Carl-Henrik Nordström

Improved outcome after severe head injury with a new therapy based on principles for brain volume regulation and preserved microcirculation.

OBJECTIVEnTo assess the new Lund therapy of posttraumatic brain edema, based on principles for brain-volume regulation and improved microcirculation.nnnDESIGNnA prospective, nonrandomized outcome study over a 5-yr period on severely head-injured patients with increased intracranial pressure, comparing the results with a historical control group with the same selection criteria for patients who were treated according to conventional principles.nnnSETTINGnGeneral intensive care unit of a university hospital.nnnPATIENTSnFifty-three consecutive head-injured patients with a Glasgow Coma Score of <8, and with increased intracranial pressure (>25 mm Hg), despite conventional treatment.nnnINTERVENTIONSnInterstitial fluid resorption was obtained by lowering intracapillary hydrostatic pressure, by preserving normal colloid osmotic pressure, and by maintaining a normovolemic (normal albumin/serum and hemoglobin/serum), not overtransfused patient. Intracapillary pressure was reduced by the combination of precapillary vasoconstriction (low-dose thiopental, dihydroergotamine) and reduction of mean arterial pressure, the latter attained with a beta1-antagonist (metoprolol 0.2 to 0.3 mg/kg/24 hrs iv) and an alpha2-agonist (clonidine 0.4 to 0.8 microg/kg x 4 to 6 iv). Clonidine, in combination with normovolemia, also improves microcirculation by reducing catecholamines in plasma. Intracranial blood volume was reduced by arterial (low-dose thiopental sodium and dihydroergotamine) and large-vein (dihydroergotamine) vasoconstriction. The start dose of dihydroergotamine (maximum 0.9 microg/kg/hr) was successively reduced toward discontinuation within 4 to 5 days.nnnMEASUREMENTS AND MAIN RESULTSnThere were 8% of patients who died and the neurologic conditions of 13% remained severely damaged, compared with 47% and 11%, respectively, for the control group.nnnCONCLUSIONSnThe low mortality compared with previous outcome studies strongly indicates that this therapy improves outcome for severe head injuries. However, a randomized, controlled study is needed to reach general acceptance of this new therapy.

Assessment of the Lower Limit for Cerebral Perfusion Pressure in Severe Head Injuries by Bedside Monitoring of Regional Energy Metabolism.

Background In patients with severe traumatic brain lesions, the lower limit for cerebral perfusion pressure (CPP) is controversial. The aim of this prospective study was to assess this limit from bedside measurements of cerebral energy metabolism and to clarify whether the penumbra zone surrounding a focal lesion is more sensitive to a decrease in CPP than less-injured areas. Methods Fifty patients with severe head injury were included after evacuation of an intracranial hematoma and/or focal brain contusion. They were treated according to intensive care routine (Lund concept), including continuous monitoring of intracranial pressure. One microdialysis catheter was inserted in less-injured brain tissue (“better” position), and one or two catheters were inserted into the boundary of injured cerebral cortex (“worse” position). Concentrations of glucose, pyruvate, and lactate were analyzed and displayed bedside and were related to CPP (n = 29,495). Results Mean interstitial glucose concentration was unaffected by the level of the CPP within the studied ranges. Increases in lactate concentration (P = 0.0008) and lactate–pyruvate ratio (P = 0.01) were obtained in the “worse” but not in the “better” position at CPP less than 50 mmHg compared with the same positions at CPP greater than 50 mmHg. Conclusions The study results support the view that CPP may be reduced to 50 mmHg in patients with severe traumatic brain lesions, provided that the physiologic and pharmacologic principles of the Lund concept are recognized. In the individual patient, preservation of normal concentrations of energy metabolites within cerebral areas at risk can be guaranteed by intracerebral microdialysis and bedside biochemical analyses.

Intracerebral temperature in neurosurgical patients.

Recent laboratory results have indicated that the ischemic brain is very sensitive to minor variations in temperature. This has created new interest in hypothermia and brain temperature. There is, however, very little information available regarding human intracerebral temperature and its relation to body core temperature during normal and pathological circumstances. We therefore made continuous measurements of the temperature of the lateral ventricle in 15 neurosurgical patients utilizing a newly developed technique with copper-constantan thermocouples introduced through a plastic catheter also used for monitoring intracranial pressure. The intraventricular temperature was higher than the rectal temperature during approximately 90% of all measurements. The largest temperature gradient measured was 2.3 degrees C. Usually the difference between the temperature of the rectum and the brain was much smaller, the mean value being 0.33 degrees C. For the patients in the most severe condition, the rectal temperature was sufficiently close to the brain temperature to afford a reliable basis for adequate clinical judgment.

