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Cited by 748Traumatic Brain Injury and Neurovascular DisturbancesTraumatic Brain Injury ResearchTrauma and Emergency Care Studies

Prevention of secondary ischemic insults after severe head injury

Robertson, Claudia S., Valadka, Alex B., Hannay, H. Julia, Contant, Charles F., Gopinath, Shankar P., Cormio, Manuela, Uzura, Masahiko, Grossman, Robert G.·1999·Critical Care Medicine
DOI 10.1097/00003246-199910000-00002
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Abstract

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. SETTING: Level I trauma hospital. PATIENTS: One hundred eighty-nine adults admitted in coma because of severe head injury. INTERVENTIONS: Patients were assigned to either cerebral blood flow (CBF)-targeted or intracranial pressure (ICP)-targeted management protocols during randomly assigned time blocks. In the CBF-targeted protocol, cerebral perfusion pressure was kept at >70 mm Hg and PaCO2 was kept at approximately 35 torr (4.67 kPa). In the ICP-targeted protocol, cerebral perfusion pressure was kept at >50 mm Hg and hyperventilation to a PaCO2 of 25-30 torr (3.33-4.00 kPa) was used to treat intracranial hypertension. MEASUREMENTS AND MAIN RESULTS: The CBF-targeted protocol reduced the frequency of jugular desaturation from 50.6% to 30% (p = .006). Even when the frequency of jugular desaturation was adjusted for all confounding factors that were significant, the risk of cerebral ischemia was 2.4-fold greater with the ICP-targeted protocol. Despite the reduction in secondary ischemic insults, there was no difference in neurologic outcome. Failure to alter long-term neurologic outcome was probably attributable to two major factors. A low jugular venous oxygen saturation was treated in both groups, minimizing the injury that occurred in the ICP-targeted group. The beneficial effects of the CBF-targeted protocol may have been offset by a five-fold increase in the frequency of adult respiratory distress syndrome. CONCLUSIONS: Secondary ischemic insults caused by systemic factors after severe head injury can be prevented with a targeted management protocol. However, potential adverse effects of this management strategy may offset these beneficial effects.

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Crossref · 10.1097/00003246-199910000-00002

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  • The second stages of the pathophysiological cascade are characterized by terminal membrane depolarization accompanied by excessive release of excitatory neurotransmitters, activation of NMDA, and voltage-dependent channel opening.

    “The second stages of the pathophysiological cascade are characterized by terminal membrane depolarization accompanied by excessive release of excitatory neurotransmitters (excitotoxicity) such as glutamate and aspartate, activation of N-methyl-D-aspartate, and voltage-dependent channel opening (Na ϩ , K ϩ , Ca 2ϩ ) (97, 121-123).”

    From Pituitary Dysfunction After Traumatic Brain Injury: A Clinical and Pathophysiological Approach (2015) · cites this paper as [123]

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Authors
Robertson, C. S., Valadka, A. B., Hannay, H. J., Contant, C. F., Gopinath, S. P., Cormio, M., Uzura, M., & Grossman, R. G.
Affiliations
  • Baylor College of Medicine (US)
  • University of Houston (US)
ORCID
Venue
Critical Care Medicine
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
1999-10
Volume
27
Issue
10
Pages
2086-2095
ISSN
0090-3493 (ISSN-L)
DOI
10.1097/00003246-199910000-00002
OpenAlex
W2005333810
Cited by
748
References
27
Citations by year
2026: 6 · 2025: 20 · 2024: 20 · 2023: 11 · 2022: 11 · 2021: 19 · 2020: 17 · 2019: 15 · 2018: 22 · 2017: 37 · 2016: 32 · 2015: 33 · 2014: 33 · 2013: 34 · 2012: 30
FWCI
17.04
Type
journal article
Language
en
Open access
closed
Locations
  • Critical Care Medicine (publishedVersion)
  • PubMed (publishedVersion)
Funders
National Institute of Neurological Disorders and Stroke (NS27616)
Topics
  • Health Sciences › Medicine › Neurology › Traumatic Brain Injury and Neurovascular Disturbances
  • Health Sciences › Medicine › Epidemiology › Traumatic Brain Injury Research
  • Health Sciences › Medicine › Emergency Medicine › Trauma and Emergency Care Studies
Keywords
severe traumatic brain injury, intracranial hypertension, cerebral perfusion pressure, hyperventilation, PaCO2, neurological outcome, acute respiratory distress syndrome, coma
MeSH terms
Adolescent, Adult, Analgesics, Opioid, Brain Injuries, Catheterization, Central Venous, Brain Ischemia, Cerebrovascular Circulation, Critical Care, Diuretics, Osmotic, Drainage, Drug Therapy, Combination, Female, Follow-Up Studies, Humans, Hypnotics and Sedatives, Intracranial Pressure, Jugular Veins, Male, Oxygen, Tomography, X-Ray Computed, Trauma Centers, Trauma Severity Indices, Treatment Outcome, Intracranial Hypertension

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