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Refractory intracranial hypertension and “second-tier” therapies in traumatic brain injury

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Abstract

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).

Design

Prospective study of 407 consecutive TBI patients

Setting

Three neurosurgical intensive care units (ICU).

Measurements and 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.

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Acknowledgements

We gratefully acknowledge the contribution of Manuela Cormio MD to the development of the first version of the database and the assistance of Emiliana Calappi MD, Cristina Mattioli MD and Sara Cazzaniga BD in data collection.

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Authors and Affiliations

  1. Neuroscience Intensive Care Unit, Ospedale Maggiore Policlinico, Mangiagalli, e Regina Elena, Fondazione IRCCS, Via F. Sforza 35, 20122, Milan, Italy

    Nino Stocchetti, Clelia Zanaboni, Angelo Colombo, Laura Ghisoni, Elisa Roncati Zanier & Katia Canavesi

  2. Terapia Intensiva Neurochirurgica Ospedale S. Gerardo, Monza, Italy

    Giuseppe Citerio

  3. Terapia Intensiva Neurochirurgica Ospedale S. Raffaele, Milan, Italy

    Luigi Beretta

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  1. Nino Stocchetti
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  2. Clelia Zanaboni
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Correspondence to Nino Stocchetti.

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Stocchetti, N., Zanaboni, C., Colombo, A. et al. Refractory intracranial hypertension and “second-tier” therapies in traumatic brain injury. Intensive Care Med 34, 461–467 (2008). https://doi.org/10.1007/s00134-007-0948-9

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  • DOI: https://doi.org/10.1007/s00134-007-0948-9

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