Treatment of raised intracranial pressure following traumatic brain injury

Appropriate treatment of raised intracranial pressure (ICP) after traumatic brain injury (TBI) remains a controversial topic in neurotraumatology. Several techniques are employed clinically, which include vasopressors, osmotically active substances, hyperventilation, and decompressive surgery. This article reviews six recent papers that have examined alternative methods of treating elevated ICP. The first two papers consider a new and controversial alternative to cerebral perfusion pressure (CPP) management, which involves mild hypotension coupled with pre-capillary vasoconstriction using dihydroergotamine. The authors claim success with this treatment, and although the patient numbers are small, there is no evidence that they fare any less well than patients treated with conventional techniques. The third and fourth papers consider hypertonic saline (HTS) as a possible osmotic treatment for raised ICP. The third examines HTS given as a 23.4% bolus and found beneficial effects. The fourth examines HTS as a 1.6% constant infusion for fluid replacement and found that patients fared less well. The reason for this difference between the results for the two administration methods is unknown, although it may relate to the triggering of body homeostatic mechanisms in the case of constant infusion. The fifth paper compares glycerol and mannitol as osmotic ICP agents and found no significant differences between them. The final study reports for the first time a series of patients treated for refractory elevations in ICP with bifrontal craniectomy. They report good results, and suggest that this therapy should be formalized as a treatment option for severely elevated ICP. The pathophysiological mechanisms underlying the generation of a raised ICP belie the use of one therapy to treat all cases. Analysis of these studies demonstrates how problematic heterogeneity in the injury population can be for the assessment of possible treatments. It is clear, therefore, that effective analysis of treatments for raised ICP requires appropriate subdivision of the injured population into common pathophysiological processes and, furthermore, that the future of clinical TBI management may well require a similar stratification in order to tailor treatments for the individual patient.