Advances in Traumatic Brain Injury Care: A Problem-Solving Approach for a Heterogeneous Syndrome

  • Arturo ChieregatoEmail author


Although the definition of traumatic brain injury (TBI) tends to vary according to specialties and circumstances, it is generally accepted that “TBI is defined as an alteration in brain function, or other evidence of brain pathology, caused by an external force” (Menon et al., Arch Phys Med Rehabil 91(11):1637–40, 2010). Head injury patients are heterogeneous (Maas et al. Lancet Neurol. 7(8):728–41, 2008; Saatman et al. J Neurotrauma. 25(7):719–38, 2008), and their care must take account of their age, neurology, imaging, and associated injuries. TBI management is complex and must be specific in each step of the acute phase. The first few hours are extremely important not only for survival but also because the physician must respond to potential life-threatening changes and take all possible measures to reduce both secondary damage and disability. Understanding the physiology of TBI is important because there is minimal monitoring in the acute phase. Consequently, it may be useful to translate the common practice acquired in the neurointensive care unit (Stocchetti et al. Lancet Neurol. 16(6):452–64, 2017) to the early extra-hospital and emergency room phases. The people who care the very initial phase could improve their knowledge of the different clinical patterns following-up the patients in the early few days and weeks after hospital admission. Outcomes at 6 months should also be recorded, to benchmark the acute care and record the patient’s quality of life. This chapter focuses on these heterogeneities and on the sequential phases of patient care, assessing some practical skills. It also focuses on suggestions for the sequential problem-solving approach typical of trauma patient management.


  1. 1.
    Stocchetti N, Maas AI, Chieregato A, van der Plas AA. Hyperventilation in head injury: a review. Chest. 2005;127(5):1812–27. Review. PubMed PMID: 15888864.CrossRefGoogle Scholar
  2. 2.
    Chieregato A, Venditto A, Russo E, Martino C, Bini G. Aggressive medical management of acute traumatic subdural hematomas before emergency craniotomy in patients presenting with bilateral unreactive pupils. A cohort study. Acta Neurochir (Wien). 2017; PubMed PMID: 28435989.
  3. 3.
    Chiara O, Cimbanassi S. Organized trauma care: does volume matter and do trauma centers save lives? Curr Opin Crit Care. 2003;9(6):510–4. Review. PubMed PMID: 14639071.CrossRefGoogle Scholar
  4. 4.
    Chieregato A, Volpi A, Gordini G, Ventura C, Barozzi M, Caspani MLR, Fabbri A, Ferrari AM, Ferri E, Giugni A, Marino M, Martino C, Pizzamiglio M, Ravaldini M, Russo E, Trabucco L, Trombetti S, De Palma R. How health service delivery guides the allocation of major trauma patients in the intensive care units of the inclusive (hub and spoke) trauma system of the Emilia Romagna Region (Italy). A cross-sectional study. BMJ Open. 2017;7(9):e016415. PubMed PMID: 28965094; PubMed Central PMCID: PMC5640142.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Chieregato A, Fainardi E, Morselli-Labate AM, Antonelli V, Compagnone C, Targa L, Kraus J, Servadei F. Factors associated with neurological outcome and lesion progression in traumatic subarachnoid hemorrhage patients. Neurosurgery. 2005;56(4):671–80; discussion 671–80. PubMed PMID: 15792505.CrossRefGoogle Scholar
  6. 6.
    Fainardi E, Chieregato A, Antonelli V, Fagioli L, Servadei F. Time course of CT evolution in traumatic subarachnoid haemorrhage: a study of 141 patients. Acta Neurochir (Wien). 2004;146(3):257–63; discussion 263. PubMed PMID: 15015048.CrossRefGoogle Scholar
  7. 7.
    Servadei F, Murray GD, Penny K, Teasdale GM, Dearden M, Iannotti F, Lapierre F, Maas AJ, Karimi A, Ohman J, Persson L, Stocchetti N, Trojanowski T, Unterberg A. The value of the “worst” computed tomographic scan in clinical studies of moderate and severe head injury. European Brain Injury Consortium. Neurosurgery. 2000;46(1):70–5; discussion 75–7. PubMed PMID: 10626937.CrossRefGoogle Scholar
  8. 8.
    Fabbri A, Servadei F, Marchesini G, Stein SC, Vandelli A. Observational approach to subjects with mild-to-moderate head injury and initial non-neurosurgical lesions. J Neurol Neurosurg Psychiatry. 2008;79(10):1180–5. PubMed PMID: 18356255.CrossRefGoogle Scholar
  9. 9.
    Chieregato A, Martino C, Pransani V, Nori G, Russo E, Noto A, Simini B. Classification of a traumatic brain injury: the Glasgow Coma scale is not enough. Acta Anaesthesiol Scand. 2010;54(6):696–702. PubMed PMID: 20397980.CrossRefPubMedGoogle Scholar
  10. 10.
