Abstract
Therapeutic hypothermia, recently termed target temperature management (TTM), is the cornerstone of neuroprotective strategy. Dating to the pioneer works of Fay, nearly 75 years of basic and clinical evidence support its therapeutic value. Although hypothermia decreases the metabolic rate to restore the supply and demand of O2, it has other tissue-specific effects, such as decreasing excitotoxicity, limiting inflammation, preventing ATP depletion, reducing free radical production and also intracellular calcium overload to avoid apoptosis. Currently, mild hypothermia (33°C) has become a standard in post-resuscitative care and perinatal asphyxia. However, evidence indicates that hypothermia could be useful in neurologic injuries, such as stroke, subarachnoid hemorrhage and traumatic brain injury. In this review, we discuss the basic and clinical evidence supporting the use of TTM in critical care for acute brain injury that extends beyond care after cardiac arrest, such as for ischemic and hemorrhagic strokes, subarachnoid hemorrhage, and traumatic brain injury. We review the historical perspectives of TTM, provide an overview of the techniques and protocols and the pathophysiologic consequences of hypothermia. In addition, we include our experience of managing patients with acute brain injuries treated using endovascular hypothermia.
Highlights
Therapeutic hypothermia, recently termed target temperature management (TTM), is the cornerstone of neuroprotective strategy
Modern use of therapeutic hypothermia as a neuroprotective strategy began in the 1940s with the work of Fay [1], who reported the first series of patients with traumatic brain injury who were treated using hypothermia
Another recognized indication for hypothermia is neonatal encephalopathy, which is a model of global brain ischemia, similar to cardiac arrest, and there is substantial evidence that this treatment reduces the risk of death or disability in infants [34,35]
Summary
Ischemic injury: stroke and cardiac arrest Currently, stroke is a prevalent cause of morbimortality worldwide. Since 2002, when the trial “Hypothermia after Cardiac Arrest Study Group” demonstrated the clinical benefits of therapeutic hypothermia for improving neurological and mortality outcomes in patients suffering TV/FV cardiac arrest [3], many studies have shown the positive effects of hypothermia on neuronal protection in global brain ischemia [2,30,31]. Because hypothermia has been demonstrated to play a key role in preventing reperfusion injury, this phenomenon is less important in the focal setting of stroke [32,33] Another recognized indication for hypothermia is neonatal encephalopathy, which is a model of global brain ischemia, similar to cardiac arrest, and there is substantial evidence that this treatment reduces the risk of death or disability in infants [34,35]. An increased rate of complications was not reported [36]
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