Severe traumatic brain injury management and clinical outcome using the Lund concept

Koskinen, Lars-Owe D.; Olivecrona, Magnus; Grände, Per‐Olof

doi:10.1016/j.neuroscience.2014.06.039

Cited by 38 publications

(35 citation statements)

References 92 publications

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“…hydrocephalus, IIH and postural headache. Furthermore, since both area and flow estimations can quickly be performed using ultrasound, determination of the angle where collapse occurs could contribute to treatment of traumatic brain injury, where slight head-of-bed tilt is used to lower ICP [31, 32] and the optimal degree of head elevation is a matter of debate [33, 34]. Understanding how gravity regulates ICP is also of utmost importance for understanding changes in ICP when gravity is removed, i.e.…”

Section: Discussionmentioning

confidence: 99%

Human jugular vein collapse in the upright posture: implications for postural intracranial pressure regulation

Holmlund

Johansson

Qvarlander

et al. 2017

Fluids Barriers CNS

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BackgroundIntracranial pressure (ICP) is directly related to cranial dural venous pressure (P dural). In the upright posture, P dural is affected by the collapse of the internal jugular veins (IJVs) but this regulation of the venous pressure has not been fully understood. A potential biomechanical description of this regulation involves a transmission of surrounding atmospheric pressure to the internal venous pressure of the collapsed IJVs. This can be accomplished if hydrostatic effects are cancelled by the viscous losses in these collapsed veins, resulting in specific IJV cross-sectional areas that can be predicted from flow velocity and vessel inclination.MethodsWe evaluated this potential mechanism in vivo by comparing predicted area to measured IJV area in healthy subjects. Seventeen healthy volunteers (age 45 ± 9 years) were examined using ultrasound to assess IJV area and flow velocity. Ultrasound measurements were performed in supine and sitting positions.ResultsIJV area was 94.5 mm2 in supine and decreased to 6.5 ± 5.1 mm2 in sitting position, which agreed with the predicted IJV area of 8.7 ± 5.2 mm2 (equivalence limit ±5 mm2, one-sided t tests, p = 0.03, 33 IJVs).ConclusionsThe agreement between predicted and measured IJV area in sitting supports the occurrence of a hydrostatic-viscous pressure balance in the IJVs, which would result in a constant pressure segment in these collapsed veins, corresponding to a zero transmural pressure. This balance could thus serve as the mechanism by which collapse of the IJVs regulates P dural and consequently ICP in the upright posture.Electronic supplementary materialThe online version of this article (doi:10.1186/s12987-017-0065-2) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Human jugular vein collapse in the upright posture: implications for postural intracranial pressure regulation

Holmlund

Johansson

Qvarlander

et al. 2017

Fluids Barriers CNS

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“…A large number of studies then confirmed that outcomes tended to be significantly improved in those TBI patients if their ICP<20 mmHg or in those who responded to ICP lowering treatment [39–41]. According to clinical experience, reduced cerebral perfusion contributed to poor outcomes and a minimum cerebral perfusion pressure (CPP) of 50mmHg had been advocated in the Lund concept which was a theoretical approach to the treatment of severe TBI [42]. CPP incorporated with mean arterial blood pressure and ICP parameters was an indirect measure of cerebral perfusion.…”

Section: Discussionmentioning

confidence: 99%

Effects of Intracranial Pressure Monitoring on Mortality in Patients with Severe Traumatic Brain Injury: A Meta-Analysis

