Severe traumatic brain injury: targeted management in the intensive care unit

Abstract

Severe traumatic brain injury (TBI) is currently managed in the intensive care unit with a combined medical-surgical approach. Treatment aims to prevent additional brain damage and to optimise conditions for brain recovery. TBI is typically considered and treated as one pathological entity, although in fact it is a syndrome comprising a range of lesions that can require different therapies and physiological goals. Owing to advances in monitoring and imaging, there is now the potential to identify specific mechanisms of brain damage and to better target treatment to individuals or subsets of patients. Targeted treatment is especially relevant for elderly people-who now represent an increasing proportion of patients with TBI-as preinjury comorbidities and their therapies demand tailored management strategies. Progress in monitoring and in understanding pathophysiological mechanisms of TBI could change current management in the intensive care unit, enabling targeted interventions that could ultimately improve outcomes.

Changing care pathways and between-center practice variations in intensive care for traumatic brain injury across Europe: a CENTER-TBI analysis

“…After adjustment for case-mix and random variation between centers, we found significant between-center proportion of short-stay patients discharged alive within 72 h. This confirms the results of earlier studies that found large variation in admission and discharge policies, primarily for mild TBI patients [5,18]. This variation might reflect various factors: a search towards more individualized management [2], a lower adherence to guidelines [19], different availability of resources, or various Fig. 4 Between-center differences in ICU policies and outcome.…”

“…The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI study, registered at clinicaltrials.gov NCT02210221), entails a longitudinal prospective collection of TBI patient data across 63 centers in Europe and Israel between December 19, 2014 andDecember 17, 2017. Inclusion criteria were: (1) clinical diagnosis of TBI; (2) indication for a brain CT scan; and (3) presentation to the hospital within 24 h post-injury. The presence of a severe preexisting neurological disorder, potentially confounding outcome assessment, was the only exclusion criterion.…”

“…Traumatic brain injury (TBI) causes a social and economic global burden with about 82,000 deaths in Europe every year [1]. Patients with severe TBI often receive a highly intensive and multidisciplinary approach to prevent or mitigate both secondary brain injury and systemic complications [2]. For less severe TBI cases (without severe extracranial injury), clinicians have to estimate whether they will benefit from ICU admission, since guidelines with high-level evidence on ICU admission criteria are lacking.…”

Circulating Brain Injury Exosomal Proteins following Moderate-to-Severe Traumatic Brain Injury: Temporal Profile, Outcome Prediction and Therapy Implications

“…In observational studies, severe TBI-related death rate is high (approximately 30%-40%), with no clear change since 1990 [3]. Among TBI survivors, nearly half of those with moderate or severe TBI require years of intensive therapy and face substantial disability and reduced life expectancy, with ensuing disruptive effects and enormous costs to the individuals as well as to their families and society [4,5]. Such dramatic/staggering burden stands in striking contrast to the lack of effective interventions.…”

The Intervention Threshold for Intracranial Pressure of Traumatic Brain Injury Patients Can Be Determined by Clustering Algorithms and Is Observed to Be 13 mm Hg

“…[1] The criterion of when ICP is 'elevated' obviously needs to be known; otherwise, a necessary medical intervention may be missed. Current literature defines the threshold for elevated ICP as 20 mm Hg [2][3][4][5][6] or higher (up to 30 mm Hg [7]). We note that the most recent review of the ICP threshold guidelines relies on "conventional wisdom" to justify this threshold, [8,9] rather than on statistical methodology, as Level I evidence is lacking.…”