title: Applying cerebral hypothermia and brain oxygen monitoring in treating severe traumatic brain injury.
abstract: BACKGROUND
  Severe traumatic brain injury (TBI) was to be one of the major health problems encountered in modern medicine and had an incalculable socioeconomic impact. The initial cerebral damage after acute brain injury is often exacerbated by postischemic hyperthermia and worsens the outcome. Hypothermia is one of the current therapies designed to combat this deleterious effect. The brain tissue oxygen (P(ti)o(2))-guided cerebral perfusion pressure (CPP) management was successfully reduced because of cerebral hypoxic episodes following TBI.
  
  
  METHODS
  Forty-five patients with severe TBI whose Glasgow Coma Scale (GCS) score ranged between 4 and 8 during September 2006 and August 2007 were enrolled in China Medical University Hospital, Taichung, Taiwan. One patient with a GCS score of 3 was excluded for poor outcome. These patients were randomized into three groups. Group A (16 patients) was intracranial pressure/cerebral perfusion pressure (ICP/CPP)-guided management only, Group B (15 patients) was ICP/CPP guided with mild hypothermia, and Group C (14 patients) was combined mild hypothermia and P(ti)o(2) guided with CPP management on patients with severe TBI. All patients were treated with ICP/CPP management (ICP <20 mm Hg, CPP >60 mm Hg). However, the group with P(ti)o(2) monitoring was required to raise the P(ti)o(2) above 20 mm Hg. Length of intensive care unit stay, ICP, P(ti)o(2), Glasgow Outcome Scale (GOS) score, mortality, and complications were analyzed.
  
  
  RESULTS
  The ICP values progressively increased in the first 3 days but showed smaller changes in hypothermia groups (Groups B and C) and were significantly lower than those of the normothermia group (Group A) at the same time point. We also found out that the averaged ICP were significantly related to days and the daily variations [measured as (daily observation - daily group mean)(2)] of ICP were shown to the significantly different among three treatment groups after the third posttraumatic day. The values of P(ti)o(2) in Group C tended to rise when the ICP decreased were also observed. A favorable outcome is divided by the result of GOS scores. The percentage of favorable neurologic outcome was 50% in the normothermia group, 60% in the hypothermia-only group, and 71.4% in the P(ti)o(2) group, with statistical significance. The percentage of mortality was 12.5% in the normothermia group, 6.7% in the hypothermia-only group, and 8.5% in the P(ti)o(2) group, without statistical significance in three groups. Complications included pulmonary infections, peptic ulcer, and leukocytopenia (43.8% in the normothermia group, 55.6% in the hypothermia-only group, and 50% in the P(ti)o(2) group).
  
  
  CONCLUSIONS
  Therapeutic mild hypothermia combined with P(ti)o(2)-guided CPP/ICP management allows reducing elevated ICP before 24 hours after injury, and daily variations of ICP were shown to be significantly different among the three treatment groups after the third posttraumatic day. It means that the hypothermia groups may reduce the ICP earlier and inhibit the elicitation of acute inflammation after cerebral contusion. Our data also provided evidence that early treatment that lowers P(ti)o(2) may improve the outcome and seems the best medical treatment method in these three groups. We concluded that therapeutic mild hypothermia combined with P(ti)o(2)-guided CPP/ICP management provides beneficial effects when treating TBI, and a multicenter randomized trial needs to be undertaken.
authors.affiliation: Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan, Republic of China.
authors.forename: Han-Chung
authors.initials: HC
authors.lastname: Lee
authors.forename: Hao-Che
authors.initials: HC
authors.lastname: Chuang
authors.forename: Der-Yang
authors.initials: DY
authors.lastname: Cho
authors.forename: Kuang-Fu
authors.initials: KF
authors.lastname: Cheng
authors.forename: Pao-Hsuan
authors.initials: PH
authors.lastname: Lin
authors.forename: Chun-Chung
authors.initials: CC
authors.lastname: Chen
mesh_terms: D000328:Adult; D001930:Brain Injuries / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D002560:Cerebrovascular Circulation; D003399:Craniotomy; D003422:Critical Care / Q000191:economics / Q000379:methods; D005260:Female; D015600:Glasgow Coma Scale; D017721:Hospital Costs; D006801:Humans; D007036:Hypothermia, Induced / Q000191:economics / Q000379:methods*; D002534:Hypoxia, Brain / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D007427:Intracranial Pressure; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000191:economics / Q000379:methods*; D010100:Oxygen / Q000378:metabolism*; D055815:Young Adult
chemical_list: D010100:Oxygen