Traumatic Brain Injury Care Research Articles

“Gender matters”: the development of infographics to raise awareness and promote gender-transformative care in traumatic brain injury

ABSTRACT Purpose To develop a series of infographics providing persons with traumatic brain injury (TBI) and their circle of care with evidence-based information on sex and gender topics in TBI. Materials and Methods We employed an iterative participatory design engaging knowledge users, scientists, and experts in brain injury and patient education. To inform infographic content, we conducted an information needs assessment with knowledge users through semi-structured interviews and referred to our previously published evidence syntheses on TBI topics. We followed principles of graphic design and science communication to create materials reflecting lived experiences of knowledge users. Results We created a series of infographics with actionable messages and visual representations of evidence-based information. We achieved a Flesch Reading-Ease score of 60.1, corresponding to a Grade 7/8 reading level. The infographics met the color contrast criteria of the Web Content Accessibility Guidelines. Knowledge users found the material useful, visually appealing, and helpful in understanding complex topics. Conclusions There is value in merging art and science to develop educational materials that meet the unique information needs of knowledge users. Iterative participatory design engaging diverse stakeholders is essential for co-creating knowledge translation tools to improve access to health information and quality of care after TBI.

Abstract Su601: Missed Hypoxia in the Prehospital Care of Major Traumatic Brain Injury: Discrepancies Between Continuous Monitor Data and Clinical Documentation

Background: It is well established that prehospital hypoxia dramatically increases mortality in Traumatic Brain Injury (TBI). Thus, in EMS TBI research, case ascertainment and risk adjustment are highly dependent upon documentation of in-field O 2 saturation (SpO 2 ). Objective: To compare the rate of hypoxia identified by EMS personnel and documented in EMS patient care records (PCR) versus the actual rate of hypoxia recorded by continuous, non-invasive monitoring in TBI. Methods: A subset of major TBI cases (moderate/severe) from 5 EMS agencies reporting monitor data (Philips MRx™) in the EPIC EMS TBI Study (NIH 1R01NS071049) were evaluated (02/13-02/18). All monitor data available for post-hoc review were displayed and accessible to the providers during EMS care. We compared PCR documentation of hypoxia (SpO 2 <90%) to continuous monitor data in TBI patients (nasal canula O 2 , mask, basic or advanced airway). Statistic: exact McNemar’s test, α=0.05. Results: 120 cases were included [med. age 50; IQR (23.8, 68); 65% male. Monitors recorded 44 hypoxic cases (36.7%; 95%CI 28.1, 45.9%). Only 8 (6.7%; 2.9, 12.7%) were documented in the PCR (p<0.0001; Figure). Three machine-detected hypoxia cases had no PCR-documented SpO 2 at all. Conclusions: The difference in PCR-documented and monitor-identified hypoxia was dramatic. The monitor data revealed a five-fold greater incidence of hypoxia than that documented by EMS providers. This may be partially explained by the continuous nature of pulse oximetry in the face of ongoing care responsibilities and scene distractions. The field environment may cause providers to miss low readings as they fluctuate moment-by-moment. These findings have major clinical implications. While some of the discrepancy between PCR reporting and monitor data might simply be failure to document hypoxia, the much more concerning implication is that many cases might be unrecognized and untreated. Furthermore, these findings have important implications for case ascertainment, confounding, and risk-adjustment in EMS TBI research. Whenever possible, quality improvement and research projects should utilize continuous non-invasive monitor data to identify and evaluate hypoxic patients in the setting of TBI. These findings may also have implications for identifying hypoxia in EMS patients with other critical conditions.

The National Association of EMS Physicians Compendium of Prehospital Trauma Management Position Statements and Resource Documents

This prologue to the NAEMSP Prehospital Trauma Compendium describes the rationale for and the process used in developing the compendium manuscripts. It also provides a summary of other contemporary works discussing additional elements of prehospital trauma care including hemorrhage control, airway and ventilation management, pain management, care for traumatic brain injury, and trauma triage.

