Abstract
BACKGROUNDSevere traumatic brain injury (TBI) requires individualized, physiology-based management to avoid secondary brain injury. Recent improvements in quantitative assessments of metabolism, oxygenation, and subtle examination changes may potentially allow for more targeted, rational approaches beyond simple intracranial pressure (ICP)-based management. The authors present a case in which multimodality monitoring assisted in decision-making for decompressive craniectomy.OBSERVATIONSThis patient sustained a severe TBI without mass lesion and was monitored with a multimodality approach. Although imaging did not seem grossly worrisome, ICP, pressure reactivity, brain tissue oxygenation, and pupillary response all began worsening, pushing toward decompressive craniectomy. All parameters normalized after decompression, and the patient had a satisfactory clinical outcome.LESSONSGiven recent conflicting randomized trials on the utility of decompressive craniectomy in severe TBI, precision, physiology-based approaches may offer an improved strategy to determine who is most likely to benefit from aggressive treatment. Trials are underway to test components of these strategies.
Highlights
Severe traumatic brain injury (TBI) requires individualized, physiology-based management to avoid secondary brain injury
We present a case of a patient with severe TBI managed with Multimodality monitoring (MMM) in whom these variables assisted in decision-making for decompressive craniectomy (DC) with improvement in both monitoring variables and neurological function after intervention
We believe that rapidly worsening PRx, PbO2, and pupillary reactivity were evidence of impending herniation, and all these physiological measures rapidly improved after DC
Summary
Severe traumatic brain injury (TBI) requires individualized, physiology-based management to avoid secondary brain injury. Severe traumatic brain injury (TBI) represents a significant public health problem and is characterized by complex physiology, making individualized, targeted care desirable.[1] neurocritical care and surgical strategies seek to minimize the secondary brain injury that follows the initial injury,[2] it is increasingly being recognized that the physiology of the injured brain can change between patients and even within a given patient over the course of observation This necessitates a precision medicine approach in which therapy is directed toward the individual patient’s physiology.[3] Multimodality monitoring (MMM) may provide better insight into the physiological changes occurring in real time, supplementing the bedside neurological examination and allowing use of directed therapies. We present a case of a patient with severe TBI managed with MMM in whom these variables assisted in decision-making for DC with improvement in both monitoring variables and neurological function after intervention
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