    Suntharalingam G, Handy J, Walsh A. Regionalisation of critical care: can we sustain an intensive care unit in every hospital? Anaesthesia. 2014;69(10):1069–73. Erratum in: Anaesthesia. 2014;69(11):1298. PubMed PMID: 25204233.CrossRefPubMedGoogle Scholar
  11. 11.
    Sharshar T, Citerio G, Andrews PJ, Chieregato A, Latronico N, Menon DK, Puybasset L, Sandroni C, Stevens RD. Neurological examination of critically ill patients: a pragmatic approach. Report of an ESICM expert panel. Intensive Care Med. 2014;40(4):484–95. PubMed PMID: 24522878.CrossRefPubMedGoogle Scholar
  12. 12.
    Menon DK, Schwab K, Wright DW, Maas AI. Demographics and Clinical Assessment Working Group of the International and Interagency Initiative toward Common Data Elements for Research on Traumatic Brain Injury and Psychological Health. Position statement: definition of traumatic brain injury. Arch Phys Med Rehabil. 2010;91(11):1637–40. Review. PubMed PMID: 21044706.CrossRefPubMedGoogle Scholar
  13. 13.
    Saatman KE, Duhaime AC, Bullock R, Maas AI, Valadka A, Manley GT, Team WS, Members AP. Classification of traumatic brain injury for targeted therapies. J Neurotrauma. 2008;25(7):719–38. PubMed PMID: 18627252; PubMed Central PMCID: PMC2721779.CrossRefGoogle Scholar
  14. 14.
    Stocchetti N, Pagan F, Calappi E, Canavesi K, Beretta L, Citerio G, Cormio M, Colombo A. Inaccurate early assessment of neurological severity in head injury. J Neurotrauma. 2004;21(9):1131–40. PubMed PMID: 15453984.CrossRefGoogle Scholar
  15. 15.
    Chieregato A, Malacarne P, Cocciolo F, Ravaldini M, Russo E, Viaggi B, Giardino M, Rossi C, Simini B, Bertolini G. Aggressive versus conservative antibiotic use to prevent and treat ventilator-associated pneumonia in patients with severe traumatic brain injury: comparison of two case series. Minerva Anesthesiol. 2017;83(6):553–62. PubMed PMID: 28275224.CrossRefGoogle Scholar
  16. 16.
    Stocchetti N, Picetti E, Berardino M, Buki A, Chesnut RM, Fountas KN, Horn P, Hutchinson PJ, Iaccarino C, Kolias AG, Koskinen LO, Latronico N, Maas AI, Payen JF, Rosenthal G, Sahuquillo J, Signoretti S, Soustiel JF, Servadei F. Clinical applications of intracranial pressure monitoring in traumatic brain injury: report of the Milan consensus conference. Acta Neurochir (Wien). 2014;156(8):1615–22. PubMed PMID: 24849391.CrossRefPubMedGoogle Scholar
  17. 17.
    Latronico N, Bolton CF. Critical illness polyneuropathy and myopathy: a major cause of muscle weakness and paralysis. Lancet Neurol. 2011;10(10):931–41. Review. PubMed PMID: 21939902.CrossRefPubMedGoogle Scholar
  18. 18.
    Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W, Petroni G, Lujan S, Pridgeon J, Barber J, Machamer J, Chaddock K, Celix JM, Cherner M, Hendrix T. A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med. 2012;367(26):2471–81. PubMed PMID: 23234472; PubMed Central PMCID: PMC3565432.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Cremer OL, van Dijk GW, van Wensen E, Brekelmans GJ, Moons KG, Leenen LP, Kalkman CJ. Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury. Crit Care Med. 2005;33(10):2207–13. PubMed PMID: 16215372.CrossRefGoogle Scholar
  20. 20.
    Maas AI, Schouten JW, Stocchetti N, Bullock R, Ghajar J. Questioning the value of intracranial pressure (ICP) monitoring in patients with brain injuries. J Trauma. 2008;65(4):966–7. PubMed PMID: 18849824.CrossRefGoogle Scholar
  21. 21.
    Shafi S, Diaz-Arrastia R, Madden C, Gentilello L. Intracranial pressure monitoring in brain-injured patients is associated with worsening of survival. J Trauma. 2008;64(2):335–40. PubMed PMID 18301195.CrossRefPubMedGoogle Scholar
  22. 22.
    Stocchetti N, Maas AI. Traumatic intracranial hypertension. N Engl J Med. 2014;370(22):2121–30. Review. PubMed PMID: 24869722.CrossRefPubMedGoogle Scholar
  23. 23.
    Stocchetti N, Zanaboni C, Colombo A, Citerio G, Beretta L, Ghisoni L, Zanier ER, Canavesi K. Refractory intracranial hypertension and “second-tier” therapies in traumatic brain injury. Intensive Care Med. 2008;34(3):461–7. PubMed PMID: 18066523.CrossRefGoogle Scholar
  24. 24.
    Czosnyka M, Smielewski P, Piechnik S, Schmidt EA, Al-Rawi PG, Kirkpatrick PJ, Pickard JD. Hemodynamic characterization of intracranial pressure plateau waves in head-injury patients. J Neurosurg. 1999;91(1):11–9. PubMed PMID: 10389874.CrossRefGoogle Scholar
  25. 25.