Impact of the COVID-19 Pandemic on Traumatic Brain Injury Care: Analysis from a Tertiary Emergency Center in Japan

Impact of the COVID-19 Pandemic on Traumatic Brain Injury Care: Analysis from a Tertiary Emergency Center in Japan

Trends in Medicare Utilization and Reimbursement for Traumatic Brain Injury: 2003–2021

Traumatic brain injury (TBI) is a significant public health issue among Medicare beneficiaries, with many specialties reporting consistent annual decreases in utilization and reimbursement. This study investigates the trends in Medicare utilization and rates of reimbursement for neurosurgical procedures related to TBI from 2003 to 2021, aiming to provide insights into the economic aspects of TBI care. Utilizing the Medicare Part B National Summary Data files, we analyzed 14 neurosurgical procedures over the 18-year period, assessing the changes in procedural volume and mean reimbursement per procedure, adjusted for inflation to the 2021 USD using the Consumer Price Index. From 2003 to 2021, TBI-related neurosurgical interventions showed a total percent change of −15.39% in procedural volume and −3.11% in inflation-adjusted mean reimbursement per procedure. Linear regression analyses indicated a significant downward trend in the overall procedural volume (p < 0.001) but no significant trend in the inflation-adjusted mean reimbursement rates (p = 0.585). Subgroup analyses did not reveal significant changes in the reimbursement rates for decompressive craniotomy/craniectomy, cranioplasty, intracranial pressure management, and traumatic fracture/penetration procedures. Our study indicates a significant decrease in neurosurgical TBI procedural volumes, while reimbursement rates remained stable when adjusted for inflation, highlighting the need for policy adjustments to ensure adequate resources for TBI care.

A Survey to Determine Health Utility States After a Traumatic Brain Injury (TBI): Influence of a History of TBI on Disability Perceptions.

Background The Glasgow Outcome Scale-Extended (GOSE) has emerged as one of the most widely used outcome instruments for evaluating ongoing disability and recovery after traumatic brain injury (TBI). The influence of a personal history of TBI on disability perception and quality of life is not well understood. This study aimed to assess changes in health utility states using the GOSE among individuals with severe TBI and their caregivers compared to a general population group. We hypothesized that individuals with a history of TBI, either as patients or caregivers, would recognize health utility associated with a more severe disability than the general population group. Methodology This cross-sectional, observational study included 300 individuals with a history of severe TBI, 300 designated primary caregivers or family members, with 1:1 participation for each subject with severe TBI, and 300 participants from the general population. A computer-based survey was developed based on the GOSE. Participants assessed hypothetical scenarios representing one-year post-TBI outcomes using a standard gamble approach. The main measure for this study was participants' perceptions of health-related quality of life and preferences for different GOSE health states following TBI. Results Of the 900 initial participants, 10 were excluded. Among the remaining 890 participants, lower GOSE states were rated to have lower health utilities. The general population group exhibited a notable decrease in health utility ratings from GOSE4 to GOSE3. Individuals with a history of severe TBI and their caregivers or family members experienced the most substantial decline in health utility ratings between GOSE3 and GOSE2. TBI and caregiver/family member status correlated with higher health utility ratings. Conclusions This study validated the use of the GOSE as a health utility metric and emphasized the subjective nature of acceptable outcomes. These findings underscore the need for considering personal experiences and preferences in decision-making regarding TBI care.

Adverse childhood experiences in adults with chronic traumatic brain injury: Support for a life course approach to brain injury rehabilitation

BackgroundAdverse childhood experiences (ACEs) confer greater risk for adult traumatic brain injury (TBI), but little is known about their effects on post-injury outcomes. ObjectiveTo determine the prevalence and correlates of conventionally defined ACEs (occurring within household/in private; e.g., physical abuse) and community-level ACEs (e.g., bullying) after TBI. MethodsParticipants were 85 Philadelphia-area TBI Model System participants with chronic (>1 year post-injury) TBI. We examined cross-sectional associations between total conventional and community ACEs reported (out of 21) before age 18, mental health symptoms, and health-related quality of life (HRQoL), as well as relationships between ACEs and neighborhood deprivation (census-derived neighborhood socioeconomic status). ResultsThe median number of total ACEs was 3 (range: 0–17). Emotional abuse, physical abuse, and alcohol abuse in the household were the most common conventional ACEs (each at 36.5 %). Witnessing violence (45 %) was the most common community ACE. Black individuals (n = 32) reported more community ACEs (p < .001) than White individuals (n = 45). Community ACEs were significantly associated with greater neighborhood deprivation, though this relationship was confounded by race. Total ACEs was significantly related to more severe mental health symptoms (p < .001) and poorer HRQoL (p = .005), even after covariate adjustment. A fully-adjusted path model supported mental health as a mediator between total ACEs and HRQoL. ConclusionsResults of this preliminary study reveal an appreciable prevalence and potential far-reaching consequences of conventional and community ACEs among those with chronic TBI. The results underscore the value of trauma-informed and life course approaches to research and clinical care in TBI.

