Management of traumatic brain injury: a narrative review of current evidence

Abstract

Globally, approximately 70 million people sustain traumatic brain injury each year and this can have significant physical, psychosocial and economic consequences for patients, their families and society. The aim of this review is to provide clinicians with a summary of recent studies of direct relevance to the management of traumatic brain injury in order to promote best clinical practice. The use of tranexamic acid in the management of traumatic brain injury has been the focus of several studies, with one large randomised controlled trial suggesting a reduction in all-cause mortality within 24 h of injury. The use of therapeutic hypothermia does not improve neurological outcomes and maintenance of normothermia remains the optimal management strategy. For seizure management, levetiracetam appears to be as effective as phenytoin, but the optimal dose remains unclear. There has been a lack of clear outcome benefit for any individual osmotherapy agent, with no difference in mortality or neurological recovery. Early tracheostomy (< 7 days from injury) for patients with traumatic brain injury is associated with a reduction in the incidence of ventilator-associated pneumonia and duration of mechanical ventilation, critical care and hospital stay. Further research is needed in order to determine the optimal package of care and interventions. There is a need for research studies to focus on patient-centred outcome measures such as long-term neurological recovery and quality of life.

Surgical management of chronic subdural haematoma: looking beyond anaesthetic technique

“…Both factors are associated with a greater risk of worse outcomes [16], and the authors may have unintentionally not included those patients with the greatest potential for benefit from the intervention. Over the last 20 years, much of the research into traumatic brain injury has focused on attempting to find a 'magic bullet' intervention and has not included older patients with medical comorbidities [17]. For interventions to be of clinical utility, it is vital that study protocols include patients who are reflective of those encountered in day-to-day clinical practice.…”

Traumatic brain injury, omega‐3 fatty acids, glutathione and ketosis

“…In his excellent narrative review of recent research into the management of traumatic brain injury, Wiles concludes "it is likely that the greatest benefits will be found from multifaceted interventions and consist of care bundles"[1].He echoes similar conclusions drawn in the sameAnaesthesia supplement by Dhesi and Moppett[2] and Swarbrick and Partridge[3], into the neuroprotective management of older patients, particularly those with nontraumatic brain injury and delirium, respectively. To this end, and in the spirit of aggregating marginal treatment gains, I would like to ask Dr Wiles whether he would currently consider using other low-cost, low-risk neuroprotective interventions for which there is an increasing body of recently published evidence, but which are not addressed in his review?…”

“…In his excellent narrative review of recent research into the management of traumatic brain injury, Wiles concludes “ it is likely that the greatest benefits will be found from multifaceted interventions and consist of care bundles ” [1]. He echoes similar conclusions drawn in the same Anaesthesia supplement by Dhesi and Moppett [2] and Swarbrick and Partridge [3], into the neuroprotective management of older patients, particularly those with non‐traumatic brain injury and delirium, respectively.…”

In search of the perfect outcome in neuroanaesthesia and neurocritical care

“…This issue of Anaesthesia includes several thorough and informative reviews on neuroanaesthesia topics, including mechanical thrombectomy [1], traumatic brain injury (TBI) [2] and peri‐operative neurological monitoring [3]. These reviews provide a valuable synthesis of the current evidence base and have a common thread: much of the current literature focuses on surrogate or short‐term outcomes, and lacks adequate inclusion of long‐term, patient‐centred outcomes for neurological conditions and procedures.…”