Shen

Wang

et al. 2016

PLoS ONE

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BackgroundThe Brain Trauma Foundation (BTF) guidelines published in 2007 suggest some indications for intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI). However, some studies had not shown clinical benefit in patients with severe TBI; several studies had even reported that ICP monitoring was associated with an increased mortality rate. The effect of ICP monitoring has remained controversial, regardless of the ICP monitoring guidelines. Here we performed a meta-analysis of published studies to assess the effects of ICP monitoring in patients with severe TBI.MethodsWe searched three comprehensive databases, the Cochrane Library, PUBMED, and EMBASE, for studies without limitations published up to September 2015. Mortality, ICU LOS, and hospital LOS were analyzed with Review Manager software according to data from the included studies.ResultsEighteen eligible studies involving 25229 patients with severe TBI were included in our meta-analysis. The results indicated no significant reduction in the ICP monitored group in mortality (hospitalized before 2007), hospital mortality (hospitalized before 2007), mortality in randomized controlled trials. However, overall mortality, mortality (hospitalized after 2007), hospital mortality (hospitalized after 2007), mortality in observational studies (hospitalized after 2007), 2-week mortality, 6-month mortality, were reduced in ICP monitored group. Patients with an increased ICP were more likely to require ICP monitoring.ConclusionSuperior survival was observed in severe TBI patients with ICP monitoring since the third edition of “Guidelines for the Management of Severe Traumatic Brain Injury,” which included “Indications for intracranial pressure monitoring,” was published in 2007.

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“…The antihypertensive therapy needs time to act, and it may take hours or even a day before the raised ICP shows signs of reduction after the start of antihypertensive therapy. It is, therefore, better to counteract an increase in ICP early by starting the ICP-reducing therapy as soon as possible after arrival at the hospital, regardless of the prevailing ICP, as recommended in the LC (3, 8). …”

Section: Blood Pressure and Cppmentioning

confidence: 99%

“…In the alternative guidelines, the ICP-reducing therapy should start when ICP is above 20 mmHg (4, 6), a value that has been increased to 22 mmHg in the latest update from the Brain Trauma Foundation (7). In contrast, the LC recommends that the therapy should start early after arrival at the hospital irrespective of prevailing ICP (3, 8). This will counteract an increase in ICP prophylactically from the start.…”

Section: Introductionmentioning

confidence: 99%

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Critical Evaluation of the Lund Concept for Treatment of Severe Traumatic Head Injury, 25 Years after Its Introduction

Grände

2017

Front. Neurol.

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When introduced in 1992, the Lund concept (LC) was the first complete guideline for treatment of severe traumatic brain injury (s-TBI). It was a theoretical approach, based mainly on general physiological principles—i.e., of brain volume control and optimization of brain perfusion and oxygenation of the penumbra zone. The concept gave relatively strict outlines for cerebral perfusion pressure, fluid therapy, ventilation, sedation, nutrition, the use of vasopressors, and osmotherapy. The LC strives for treatment of the pathophysiological mechanisms behind symptoms rather than just treating the symptoms. The treatment is standardized, with less need for individualization. Alternative guidelines published a few years later (e.g., the Brain Trauma Foundation guidelines and European guidelines) were mainly based on meta-analytic approaches from clinical outcome studies and to some extent from systematic reviews. When introduced, they differed extensively from the LC. We still lack any large randomized outcome study comparing the whole concept of BTF guidelines with other guidelines including the LC. From that point of view, there is limited clinical evidence favoring any of the s-TBI guidelines used today. In principle, the LC has not been changed since its introduction. Some components of the alternative guidelines have approached those in the LC. In this review, I discuss some important principles of brain hemodynamics that have been lodestars during formulation of the LC. Aspects of ventilation, nutrition, and temperature control are also discussed. I critically evaluate the most important components of the LC 25 years after its introduction, based on hemodynamic principles and on the results of own an others experimental and human studies that have been published since then.

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Severe traumatic brain injury management and clinical outcome using the Lund concept

Cited by 38 publications

References 92 publications

Human jugular vein collapse in the upright posture: implications for postural intracranial pressure regulation

Human jugular vein collapse in the upright posture: implications for postural intracranial pressure regulation

Effects of Intracranial Pressure Monitoring on Mortality in Patients with Severe Traumatic Brain Injury: A Meta-Analysis

Critical Evaluation of the Lund Concept for Treatment of Severe Traumatic Head Injury, 25 Years after Its Introduction

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