initials: CH
authors.lastname: Nordström
mesh_terms: D000208:Acute Disease; D000328:Adult; D001929:Brain Edema / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D002560:Cerebrovascular Circulation / Q000187:drug effects; D016009:Chi-Square Distribution; D003131:Combined Modality Therapy; D006259:Craniocerebral Trauma / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D006874:Hydrostatic Pressure; D019586:Intracranial Hypertension / Q000401:mortality / Q000503:physiopathology / Q000628:therapy; D008833:Microcirculation / Q000187:drug effects / Q000503:physiopathology; D008875:Middle Aged; D011446:Prospective Studies; D016896:Treatment Outcome