Epidural temperature and possible intracerebral temperature gradients in man

Although it has been known for a long time that pronounced hypothermia has a protective effect on the brain during ischemia, and that severe hyperthermia damages neuronal tissue, knowledge of human brain temperature is very limited. The recent findings by two independent research groups, that even small differences in brain temperature significantly influence the degree of neuronal damage following cerebral ischemia, became the incentive for measuring brain temperature in neurosurgical patients. The temperature of the lateral ventricle, epidural space, membrana tympani and rectum were measured with copper-constantan thermocouples. During the implantation of an intraventricular catheter for measuring intracranial pressure, a temperature gradient of 0.4-1.0 degrees C between the lateral ventricle and the epidural space was noted. Continuous measurements for 1-5 days showed that the rectal temperature usually adequately reflects the temperature of the epidural space, although the temperature of the membrana tympani followed changes in epidural temperature more closely. However, at times, and in one patient during most of the time, the temperature of the epidural space was up to 1 degree C above rectal temperature. The relevance of these findings for the care of neurosurgical patients is discussed in relationship to what is known about brain temperature from animal experiments.

Complications due to Prolonged Ventricular fluid Pressure Recording

All complications in a consecutive series of 648 patients subjected to prolonged recording of the ventricular fluid pressure (VFP) during 1982–1986 were registered and analysed. The procedure did not cause permanent symptoms or deficits in any case except for one haemorrhagic complication. Definite infections caused by the VFP recording were found in 4.3% of the 540 patients (83%) surviving their disease or lesion, and in 1.9% in non-survivors. These infections were almost exclusively registered in patients treated with prolonged drainage of hemorrhagic ventricular fluid, while definite infections in other patients were found in only 1.3%. Most infections were caused by Staphylococcus epidermidis and all infections could be treated successfully. Infection did not cause or contribute to the lethal outcome in any case. In 60% of the cases with infectious complications laboratory signs of ventriculitis occurred after a surgical revision of the ventriculostomy. The duration of VFP recording was of subordinate...

Psychosocial outcome 5–8 years after severe traumatic brain lesions and the impact of rehabilitation services

This study addresses three questions. First, what is the long-term psychosocial outcome for severely head-injured patients? Second, is an increased survival rate associated with an increase in the number of patients with a poor quality of life? Third, do rehabilitation services affect the final outcome? The long-term outcome was assessed by means of questionnaires for self-ratings, interviews with patients and relatives and neurophysical examinations. One hundred and six patients initially judged as good recovery/moderate disability (GR/MD) 6 months post-injury participated in the study. Forty to 50% of these patients showed co-ordination disturbances; more than 20% had speech disorders and cranial nerve deficits. Twenty-eight per cent had psychiatric symptom scores on the Hopkins Symptom Checklist (HSCL) indicating need of treatment. Social function according to the Social Adjustment Scale--Self-Report (SAS--SR) showed that 40% had problems concerning interpersonal relations and 20-30% had problems within the field of leisure activities, but few problems were reported on work activities and economy. The Comprehensive Psychopathological Rating Scale (CPRS) revealed that hostile feelings, failing memory and fatiguability were common symptoms and were reported by relatives in 71%, 52% and 48%, respectively, but the mean distress levels were moderate. A correlation was seen between quality of life reported by relatives and the degree of mental and social disability according to the Bond Outcome Scale, but the correlation to neurophysical handicap was rather weak. The majority of patients were able to return to a productive social life. The proportion of patients with a poor long-term outcome did not increase after introduction of an aggressive management protocol for head injuries. Data indicated that improvements in facilities for rehabilitation may positively affect psychosocial adjustment.

Reduced mortality after severe head injury will increase the demands for rehabilitation services.

