PURPOSE:Secondary brain ischaemia (SBI) usually develops after aneurysmal subarachnoid haemorrhage (SAH) and severe traumatic brain injury (TBI). Current approaches to managing these conditions are based either on intracranial pressure-targeted therapy (ICP-targeted) with cerebral microdialysis (CM) monitoring according to the modified Lund concept or cerebral perfusion pressure-targeted therapy (CPP-targeted). We present a prospective, randomised controlled study comparing relative effectiveness of the two management strategies. METHODS:Sixty comatose operated patients with SBI following aneurysmal SAH and severe TBI were randomised into ICP-targeted therapy with CM monitoring and CPP-targeted therapy groups. Mortality rates in both groups were calculated and tissue biochemical signs of cerebral ischaemia were analysed using CM. Measured CM data were related to outcome (Glasgow Outcome Scale [GOS] score 1, 2 and 3 for poor outcome or GOS score 4 and 5 for good outcome). RESULTS: Patients treated with ICP-targeted therapy with CM monitoring had significantly lower mortality rate as compared with those treated with CPP-targeted therapy (P=0.03). Patients monitored with CM who had poor outcome had lower mean values of glucose and higher mean values of glycerol and lactate/pyruvate ratio as compared with those who had good outcome (glucose: P=0.003; glycerol: P=0.02; lactate/pyruvate ratio: P=0.01). There was no difference in the mortality outcome between aneurysmal SAH and severe TBI in the two groups (P=0.28 for ICP-targeted therapy with CM monitoring, P=0.36 for CPP-targeted therapy). Also, there were no differences in the CM values between patients with aneurysmal SAH and severe TBI who underwent ICP-targeted therapy (glucose: P=0.23; glycerol: P=0.41; lactate/pyruvate ratio: P=0.40). CONCLUSION: The modified Lund concept, directed at bedside real-time monitoring of brain biochemistry by CM showed better results compared to CPP-targeted therapy in the treatment of comatose patients sustaining SBI after aneurysmal SAH and severe TBI.
RCT Entities:
PURPOSE: Secondary brain ischaemia (SBI) usually develops after aneurysmal subarachnoid haemorrhage (SAH) and severe traumatic brain injury (TBI). Current approaches to managing these conditions are based either on intracranial pressure-targeted therapy (ICP-targeted) with cerebral microdialysis (CM) monitoring according to the modified Lund concept or cerebral perfusion pressure-targeted therapy (CPP-targeted). We present a prospective, randomised controlled study comparing relative effectiveness of the two management strategies. METHODS: Sixty comatose operated patients with SBI following aneurysmalSAH and severe TBI were randomised into ICP-targeted therapy with CM monitoring and CPP-targeted therapy groups. Mortality rates in both groups were calculated and tissue biochemical signs of cerebral ischaemia were analysed using CM. Measured CM data were related to outcome (Glasgow Outcome Scale [GOS] score 1, 2 and 3 for poor outcome or GOS score 4 and 5 for good outcome). RESULTS:Patients treated with ICP-targeted therapy with CM monitoring had significantly lower mortality rate as compared with those treated with CPP-targeted therapy (P=0.03). Patients monitored with CM who had poor outcome had lower mean values of glucose and higher mean values of glycerol and lactate/pyruvate ratio as compared with those who had good outcome (glucose: P=0.003; glycerol: P=0.02; lactate/pyruvate ratio: P=0.01). There was no difference in the mortality outcome between aneurysmalSAH and severe TBI in the two groups (P=0.28 for ICP-targeted therapy with CM monitoring, P=0.36 for CPP-targeted therapy). Also, there were no differences in the CM values between patients with aneurysmalSAH and severe TBI who underwent ICP-targeted therapy (glucose: P=0.23; glycerol: P=0.41; lactate/pyruvate ratio: P=0.40). CONCLUSION: The modified Lund concept, directed at bedside real-time monitoring of brain biochemistry by CM showed better results compared to CPP-targeted therapy in the treatment of comatosepatients sustaining SBI after aneurysmalSAH and severe TBI.
Authors: Mayur B Patel; John W McKenna; JoAnn M Alvarez; Ayaka Sugiura; Judith M Jenkins; Oscar D Guillamondegui; Pratik P Pandharipande Journal: Trials Date: 2012-09-26 Impact factor: 2.279
Authors: Peter J Hutchinson; Ibrahim Jalloh; Adel Helmy; Keri L H Carpenter; Elham Rostami; Bo-Michael Bellander; Martyn G Boutelle; Jeff W Chen; Jan Claassen; Claire Dahyot-Fizelier; Per Enblad; Clare N Gallagher; Raimund Helbok; Lars Hillered; Peter D Le Roux; Sandra Magnoni; Halinder S Mangat; David K Menon; Carl-Henrik Nordström; Kristine H O'Phelan; Mauro Oddo; Jon Perez Barcena; Claudia Robertson; Elisabeth Ronne-Engström; Juan Sahuquillo; Martin Smith; Nino Stocchetti; Antonio Belli; T Adrian Carpenter; Jonathan P Coles; Marek Czosnyka; Nil Dizdar; J Clay Goodman; Arun K Gupta; Troels H Nielsen; Niklas Marklund; Ambroise Montcriol; Mark T O'Connell; Maria A Poca; Asita Sarrafzadeh; Richard J Shannon; Jane Skjøth-Rasmussen; Peter Smielewski; John F Stover; Ivan Timofeev; Paul Vespa; Elizabeth Zavala; Urban Ungerstedt Journal: Intensive Care Med Date: 2015-09 Impact factor: 17.440
Authors: Frederick A Zeiler; Eric Peter Thelin; Adel Helmy; Marek Czosnyka; Peter J A Hutchinson; David K Menon Journal: Acta Neurochir (Wien) Date: 2017-10-07 Impact factor: 2.216