    Stocchetti N, Paternò R, Citerio G, Beretta L, Colombo A. Traumatic brain injury in an aging population. J Neurotrauma. 2012;29(6):1119–25. PubMed PMID: 22220762.CrossRefPubMedGoogle Scholar
  26. 26.
    Cormio M, Citerio G. Continuous low dose diclofenac sodium infusion to control fever in neurosurgical critical care. Neurocrit Care. 2007;6(2):82–9. PubMed PMID: 17522789.CrossRefGoogle Scholar
  27. 27.
    Magnoni S, Tedesco C, Carbonara M, Pluderi M, Colombo A, Stocchetti N. Relationship between systemic glucose and cerebral glucose is preserved in patients with severe traumatic brain injury, but glucose delivery to the brain may become limited when oxidative metabolism is impaired: implications for glycemic control. Crit Care Med. 2012;40(6):1785–91. Scholar
  28. 28.
    Nordström CH, Reinstrup P, Xu W, Gärdenfors A, Ungerstedt U. Assessment of the lower limit for cerebral perfusion pressure in severe head injuries by bedside monitoring of regional energy metabolism. Anesthesiology. 2003;98(4):809–14. PubMed PMID: 12657839.CrossRefGoogle Scholar
  29. 29.
    Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D’Urso P, Kossmann T, Ponsford J, Seppelt I, Reilly P, Wolfe R, DECRA Trial Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med. 2011;364(16):1493–502. PubMed PMID: 21434843.CrossRefGoogle Scholar
  30. 30.
    Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J, Anderson I, Bulters DO, Belli A, Eynon CA, Wadley J, Mendelow AD, Mitchell PM, Wilson MH, Critchley G, Sahuquillo J, Unterberg A, Servadei F, Teasdale GM, Pickard JD, Menon DK, Murray GD, Kirkpatrick PJ, Collaborators RESCUET. Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med. 2016;375(12):1119–30. PubMed PMID:27602507.CrossRefPubMedGoogle Scholar
  31. 31.
    Adams JH, Jennett B, McLellan DR, Murray LS, Graham DI. The neuropathology of the vegetative state after head injury. J Clin Pathol. 1999;52(11):804–6. PubMed PMID: 10690167; PubMed Central PMCID: PMC501589.CrossRefGoogle Scholar
  32. 32.
    Graham DI, Maxwell WL, Adams JH, Jennett B. Novel aspects of the neuropathology of the vegetative state after blunt head injury. Prog Brain Res. 2005;150:445–55. PubMed PMID: 16186041.CrossRefGoogle Scholar
  33. 33.
    Sharp DJ, Scott G, Leech R. Network dysfunction after traumatic brain injury. Nat Rev Neurol. 2014;10(3):156–66. Review. PubMed PMID: 24514870.CrossRefPubMedGoogle Scholar
  34. 34.
    Geurts M, Macleod MR, van Thiel GJ, van Gijn J, Kappelle LJ, van der Worp HB. End-of-life decisions in patients with severe acute brain injury. Lancet Neurol. 2014;13(5):515–24. Review. PubMed PMID: 24675048.CrossRefPubMedGoogle Scholar
  35. 35.
    Hukkelhoven CW, Steyerberg EW, Rampen AJ, Farace E, Habbema JD, Marshall LF, Murray GD, Maas AI. Patient age and outcome following severe traumatic brain injury: an analysis of 5600 patients. J Neurosurg. 2003;99(4):666–73. Review. PubMed PMID: 14567601.CrossRefGoogle Scholar
  36. 36.
    Stocchetti N, Carbonara M, Citerio G, Ercole A, Skrifvars MB, Smielewski P, Zoerle T, Menon DK. Severe traumatic brain injury: targeted management in the intensive care unit. Lancet Neurol. 2017;16(6):452–64. Review. PubMed PMID: 28504109.CrossRefPubMedGoogle Scholar
  37. 37.
    Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol. 2008;7(8):728–41. Review. PubMed PMID: 18635021.CrossRefGoogle Scholar
  38. 38.
    Chieregato A, Paci G, Portolani L, Ravaldini M, Fabbri C, Martino C, Russo E, Simini B. Satisfaction of patients’ next of kin in a ‘Hub & Spoke’ ICU network. Anaesthesia. 2014;69(10):1117–26. PubMed PMID: 25204238.
  39. 39.
    Stocchetti N, Zanier ER. Chronic impact of traumatic brain injury on outcome and quality of life: a narrative review. Crit Care. 2016;20(1):148. Review. PubMed PMID: 27323708; PubMed Central PMCID: PMC4915181.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Chieregato A. The syndrome of the sunken skin flap: a neglected potentially reversible phenomenon affecting recovery after decompressive craniotomy. Intensive Care Med. 2006;32(10):1668–9. PubMed PMID: 16917776.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.NeurorianimazioneASST Grande Ospedale Metropolitano NiguardaMilanItaly

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