https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(00)02689-1.pdf

Traumatic brain injury.

Traumatic brain injury (TBI) is a major health and socioeconomic problem that affects all societies. In recent years, patterns of injury have been changing, with more injuries, particularly contusions, occurring in older patients. Blast injuries have been identified as a novel entity with specific characteristics. Traditional approaches to the classification of clinical severity are the subject of debate owing to the widespread policy of early sedation and ventilation in more severely injured patients, and are being supplemented with structural and functional neuroimaging. Basic science research has greatly advanced our knowledge of the mechanisms involved in secondary damage, creating opportunities for medical intervention and targeted therapies; however, translating this research into patient benefit remains a challenge. Clinical management has become much more structured and evidence based since the publication of guidelines covering many aspects of care. In this Review, we summarise new developments and current knowledge and controversies, focusing on moderate and severe TBI in adults. Suggestions are provided for the way forward, with an emphasis on epidemiological monitoring, trauma organisation, and approaches to management.

https://www.thelancet.com/pdfs/journals/laneur/PIIS1474-4422(08)70164-9.pdf

Moderate and severe traumatic brain injury in adults.

Purpose— The aim of this statement is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage. Methods— A formal literature search of Medline was performed through the end date of August 2006. The results of this search were complemented by additional articles on related issues known to the writing committee. Data were synthesized with the use of evidence tables. The American Heart Association Stroke Council’s Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 5 expert peer reviewers and by the members of the Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years’ time. Results— Evidence-based guidelines are presented for the diagnosis of intracerebral hemorrhage, the management of increased arterial blood pressure and intracranial pressure, the treatment of medical complications of intracerebral hemorrhag...

http://www.sisalombardia.it/pdfs/stroke-2007_38_2001.pdf

Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group.

Intracranial pressure (ICP) is derived from cerebral blood and cerebrospinal fluid (CSF) circulatory dynamics and can be affected in the course of many diseases of the central nervous system. Monitoring of ICP requires an invasive transducer, although some attempts have been made to measure it non-invasively. Because of its dynamic nature, instant CSF pressure measurement using the height of a fluid column via lumbar puncture may be misleading. An averaging over 30 minutes should be the minimum, with a period of overnight monitoring in conscious patients providing the optimal standard. Computer-aided recording with online waveform analysis of ICP is very helpful. Although there is no “Class I” evidence, ICP monitoring is useful, if not essential, in head injury, poor grade subarachnoid haemorrhage, stroke, intracerebral haematoma, meningitis, acute liver failure, hydrocephalus, benign intracranial hypertension, craniosynostosis etc. Information which can be derived from ICP and its waveforms includes cerebral perfusion pressure (CPP), regulation of cerebral blood flow and volume, CSF absorption capacity, brain compensatory reserve, and content of vasogenic events. Some of these parameters allow prediction of prognosis of survival following head injury and optimisation of “CPP-guided therapy”. In hydrocephalus CSF dynamic tests aid diagnosis and subsequent monitoring of shunt function.

https://jnnp.bmj.com/content/jnnp/75/6/813.full.pdf

Monitoring and interpretation of intracranial pressure

Practice guidelines for physicians who treat children with brain trauma are long overdue. A significant barrier to producing guidelines has been the lack of data from well-designed, controlled studies that address each specific juncture of the acute treatment phase. Our goal with this document was to assimilate the scarce data that exist and present it within an evidencebased framework in order to provide treatment guidelines. With topics for which there were no evidence-based data, we worked as a group to achieve consensus and provided treatment options. To accomplish this, we assembled a multidisciplinary team of clinicians and researchers, keeping in mind that the presence of multiple perspectives would minimize bias. Although we recognize that this list is not complete, it represents a multidisciplinary group of clinicians and scientists with considerable expertise in key areas relevant to the project. We consider this work a “document in progress” and are committed to its ongoing revision and to incorporating additional areas of expertise that may not currently be represented. It is our goal that these guidelines be used to distinguish important areas of research, so that future revisions will contain more substantial evidence. A number of acknowledgments must be

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

Objective:The purpose of this study was to compare the effects of two acute-care management strategies on the frequency of jugular venous desaturation and refractory intracranial hypertension and on long-term neurologic outcome in patients with severe head injury.Design:Randomized clinical trial.Set

H. Hannay

Papers

Prevention of secondary ischemic insults after severe head injury.