Ischemic Microvascular Failure in Severe Head Injury

  • S. Cotev
  • L. A. Eidelman
  • Y. G. Weiss


It is becoming increasingly evident that cerebral dysfunction and outcome after severe (i.e., Glasgow Coma Scale — GCS ≤ 8) head injury (SHI) are related, as a rule, not only to the initial structural injury to the brain, but also to a variety of secondary pathophysiological mechanisms, the common denominator of which is ischemia. The ischemic insult apparently initiates several known (and probably many others yet unknown) metabolic/biochemical cascades that are often interacting, and may also, in themselves additionally contribute to the ischemic insult. Many pathways of the injurious pattern had been described and recently reviewed (1–3). Accordingly, reports of improved animal outcome have often appeared which were related to employment of various specific antagonists/competitors/inhibitors to either block, blunt or treat steps in these injurious pathways. The reports from the laboratories leave little doubt as to the relevance of these cascades to the clinical equivalent following SHI in man. Several recent reports have now come from studies in humans that tend to reinforce the evidence from the laboratory. The use of pharmacological agents to prevent, or treat the results of these cascades in humans must still be viewed as experimental at the time these lines are being written. It is not the intention of this presentation to review the extensive research that we and many others had published on the chain of very important events associated with the secondary ischemic injury following SHI.


