Neurocritical care for traumatic brain injury

Abstract

In Japan, there has been a decrease in head injuries due to traffic accidents, but an increase in these injuries in the elderly due to a fall or a slip. This increase is associated with the rapid aging of society. Thus, diffuse brain injury has decreased, while focal brain injury has increased. More effective surgical interventions have reduced mortality, but other outcomes have not changed. Intracranial pressure (ICP) monitoring is required in intensive treatment of severe head injury, but the Japan Neurotrauma Data Bank showed a reduced rate of ICP monitoring from 36.0% of cases in 1998 to 28.0% in 2009. Patients who underwent ICP monitoring tended to be younger and had cerebral edema based on head CT. Good outcomes were significantly more common in patients with an ICP ≤20 mmHg, whereas mortality was significantly higher in patients with an ICP>40 mmHg. Procedures for ICP monitoring varied in terms of measurement sites and devices. The normal recommendation is to measure ICP using a ventricular catheter, but ICP in Japan is more frequently measured in the brain parenchyma, followed by the subdural space and ventricle. Treatment of intracranial hypertension starts with noninvasive pharmacotherapy. Decompressive craniectomy is used as the final option. The Japan Neurotrauma Data Bank showed that these therapies were used in patients who underwent ICP monitoring and led to a significant decrease in mortality, but did not improve functional outcomes. A mutual understanding of treatment policies between neurosurgeons and neurointensivists leading to an integrated therapeutic approach is likely to improve the treatment outcomes of head injury.