Initial neurocritical care of severe traumatic brain injury: New paradigms and old challenges

Abstract

Background: Early neurocritical care aims to ameliorate secondary traumatic brain injury (TBI) and improve neural salvage. Increased engagement of neurosurgeons in neurocritical care is warranted as daily briefings between the intensivist and the neurosurgeon are considered a quality indicator for TBI care. Hence, neurosurgeons should be aware of the latest evidence in the neurocritical care of severe TBI (sTBI).

Methods: We conducted a narrative literature review of bibliographic databases (PubMed and Scopus) to examine recent research of sTBI.

Results: This review has several take-away messages. The concept of critical neuroworsening and its possible causes is discussed. Static thresholds of intracranial pressure (ICP) and cerebral perfusion pressure may not be optimal for all patients. The use of dynamic cerebrovascular reactivity indices such as the pressure reactivity index can facilitate individualized treatment decisions. The use of ICP monitoring to tailor treatment of intracranial hypertension (IHT) is not routinely feasible. Different guidelines have been formulated for different scenarios. Accordingly, we propose an integrated algorithm for ICP management in sTBI patients in different resource settings. Although hyperosmolar therapy and decompressive craniectomy are standard treatments for IHT, there is a lack high-quality evidence on how to use them. A discussion of the advantages and disadvantages of invasive ICP monitoring is included in the study. Addition of beta-blocker, anti-seizure, and anticoagulant medications to standardized management protocols (SMPs) should be considered with careful patient selection.

Conclusion: Despite consolidated research efforts in the refinement of SMPs, there are still many unanswered questions and novel research opportunities for sTBI care.

Keywords: Intracranial hypertension; Intracranial pressure monitoring; Neurocritical care; Neurotrauma; Thromboembolism prophylaxis; Traumatic brain injury.

Figure 1:

Algorithmic approach to the management of raised intracranial pressure. BP: Blood pressure, CPP: Cerebral perfusion pressure, CT: Computed tomography, EEG: Electroencephalogram, EVD: External ventricular drain, GCS: Glasgow Coma Scale, ICP: Intracranial pressure, MAP: Mean arterial pressure, OR: Operating room. *A postoperative CT scan is obtained, and patients are reclassified using the Marshall classification using a dual system. **Escalating treatment is defined as using another measure from the same tier of therapy or upgrading to a higher tier. ^Refers to the dosing frequency of hyperosmolar therapy.