Primary objective : In 1989, a new therapy to reduce intracranial pressure in severely head-injured patients was introduced in Lund. The new treatment reduced mortality significantly. The present study describes the quality of life for the survivors Methods and procedures : The study includes 53 patients treated during 1989?1994, according to a new treatment protocol for increased intracranial pressure (?Lund concept group). During 1982?1986, 38 patients were managed according to a protocol including high dose thiopentone (?Thiopentone group). The two groups are compared regarding neurophysical and psychiatric symptoms as well as aspects regarding the patients role, performance, interpersonal relationship, frictions, feelings and satisfaction in work, areas of social and leisure activities, and extended family. Results : Mortality was reduced from 47% to 8%, but the number of patients with a persistent vegetative state and/or remaining severe disability did not increase. However, the number of patients with persisting emotional and intellectual deficits increased significantly. Conclusion : The new treatment regime has dramatically increased the number of survivors after severe head trauma. Although most patients have a favourable outcome, there are more patients with remaining sequelae and disabilities, and the demand for qualified rehabilitation has increased.PRIMARY OBJECTIVEnIn 1989, a new therapy to reduce intracranial pressure in severely head-injured patients was introduced in Lund. The new treatment reduced mortality significantly. The present study describes the quality of life for the survivors.nnnMETHODS AND PROCEDURESnThe study includes 53 patients treated during 1989-1994, according to a new treatment protocol for increased intracranial pressure (Lund concept group). During 1982-1986, 38 patients were managed according to a protocol including high dose thiopentone (Thiopentone group). The two groups are compared regarding neurophysical and psychiatric symptoms as well as aspects regarding the patients role, performance, interpersonal relationship, frictions, feelings and satisfaction in work, areas of social and leisure activities, and extended family.nnnRESULTSnMortality was reduced from 47% to 8%, but the number of patients with a persistent vegetative state and/or remaining severe disability did not increase. However, the number of patients with persisting emotional and intellectual deficits increased significantly.nnnCONCLUSIONnThe new treatment regime has dramatically increased the number of survivors after severe head trauma. Although most patients have a favourable outcome, there are more patients with remaining sequelae and disabilities, and the demand for qualified rehabilitation has increased.

Cerebral Vasoconstriction by Indomethacin in Intracranial Hypertension: An Experimental Investigation in Pigs

BackgroundUncontrolled increase in intracranial pressure is the most significant cause of mortality in patients with severe traumatic brain lesions, and the efficacy of common nonsurgical treatments has been questioned. Pharmacologically induced cerebral vasoconstriction aiming at a decrease of cere

Severe traumatic brain lesions in Sweden. Part I: Aspects of management in non-neurosurgical clinics

This paper reports a study of 587 consecutive patients treated for severe traumatic brain lesions (coma greater than 6 hours) during 1977-1984. Epidemiology, management and outcome were documented in 425 patients during the first part of the study (1977-1982) as a basis for future efforts at improvements. A total of 70-80 patients with severe head injuries were admitted annually to the Department of Neurosurgery in Lund and 88.6% of these patients were referred from 14 local hospitals, most of which are situated more than 50 km from Lund. Half of the patients were older than 40 years and 25% older than 60. Focal intracranial mass lesions were diagnosed in 64% of the patients. In the total study 41% of the patients were described as talk and deteriorate and 13% as talk and die. In 1983 a protocol for primary management was introduced in all local hospitals in the region. The management protocol caused a significant decrease (p less than or equal to 0.05) in the number of explorative craniotomies in local hospitals and a virtual disappearance of late surgical procedures (greater than 6 hours after injury). A fall was observed in the number of patients arriving at the Department of Neurosurgery with respiratory insufficiency. The study illustrates the epidemiology of severe head injuries in Sweden and the present state of management of these patients in non-neurosurgical departments. It is concluded that an overall outcome comparable to other reported series is also feasible in regions with a relatively sparse population and large geographical distances provided that strict recommendations for initial management are given to the local hospitals.

Severe traumatic brain lesions in Sweden. Part 2: Impact of aggressive neurosurgical intensive care.

During a 6 year period (1977-1982), 425 patients were treated in the Department of Neurosurgery, University Hospital of Lund, for severe traumatic brain lesions (coma greater than 6 hours). From 1983 a more aggressive management protocol was introduced including early recording of intracranial pressure (ICP) and 162 patients were included in the study 1983-1984. A dangerous increase in ICP in spite of adequate surgical treatment and moderately controlled hyperventilation was the incentive for barbiturate coma therapy in selected patients. In the first part of the study overall mortality was 48% whereas 39% of the patients reached good recovery/moderate disability 6 months after injury. During the second part of the study the corresponding figures were 35% and 54%, respectively (in both cases p less than or equal to 0.01). In the group of patients with focal intracranial mass lesions mortality decreased from 59% to 46% (p less than or equal to 0.05) and good recovery/moderate disability increased from 30% to 42% (p less than or equal to 0.05). Improvement in outcome was even more pronounced in patients with no-mass lesions, mortality decreased from 30% to 12% and good recovery/moderate disability increased from 56% to 80% (p less than or equal to 0.05 and p less than or equal to 0.01, respectively). No change occurred in age distribution or in the types of intracranial lesions that could explain these improvements. It is concluded that aggressive neurosurgical intensive care significantly improves outcome in patients with severe traumatic brain lesions.