Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations

Hawryluk, Gregory; Rubiano, Andrés M.; Totten, Annette M; O’Reilly, Cindy; Ullman, Jamie S.; Bratton, Susan L.; Chesnut, Randall M.; Harris, Odette A.; Kissoon, Niranjan; Shutter, Lori; Tasker, Robert C.; Vavilala, Monica S.; Wilberger, Jack E.; Wright, David W.; Lumba‐Brown, Angela; Ghajar, Jamshid

doi:10.1093/neuros/nyaa278

Cited by 273 publications

(152 citation statements)

References 18 publications

Supporting

Mentioning

137

Contrasting

Unclassified

Order By: Relevance

“…However, the current Brain Trauma Foundation (BTF) guidelines recommend ICP monitoring in unconscious TBI patients and suggest an upper threshold at 22 mmHg ( 7 ). In the case of higher ICP, lowering therapies such as evacuation of significant intracranial hematomas, mild hyperventilation, cerebrospinal fluid (CSF) drainage, barbiturates, and decompressive craniectomy may be used in tiered protocols ( 7 , 16 , 17 ).…”

Section: Traditional Treatment Targets In Neurointensive Carementioning

confidence: 99%

Fine Tuning of Traumatic Brain Injury Management in Neurointensive Care—Indicative Observations and Future Perspectives

2021

View full text Add to dashboard Cite

Neurointensive care (NIC) has contributed to great improvements in clinical outcomes for patients with severe traumatic brain injury (TBI) by preventing, detecting, and treating secondary insults and thereby reducing secondary brain injury. Traditional NIC management has mainly focused on generally applicable escalated treatment protocols to avoid high intracranial pressure (ICP) and to keep the cerebral perfusion pressure (CPP) at sufficiently high levels. However, TBI is a very heterogeneous disease regarding the type of injury, age, comorbidity, secondary injury mechanisms, etc. In recent years, the introduction of multimodality monitoring, including, e.g., pressure autoregulation, brain tissue oxygenation, and cerebral energy metabolism, in addition to ICP and CPP, has increased the understanding of the complex pathophysiology and the physiological effects of treatments in this condition. In this article, we will present some potential future approaches for more individualized patient management and fine-tuning of NIC, taking advantage of multimodal monitoring to further improve outcome after severe TBI.

show abstract

Section: Traditional Treatment Targets In Neurointensive Carementioning

confidence: 99%

Fine Tuning of Traumatic Brain Injury Management in Neurointensive Care—Indicative Observations and Future Perspectives

2021

View full text Add to dashboard Cite

show abstract

“…These cases necessitate NWTs for early detection. This may become more pertinent with the 2020 BTF update recommending decompressive craniectomy for control of late, medically refractory ICP elevation ( 86 ). Table 1 outlines the indications and contraindications.…”

Section: The Nwtmentioning

confidence: 99%

“…Most data indicate that sustained elevations in ICP, and ICP elevation refractory to medical management are deleterious and associated with worse outcomes ( 76 , 83 , 97 ). Consistently, the 2020 BTF update recommends decompressive craniectomy for ICP control only when prolonged and medically recalcitrant, noting late intervention improves mortality whereas early intervention does not ( 86 , 98 ). The concept of “ICP dose” is becoming increasingly investigated.…”

Section: The Nwtmentioning

confidence: 99%

Neurologic Assessment of the Neurocritical Care Patient

Musick

Alberico

2021

Front. Neurol.

View full text Add to dashboard Cite

Sedation is a ubiquitous practice in ICUs and NCCUs. It has the benefit of reducing cerebral energy demands, but also precludes an accurate neurologic assessment. Because of this, sedation is intermittently stopped for the purposes of a neurologic assessment, which is termed a neurologic wake-up test (NWT). NWTs are considered to be the gold-standard in continued assessment of brain-injured patients under sedation. NWTs also produce an acute stress response that is accompanied by elevations in blood pressure, respiratory rate, heart rate, and ICP. Utilization of cerebral microdialysis and brain tissue oxygen monitoring in small cohorts of brain-injured patients suggests that this is not mirrored by alterations in cerebral metabolism, and seldom affects oxygenation. The hard contraindications for the NWT are preexisting intracranial hypertension, barbiturate treatment, status epilepticus, and hyperthermia. However, hemodynamic instability, sedative use for primary ICP control, and sedative use for severe agitation or respiratory distress are considered significant safety concerns. Despite ubiquitous recommendation, it is not clear if additional clinically relevant information is gleaned through its use, especially with the contemporaneous utilization of multimodality monitoring. Various monitoring modalities provide unique and pertinent information about neurologic function, however, their role in improving patient outcomes and guiding treatment plans has not been fully elucidated. There is a paucity of information pertaining to the optimal frequency of NWTs, and if it differs based on type of injury. Only one concrete recommendation was found in the literature, exemplifying the uncertainty surrounding its utility. The most common sedative used and recommended is propofol because of its rapid onset, short duration, and reduction of cerebral energy requirements. Dexmedetomidine may be employed to facilitate serial NWTs, and should always be used in the non-intubated patient or if propofol infusion syndrome (PRIS) develops. Midazolam is not recommended due to tissue accumulation and residual sedation confounding a reliable NWT. Thus, NWTs are well-tolerated in selected patients and remain recommended as the gold-standard for continued neuromonitoring. Predicated upon one expert panel, they should be performed at least one time per day. Propofol or dexmedetomidine are the main sedative choices, both enabling a rapid awakening and consistent NWT.

show abstract

“…Most published cisternostomy studies are either observational (retrospective and nonrandomized), run in single centers, or have small sample sizes [ 29 – 35 ]. This diminishes the quality of evidence generated and has precluded their inclusion in TBI meta-analyses and guidelines [ 3 , 4 ]. Further studies are needed for cisternostomy to be accepted as an option for TBI management.…”

Section: Quality Of Evidencementioning

confidence: 99%

The Rise of Inflow Cisternostomy in Resource-Limited Settings: Rationale, Limitations, and Future Challenges

Kanmounye¹

2021

Emergency Medicine International

View full text Add to dashboard Cite

Low- and middle-income countries (LMICs) bear most of the global burden of traumatic brain injury (TBI), but they lack the resources to address this public health crisis. For TBI guidelines and innovations to be effective, they must consider the context in LMICs; keeping this in mind, this article will focus on the history, pathophysiology, practice, evidence, and implications of cisternostomy. In this narrative review, the author discusses the history, pathophysiology, practice, evidence, and implications of cisternostomy. Cisternostomy for the management of TBI is an innovation developed in LMICs, primarily for LMICs. Its practice is based on the cerebrospinal fluid shift edema theory that attributes injury to increased pressure within the subarachnoid space due to subarachnoid hemorrhage and subsequent dysfunction of glymphatic drainage. Early reports of the technique report significant improvements in the Glasgow Outcome Scale, lower mortality rates, and shorter intensive care unit durations. Most reports are single-center studies with small sample sizes, and the technique requires experience and skill. These limitations have led to criticisms and slow adoption of the technique. Further research is needed to establish the effect of cisternostomy on TBI outcomes.

show abstract

Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations

Cited by 273 publications

References 18 publications

Fine Tuning of Traumatic Brain Injury Management in Neurointensive Care—Indicative Observations and Future Perspectives

Fine Tuning of Traumatic Brain Injury Management in Neurointensive Care—Indicative Observations and Future Perspectives

Neurologic Assessment of the Neurocritical Care Patient

The Rise of Inflow Cisternostomy in Resource-Limited Settings: Rationale, Limitations, and Future Challenges

Contact Info

Product

Resources

About