What are the recommended treatments for brain injury?

Management of Traumatic Brain Injury

The immediate priorities in brain injury management are airway control through endotracheal intubation with end-tidal CO2 monitoring, aggressive maintenance of systolic blood pressure >110 mmHg using vasopressors without delay, urgent non-contrast CT imaging, and ICP monitoring in severe cases to guide pressure-directed therapy. 1

Pre-Hospital and Emergency Stabilization

Airway Management

• Establish tracheal intubation and mechanical ventilation immediately, beginning in the pre-hospital period, as airway control is the absolute priority. 1, 2
• Monitor end-tidal CO2 continuously to confirm correct tube placement and maintain PaCO2 within normal range, as hypocapnia induces cerebral vasoconstriction and risks brain ischemia. 1, 2
• Avoid hyperventilation unless there is acute herniation, as it can worsen cerebral perfusion. 3

Hemodynamic Management

• Maintain systolic blood pressure >110 mmHg from first contact, as even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological outcome. 1, 2
• Use vasopressors (phenylephrine or norepinephrine) immediately for hypotension rather than waiting for fluid resuscitation or sedation adjustment, as these have delayed hemodynamic effects. 1, 2
• This represents a critical paradigm shift—do not delay vasopressor initiation while attempting volume resuscitation. 1

Imaging Strategy

• Obtain non-contrast CT of the brain and cervical spine immediately without delay to guide neurosurgical procedures and monitoring techniques. 1, 2, 4
• Use inframillimetric reconstructions with thickness >1mm, visualized with double window (central nervous system and bone). 1, 2
• Consider CT-angiography when risk factors for vascular injury exist, particularly with fractures near major vessels or in patients with cervical spine injury. 3, 4

Neurosurgical Intervention Criteria

Immediate surgical evacuation is indicated for: 1, 2, 4

• Symptomatic extradural hematoma (any location)
• Acute subdural hematoma with thickness >5mm and midline shift >5mm
• Brain contusions with mass effect
• Acute hydrocephalus requiring drainage
• Open displaced skull fracture
• Closed displaced skull fracture with brain compression (thickness >5mm, midline shift >5mm)

Intracranial Pressure Management

ICP Monitoring Indications

• Implement ICP monitoring in severe TBI when neurological assessment is not feasible to detect intracranial hypertension and guide pressure-directed therapy. 3, 1
• ICP monitoring is particularly indicated when CT shows: compressed basal cisterns (Marshall III), midline shift >5mm (Marshall IV), non-evacuated mass lesion, or traumatic subarachnoid hemorrhage. 3
• ICP 20-40 mmHg increases mortality risk 3.95-fold, while ICP >40 mmHg increases it 6.9-fold. 3

Treatment of Elevated ICP

• External ventricular drainage is suggested as first-line treatment for persistent intracranial hypertension despite sedation and correction of secondary brain insults. 3
• Drainage of even small volumes of CSF can markedly reduce ICP. 3
• Hyperosmolar agents can be used, though specific protocols should follow institutional guidelines. 5

Decompressive Craniectomy

• Consider decompressive craniectomy for refractory intracranial hypertension in multidisciplinary discussion, recognizing it reduces mortality (26.9% vs 48.9%) but increases poor neurological outcomes (8.5% vs 2.1%). 3
• Large unilateral temporal craniectomy (>100 cm²) with enlarged dura mater plasty is the preferred technique for focal lesions. 3
• Avoid bifrontal craniectomy for diffuse injury, as the DECRA study showed worse outcomes (70% poor outcome vs 51% in controls). 3
• Age thresholds of 60-70 years were used in trials; decisions must be individualized beyond these ages. 3

Temperature Management

• Maintain normothermia using targeted temperature control, as hyperthermia increases complications and unfavorable outcomes including death. 3, 1, 2
• Fever is prevalent in neuro-ICU and contributes to secondary injury through increased cerebral metabolism and ICP. 3
• The optimal temperature targets and duration remain under investigation, but fever prevention is clearly beneficial. 3

Sedation and Analgesia

• Use continuous infusions of sedatives rather than boluses to prevent hemodynamic instability. 1, 2
• Propofol administered by continuous infusion can decrease ICP independently of blood pressure changes. 1
• Avoid hypotensive sedative agents; barbiturates, midazolam boluses, and opioid boluses can cause arterial hypotension. 3
• Daily interruption of sedation may be deleterious to cerebral hemodynamics in patients with high ICP. 3

Ventilation Management

• Increasing PEEP from 0 to 5,6-10, and 11-15 cm H₂O is associated with decreased ICP and improved cerebral perfusion pressure. 1
• Maintain normocapnia; avoid routine hyperventilation except for acute herniation. 3

Supportive Care

• Implement detection and prevention strategies for post-traumatic seizures. 1, 2
• Maintain biological homeostasis including osmolarity, glycemia, and adrenal axis function. 1, 2
• Provide nutritional support early in the ICU course. 5

Critical Pitfalls to Avoid

• Never delay vasopressor initiation while waiting for "adequate fluid resuscitation"—this is a common error that worsens outcomes. 1, 2
• Never use bolus sedation instead of continuous infusions, as this causes hemodynamic instability. 1, 2
• Never delay transfer to a specialized neurosurgical center for "stabilization" at a non-neurosurgical facility. 1, 2
• Do not routinely hyperventilate patients, as this can worsen cerebral ischemia. 3

Long-Term Considerations

• The most disabling long-term problems are neuropsychiatric sequelae including personality change, cognitive impairment (attention, memory, executive function), depression, and anxiety rather than physical deficits. 6, 7
• Cognitive rehabilitation is useful for memory impairments and may benefit attention and executive function in patients with mild to moderate impairments. 6
• Psychostimulants (methylphenidate, dextroamphetamine, amantadine) may modestly improve arousal, processing speed, and reduce distractibility. 6