Head Injury Cerebral Perfusion Pressure Severe Head Injury Jugular Venous Oxygen Saturation Acute Head Injury 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Siesjo BK (1992) Pathophysiology and treatment of focal cerebral ischemia. Part I: pathophysiology. J Neurosurg 77:169–184PubMedCrossRefGoogle Scholar
  2. 2.
    Siesjo BK (1992) Pathophysiology and treatment of focal cerebral ischemia. Part II: mechanisms of damage and treatment. J Neurosurg 77:337–354PubMedCrossRefGoogle Scholar
  3. 3.
    Hans P (1995) Acute management of the head-trauma patient. Curr Opin Anaesth 8:163–167CrossRefGoogle Scholar
  4. 4.
    Zupping R (1970) Cerebral acid-base and gas metabolism in brain injury. J Neurosurg 33: 498–505PubMedCrossRefGoogle Scholar
  5. 5.
    Graham DI, Adams JH, Doyle D (1978) Ischaemic brain damage in fatal non-missile head injuries. J Neurol Sci 39:213–234PubMedCrossRefGoogle Scholar
  6. 6.
    Graham DI, Ford I, Adams JH et al (1989) Ischaemic brain damage is still common in fatal non-missile head injury. J Neurol Neurosurg Psychiatry 52:346–350PubMedCrossRefGoogle Scholar
  7. 7.
    Miller JD (1985) Head injury and brain ischaemia-implications for therapy. Br J Anaesth 57:120–129PubMedCrossRefGoogle Scholar
  8. 8.
    Chesnut RM, Marshall LP, Klauber MR et al (1993) The role of secondary brain injury in determining outcome from severe head injury. J Trauma 34:216–222PubMedCrossRefGoogle Scholar
  9. 9.
    Miller JD, Sweet RC, Narayan R et al (1978) Early insults to the injured brain. JAMA 240:439–442PubMedCrossRefGoogle Scholar
  10. 10.
    Pietropaoli JA, Rogers FB, Shackford SR et al (1992) The deleterious effects of intraoperative hypotension on outcome in patients with severe head injuries. J Trauma 33:403–407PubMedCrossRefGoogle Scholar
  11. 11.
    Siegel JH, Gens DR, Mamanov T et al (1991) Effect of associated injuries and blood volume replacement on death, rehabilitation needs, and disability in blunt traumatic brain injury. Crit Care Med 19:1252–1265PubMedCrossRefGoogle Scholar
  12. 12.
    Jones PA, Andrews PJD, Midgley S et al (1994) Measuring the burden of secondary insults in head-injured patients during intensive care. J Neurosurg Anesth 6:4–14Google Scholar
  13. 13.
    Obrist WD, Langfitt TW, Jaggi JL, et al (1984) Cerebral blood flow and metabolism in comatose patients with acute head injury. Relationship to intracranial hypertension. J Neurosurg 61:241–253PubMedCrossRefGoogle Scholar
  14. 14.
    Marion DW, Darby J, Yonas H (1991) Acute regional cerebral blood flow changes caused by severe head injuries. J Neurosurg 74:407–414PubMedCrossRefGoogle Scholar
  15. 15.
    Bouma GJ, Muizelaar JP, Choi SC et al (1991) Cerebral circulation and metabohsm after severe traumatic brain injury: the elusive role of ischemia. J Neurosurg 75:685–693PubMedCrossRefGoogle Scholar
  16. 16.
    Bouma GJ, Muizelaar JP, Stringer WA et al (1992) Ultra-early evaluation of regional cerebral blood flow in severely head-injured patients using xenon-enhanced computerized tomography. J Neurosurg 77:360–368PubMedCrossRefGoogle Scholar
  17. 17.
    Martin NA, Doberstein C, Zane C et al (1992) Posttraumatic cerebral arterial spasm: transcranial Doppler ultrasound, cerebral blood flow, and angiographic findings. J Neurosurg 77:573–583Google Scholar
  18. 18.
    Steiger HJ, Aaslid R, Stooss R et al (1994) Transcranial Doppler monitoring in head injury: relations between type of injury, flow velocities, vasoreactivity, and outcome. Neurosurgery 34:79–86PubMedCrossRefGoogle Scholar
  19. 19.
    Cold GE (1989) Does acute hyperventilation provoke cerebral oligaemia in comatose patients after acute head injury? Acta Neurochir 96:100–106CrossRefGoogle Scholar
  20. 20.
    Miller JD, Becker DP, Ward JD et al (1977) Significance of intracranial hypertension in severe head injury. J Neurosurg 47:503–516PubMedCrossRefGoogle Scholar
  21. 21.
    Marmarou A, Anderson RL, Ward JD et al (1991) Impact of ICP instability and hypotension on outcome in patients with severe head trauma. J Neurosurg 75:S59-S66Google Scholar
  22. 22.
    Price DJE, Murray A (1972) The influence of hypoxia and hypotension on recovery from head injury. Injury 3:218–224PubMedCrossRefGoogle Scholar
  23. 23.
    Tsementzis SA, Gilhngham FJ, Hitchcock ER (1979) The effect of focal twitching on the intracranial pressure during paralysis and mechanical venfilafion. Ann Clin Res 11:253–257PubMedGoogle Scholar
  24. 24.
    Richards P (1986) Severe head injury: the first hour. Br Med J 293:643CrossRefGoogle Scholar
  25. 25.
    Wilden JN (1993) Rapid resuscitafion in severe head injury. Lancet 342:1378PubMedCrossRefGoogle Scholar
  26. 26.
    Gentleman D, Dearden M, Midgley S et al (1993) Guidelines for resuscitafion and transfer of pafients with serious head injury. Br Med J 307:547–552CrossRefGoogle Scholar
  27. 27.
    Klauber MR, Marshall LF, Toole BM et al (1985) Cause of dechne in head-injury mortality rate in San Diego County, Cahfornia. J Neurosurg 62:528–531PubMedCrossRefGoogle Scholar
  28. 28.
    Muizelaar JP, Marmarou A, Ward JD et al (1991) Adverse effects of prolonged hypervenfilafion in pafients with severe head injury: a randomized clinical trial. J Neurosurg 75:731–739PubMedCrossRefGoogle Scholar
  29. 29.
    Sheinberg M, Kanter MJ, Robertson CS et al (1992) Confinuous monitoring of jugular venous oxygen saturafion in head-injured pafients. J Neurosurg 76:212–217PubMedCrossRefGoogle Scholar
  30. 30.
    Chan KH, Miller JD, Dearden NM et al (1992) The effect of changes in cerebral perfusion pressure upon middle cerebral artery blood flow velocity and jugular bulb venous oxygen saturation after severe brain injury. J Neurosurg 77:55–61PubMedCrossRefGoogle Scholar
  31. 31.
    Kostron H, Rumpl E, Stampfl G et al (1985) Treatment of cerebral vasospasm following severe head injury with the calcium influx blocker nimodipine. Neurochirurgia 28:103–109PubMedGoogle Scholar
  32. 32.
    Bailey I, Bell A, Gray J et al (1991) A trial of the effect of nimodipine on outcome after head injury. Acta Neurochir 110:97–105CrossRefGoogle Scholar
  33. 33.
    The European Study Group on Nimodipine in Severe Head Injury (1994) A mulficenter trial of the efficacy of nimodipine on outcome after severe head injury. J Neurosurg 80:797–804CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia, Milano 1996

Authors and Affiliations

  • S. Cotev
  • L. A. Eidelman
  • Y. G. Weiss

There are no affiliations available

Personalised recommendations