Visualizing secondary brain insults: does the emperor have new clothes?

Excerpt

The management of patients with severe traumatic brain injury (TBI) is at a crossroads. What we know is that there are an estimated 558–790 cases of TBI per 100,000 person-years in industrialized countries annually, costing more than US$60 billion each year in the USA alone [1, 2]. We also know that it is bad to have persistently elevated intracranial pressure (ICP) after TBI. What we do not know is how best to treat elevated ICP. Guidelines include ICP monitoring and treatment as part of fundamental tenets [3]. However, recent clinical trials cast doubt on whether it is the ICP management that makes the difference and even whether our standard guidelines-based approach targeting an ICP level below 20 mmHg is beneficial at all. In the DECRA trial, decompressive craniectomy lowered ICP in TBI patients whose ICP was considered refractory, but did not improve outcome and may have even been harmful [2]. In the BEST-TRIP clinical trial, a strategy of invasive monitoring of ICP with care focused on maintaining ICP below 20 mmHg was not superior to empiric treatment based on solely clinical examination and imaging [4]. It appears that “one size does not fit all” and new approaches in assessing ICP and secondary brain injury are needed [5]. …