Jamshid Ghajar

Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition.

Author Affiliations Patrick M. Kochanek, MD, FCCM, Professor and Vice Chair, Department of Critical Care Medicine, University of Pittsburgh School of Medicine Nancy Carney, PhD, Associate Professor, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University P. David Adelson, MD, FACS, FAAP, Director, Barrow Neurological Institute at Phoenix Children’s Hospital, Chief, Pediatric Neurosurgery/ Children’s Neurosciences Stephen Ashwal, MD, Distinguished Professor of Pediatrics and Neurology, Chief of the Division of Child Neurology, Department of Pediatrics, Loma Linda University School of Medicine Michael J. Bell, MD, Associate Professor of Critical Care Medicine, University of Pittsburgh School of Medicine Susan Bratton, MD, MPH, FAAP, Professor of Pediatric Critical Care Medicine, University of Utah School of Medicine Susan Carson, MPH, Senior Research Associate, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University Randall M. Chesnut, MD, FCCM, FACS, Professor of Neurological Surgery, Orthopedics and Sports Medicine, University of Washington School of Medicine Jamshid Ghajar, MD, PhD, FACS, Clinical Professor of Neurological Surgery, Weill Cornell Medical College, President of the Brain Trauma Foundation Brahm Goldstein, MD, FAAP, FCCM, Senior Medical Director, Clinical Research, Ikaria, Inc., Professor of Pediatrics, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School Gerald A. Grant, MD, Associate Professor of Surgery and Pediatrics, Duke University School of Medicine Niranjan Kissoon, MD, FAAP, FCCM, Professor of Paediatrics and Emergency Medicine, British Columbia’s Children’s Hospital, University of British Columbia Kimberly Peterson, BSc, Research Associate, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University Nathan R. Selden, MD, PhD, FACS, FAAP, Campagna Professor and Vice Chair of Neurological Surgery, Oregon Health & Science University Robert C. Tasker, MBBS, MD, FRCP, Chair and Director, Neurocritical Care, Children’s Hospital Boston, Professor of Neurology and Anesthesia, Harvard Medical School Karen A. Tong, MD, Associate Professor of Radiology, Loma Linda University Monica S. Vavilala, MD, Professor of Anesthesiology and Pediatrics, University of Washington School of Medicine Mark S. Wainwright, MD, PhD, Director, Pediatric Neurocritical Care, Associate Professor of Pediatrics, Northwestern University Feinberg School of Medicine Craig R. Warden, MD, MPH, MS, Professor of Emergency Medicine and Pediatrics, Chief, Pediatric Emergency Services, Oregon Health & Science University/Doernbecher Children’s Hospital

Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition.

The scope and purpose of this work is 2-fold: to synthesize the available evidence and to translate it into recommendations. This document provides recommendations only when there is evidence to support them. As such, they do not constitute a complete protocol for clinical use. Our intention is that these recommendations be used by others to develop treatment protocols, which necessarily need to incorporate consensus and clinical judgment in areas where current evidence is lacking or insufficient. We think it is important to have evidence-based recommendations to clarify what aspects of practice currently can and cannot be supported by evidence, to encourage use of evidence-based treatments that exist, and to encourage creativity in treatment and research in areas where evidence does not exist. The communities of neurosurgery and neuro-intensive care have been early pioneers and supporters of evidence-based medicine and plan to continue in this endeavor. The complete guideline document, which summarizes and evaluates the literature for each topic, and supplemental appendices (A-I) are available online at https://www.braintrauma.org/coma/guidelines.

Surgical Management of Acute Subdural Hematomas

INDICATIONS FOR SURGERY An acute subdural hematoma (SDH) with a thickness greater than 10 mm or a midline shift greater than 5 mm on computed tomographic (CT) scan should be surgically evacuated, regardless of the patients Glasgow Coma Scale (GCS) score. All patients with acute SDH in coma (GCS score less than 9) should undergo intracranial pressure (ICP) monitoring. A comatose patient (GCS score less than 9) with an SDH less than 10-mm thick and a midline shift less than 5 mm should undergo surgical evacuation of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg. TIMING In patients with acute SDH and indications for surgery, surgical evacuation should be performed as soon as possible. METHODS If surgical evacuation of an acute SDH in a comatose patient (GCS < 9) is indicated, it should be performed using a craniotomy with or without bone flap removal and duraplasty.

