Refractory intracranial hypertension and "second-tier" therapies in traumatic brain injury.
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).


METHODS
Prospective study of 407 consecutive TBI patients


METHODS
Three neurosurgical intensive care units (ICU).


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.
Stocchetti
Nino
N
Neuroscience Intensive Care Unit, Ospedale Maggiore Policlinico, Mangiagalli, e Regina Elena, Fondazione IRCCS, Via F. Sforza 35, 20122 Milan, Italy. stocchet@policlinico.mi.it
Zanaboni
Clelia
C
Colombo
Angelo
A
Citerio
Giuseppe
G
Beretta
Luigi
L
Ghisoni
Laura
L
Zanier
Elisa Roncati
ER
Canavesi
Katia
K
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001930:Brain Injuries / Q000150:complications* / Q000628:therapy*; D003131:Combined Modality Therapy; D003399:Craniotomy / Q000379:methods; D019299:Decompression, Surgical; D005260:Female; D023261:Glasgow Outcome Scale; D006801:Humans; D007362:Intensive Care Units; D019586:Intracranial Hypertension / Q000209:etiology* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000379:methods; D013874:Thiopental / Q000627:therapeutic use*; D016896:Treatment Outcome
D013874:Thiopental