Traumatic Brain Injury

Pathophysiology

Edema/ICP Elevation

_{The vicious cycle of head injury}

After severe TBI w/ ↑ ICP → ⊕ feedback loop can ensue, leading ultimately to brain death. This situation can be likened to a compartment syndrome w/i the noncompliant skull. ↑ of ICP (A) → impedes CBF → ischemia → cytotoxic edema caused in part by ATP–dependent Na+-K+ pump failure. This in turn further ↑ ICP & ↓ CBF. This situation can ultimately progress to brain death if ICP becomes so high that the cerebrum is not perfused.

Articles

Key articles

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IMPACT Study

✓ the value of different prognostic factors in TBI ⇒ the most powerful independent prognostic variables identified were age, GCS motor score, pupil response, and CT finding (Marshall classification), labs (PT & glu) (J Neurotrauma. 2007)

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CRASH trial	✓ effect of early steroids Rx in adults /w TBI ⇒ ↑ death compared to placebo. (Lancet 2004)
CRASH-2	✓ the effects of early TXA Rx in TBI pts /w significant haemorrhage ⇒ ↓ mortality & death d/t bleeding w/o ↑ vascular occlusive events (Lancet 2010)

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DECRA	Efficacy of DC in severe TBI /w refractory ↑ ICP ⇒ DC ↓ ICP & ↓ ICU stay; assoc. /w worse fnx o/c at 6 mn. (N Engl J Med 2011)
RESCUEicp	✓ effectiveness of DC in pts /w TBI & refractory ↑ ICP ⇒ DC ↓ mortality; ↑ risk of severe disability & vegetative state compared to medical Tx alone. (N Engl J Med 2016)

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BEST-TRIP

✓ ICP monitoring in pts /w severe TBI improves o/c ⇒ ICP focused Tx was not better to care based on CT and Px → routine ICP monitoring does not provide additional benefits for pts o/c (N Engl J Med 2012)