Focal Lesions in Acute Mild Traumatic Brain Injury and Neurocognitive Outcome: CT versus 3T MRI

Mild traumatic brain injury (mTBI) is associated with long-term cognitive deficits. This study compared the detection rate of acute post-traumatic focal lesions on computed tomography (CT) and 3T (Tesla) magnetic resonance (MR) imaging with neurocognitive outcomes. Adults (n = 36; age range, 19-52 years) with a single episode of mTBI (Glasgow Coma Scale 13-15, as well as loss of consciousness and post-traumatic amnesia) were prospectively enrolled and had CT within 24 h of injury and 3T MR within 2 weeks of injury. The CT and MR scans were reviewed by two neuroradiologists who were blinded to clinical information. Twenty-eight of these mTBI subjects and 18 matched healthy volunteers also underwent serial neurocognitive testing. Of the 36 mTBI cases, intraparenchymal lesions were detected in 18 CT and 27 acute MR exams, consisting of hemorrhagic traumatic axonal injury (TAI) (eight CT, 17 MR), non-hemorrhagic TAI (zero CT, four MR), and cerebral contusions (13 CT, 21 MR). Mild TBI patients had significantly worse performance on working memory tasks than matched controls at the acute time point (<2 weeks), and at 1 month and at 1 year post-injury; yet there was no significant correlation of imaging findings with working memory impairment. In conclusion, 3T MR detected parenchymal lesions in 75% of this mTBI cohort with loss of consciousness and post-traumatic amnesia, a much higher rate than CT. However, the CT and 3T MR imaging findings did not account for cognitive impairment, suggesting that newer imaging techniques such as diffusion tensor imaging are needed to provide biomarkers for neurocognitive and functional outcome in mTBI.

Response anticipation and response conflict: an event-related potential and functional magnetic resonance imaging study.

Response anticipation and response conflict processes are supported by executive control. However, few neuroimaging studies have attempted to study the relationship between these two processes in the same experimental session. In this study, we isolated brain activity associated with response anticipation (after a cue to prepare vs relax) and with response conflict (responding to a target with incongruent vs congruent flankers) and examined the independence and interaction of brain networks supporting these processes using event-related potentials (ERPs) and functional magnetic resonance imaging. Response anticipation generated a contingent negative variation ERP that correlated with shorter reaction times, and was associated with activation of a thalamo-cortico-striatal network, as well as increased gamma band power in frontal and parietal regions, and decreased spectral power in theta, alpha, and beta bands in most regions. Response conflict was associated with increased activation in the anterior cingulate cortex (ACC) and prefrontal cortex of the executive control network, with an overlap in activation with response anticipation in regions including the middle frontal gyrus, ACC, and superior parietal lobule. Although the executive control network showed increased activation in response to unanticipated versus anticipated targets, the response conflict effect was not altered by response anticipation. These results suggest that common regions of a dorsal frontoparietal network and the ACC are engaged in the flexible control of a wide range of executive processes, and that response anticipation modulates overall activity in the executive control network but does not interact with response conflict processing.

Surgical management of acute epidural hematomas.

INDICATIONS FOR SURGERY An epidural hematoma (EDH) greater than 30 cm3 should be surgically evacuated regardless of the patients Glasgow Coma Scale (GCS) score. An EDH less than 30 cm3 and with less than a 15-mm thickness and with less than a 5-mm midline shift (MLS) in patients with a GCS score greater than 8 without focal deficit can be managed nonoperatively with serial computed tomographic (CT) scanning and close neurological observation in a neurosurgical center. TIMING It is strongly recommended that patients with an acute EDH in coma (GCS score < 9) with anisocoria undergo surgical evacuation as soon as possible. METHODS There are insufficient data to support one surgical treatment method. However, craniotomy provides a more complete evacuation of the hematoma.

Surgical management of traumatic parenchymal lesions

INDICATIONS Patients with parenchymal mass lesions and signs of progressive neurological deterioration referable to the lesion, medically refractory intracranial hypertension, or signs of mass effect on computed tomographic (CT) scan should be treated operatively. Patients with Glasgow Coma Scale (GCS) scores of 6 to 8 with frontal or temporal contusions greater than 20 cm3 in volume with midline shift of at least 5 mm and/or cisternal compression on CT scan, and patients with any lesion greater than 50 cm3 in volume should be treated operatively. Patients with parenchymal mass lesions who do not show evidence for neurological compromise, have controlled intracranial pressure (ICP), and no significant signs of mass effect on CT scan may be managed nonoperatively with intensive monitoring and serial imaging. TIMING AND METHODS Craniotomy with evacuation of mass lesion is recommended for those patients with focal lesions and the surgical indications listed above, under Indications. Bifrontal decompressive craniectomy within 48 hours of injury is a treatment option for patients with diffuse, medically refractory posttraumatic cerebral edema and resultant intracranial hypertension. Decompressive procedures, including subtemporal decompression, temporal lobectomy, and hemispheric decompressive craniectomy, are treatment options for patients with refractory intracranial hypertension and diffuse parenchymal injury with clinical and radiographic evidence for impending transtentorial herniation.

Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

OBJECT Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe traumatic brain injury (TBI), but there is limited evidence that monitoring and treating intracranial hypertension reduces mortality. This study uses a large, prospectively collected database to examine the effect on 2-week mortality of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP monitor. METHODS From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score <9), 1446 patients were treated with ICP-lowering therapies. Of those, 1202 had an ICP monitor inserted and 244 were treated without monitoring. Patients were admitted to one of 20 Level I and two Level II trauma centers, part of a New York State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009. This database also contains information on known independent early prognostic indicators of mortality, including age, admission GCS score, pupillary status, CT scanning findings, and hypotension. RESULTS Age, initial GCS score, hypotension, and CT scan findings were associated with 2-week mortality. In addition, patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 0.02) than those treated without an ICP monitor, after adjusting for parameters that independently affect mortality. CONCLUSIONS In patients with severe TBI treated for intracranial hypertension, the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor. Based on these findings, the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring.

Effect of early nutrition on deaths due to severe traumatic brain injury

OBJECT Traumatic brain injury (TBI) remains a serious public health crisis requiring continuous improvement in pre-hospital and inhospital care. This condition results in a hypermetabolic state that increases systemic and cerebral energy requirements, but achieving adequate nutrition to meet this demand has not been a priority in reducing death due to TBI. The effect of timing and quantity of nutrition on death within the first 2 weeks of injury was analyzed in a large prospective database of adult patients with severe TBI in New York State. METHODS The study is based on 797 patients with severe TBI (Glasgow Coma Scale [GCS] score < 9) treated at 22 trauma centers enrolled in a New York State quality improvement program between 2000 and 2006. The inhospital section of the prospectively collected database includes information on age, initial GCS score, weight and height, results of CT scanning, and daily parameters such as pupillary status, arterial hypotension, GCS score, and number of calories fed per day. RESULTS Patients who were not fed within 5 and 7 days after TBI had a 2- and 4-fold increased likelihood of death, respectively. The amount of nutrition in the first 5 days was related to death; every 10-kcal/kg decrease in caloric intake was associated with a 30-40% increase in mortality rates. This held up even after controlling for factors known to affect mortality, including arterial hypotension, age, pupillary status, initial GCS score, and CT scan findings. CONCLUSIONS Nutrition is a significant predictor of death due to TBI. Together with prevention of arterial hypotension, hypoxia, and intracranial hypertension it is one of the few therapeutic interventions that can directly affect TBI outcome.

Marked reduction in mortality in patients with severe traumatic brain injury.

OBJECT In spite of evidence that use of the Brain Trauma Foundation Guidelines for the Management of Severe Traumatic Brain Injury (Guidelines) would dramatically reduce morbidity and mortality, adherence to these Guidelines remains variable across trauma centers. The authors analyzed 2-week mortality due to severe traumatic brain injury (TBI) from 2001 through 2009 in New York State and examined the trends in adherence to the Guidelines. METHODS The authors calculated trends in adherence to the Guidelines and age-adjusted 2-week mortality rates between January 1, 2001, and December 31, 2009. Univariate and multivariate logistic regression analyses were performed to evaluate the effect of time period on case-fatality. Intracranial pressure (ICP) monitor insertion was modeled in a 2-level hierarchical model using generalized linear mixed effects to allow for clustering by different centers. RESULTS From 2001 to 2009, the case-fatality rate decreased from 22% to 13% (p < 0.0001), a change that remained significant after adjusting for factors that independently predict mortality (adjusted OR 0.52, 95% CI 0.39-0.70; p < 0.0001). Guidelines adherence increased, with the percentage of patients with ICP monitoring increasing from 56% to 75% (p < 0.0001). Adherence to cerebral perfusion pressure treatment thresholds increased from 15% to 48% (p < 0.0001). The proportion of patients having an ICP elevation greater than 25 mm Hg dropped from 42% to 29% (p = 0.0001). CONCLUSIONS There was a significant reduction in TBI mortality between 2001 and 2009 in New York State. Increase in Guidelines adherence occurred at the same time as the pronounced decrease in 2-week mortality and decreased rate of intracranial hypertension, suggesting a causal relationship between Guidelines adherence and improved outcomes. Our findings warrant future investigation to identify methods for increasing and sustaining adherence to evidence-based Guidelines recommendations.