Elevating Prehospital Traumatic Brain Injury Care: A Comparative Analysis of Civilian and Military Air Transport Guidelines

ObjectiveTraumatic brain injuries (TBIs) are a leading cause of death and disability worldwide. Establishing TBI guidelines is crucial for prehospital management. Civilian medical practices are often influenced by military trauma guidelines. This study provides a comparative analysis of prehospital TBI management by a civilian air medical evacuation service using civilian guidelines and military clinical practice guidelines from the Joint Trauma System of the Department of Defense. MethodsA retrospective review of 100 deidentified patient transport logs from a prominent civilian air medical service was conducted. The logs were compared with the service's patient care guidelines and the 2023 Joint Trauma System Clinical Practice Guidelines. Data were analyzed for adherence to 14 metrics. ResultsPatients showed improvement in preflight and postflight Glasgow Coma Scale scores and were managed according to recommendations on head elevation, oxygenation, blood pressure, and temperature by both organizations. Discrepancies between guidelines included differences in the management of ventilator settings, blood pressure, oxygenation, temperature, serum glucose, intracranial hypertension, suspected brain herniation, serum sodium levels, and seizure prophylaxis. ConclusionComparing civilian and military guidelines highlights areas for potential improvements in TBI management, such as integrating advanced monitoring and the implementation of (i-STAT, Abbott Laboratories, Chicago, IL) testing in air transport to enhance patient care and outcomes.

Machine Learning Based Prediction of Imminent ICP Insults During Neurocritical Care of Traumatic Brain Injury.

In neurointensive care, increased intracranial pressure (ICP) is a feared secondary brain insult in traumatic brain injury (TBI). A system that predicts ICP insults before they emerge may facilitate early optimization of the physiology, which may in turn lead to stopping the predicted ICP insult from occurring. The aim of this study was to evaluate the performance of different artificial intelligence models in predicting the risk of ICP insults. The models were trained to predict risk of ICP insults starting within 30min, using the Uppsala high frequency TBI dataset. A restricted dataset consisting of only monitoring data were used, and an unrestricted dataset using monitoring data as well as clinical data, demographic data, and radiological evaluations was used. Four different model classes were compared: Gaussian process regression, logistic regression, random forest classifier, and Extreme Gradient Boosted decision trees (XGBoost). Six hundred and two patients with TBI were included (total monitoring 138,411h). On the task of predicting upcoming ICP insults, the Gaussian process regression model performed similarly on the Uppsala high frequency TBI dataset (sensitivity 93.2%, specificity 93.9%, area under the receiver operating characteristic curve [AUROC] 98.3%), as in earlier smaller studies. Using a more flexible model (XGBoost) resulted in a comparable performance (sensitivity 93.8%, specificity 94.6%, AUROC 98.7%). Adding more clinical variables and features further improved the performance of the models slightly (XGBoost: sensitivity 94.1%, specificity of 94.6%, AUROC 98.8%). Artificial intelligence models have potential to become valuable tools for predicting ICP insults in advance during neurointensive care. The fact that common off-the-shelf models, such as XGBoost, performed well in predicting ICP insults opens new possibilities that can lead to faster advances in the field and earlier clinical implementations.

A Survey on the Management of Patients with Severe Traumatic Brain Injury During Pregnancy: The MAMA Study.

Trauma, including traumatic brain injury (TBI), is the leading cause of nonobstetric maternal mortality during pregnancy. Few data are available regarding the optimal management of pregnant patients with TBI, leading to a lack of dedicated guidelines. We performed an international survey to examine the management of severe TBI in pregnant patients, focusing on monitoring, therapy, and intensive care practices. This survey, endorsed by the World Society of Emergency Surgery, was composed of a questionnaire with 79 items divided into four sections: (1) general information (items 1-7), (2) management of the maternal-fetal unit (items 8-43), (3) management of intracranial hypertension (items 44-76), and (4) specific considerations (items 77-79). One hundred and twenty-two physicians from 110 centers in 35 countries responded. The main findings related to TBI care in pregnant patients included the following: (1) a lack of availability of a specific TBI protocol in pregnancy; (2) an increase in the utilization of magnetic resonance imaging as the primary neuroimaging tool; (3) higher hemoglobin thresholds for transfusion; and (4) a lower utilization of therapeutic hypothermia, neuromuscular blocking agents, and barbiturate coma. We also report large variability in the timing of cesarean section in pregnant patients with TBI (≥ 23weeks of gestation) needing an emergency craniotomy (simultaneously 23% vs. later cesarean section 50.8%). Great variability in the management of pregnant patients with severe TBI was identified worldwide from the results of our survey. These findings, highlighting the lack of robust evidence on this topic, will be helpful to stimulate future investigations and to promote educational efforts on this difficult scenario.

Practical pearls for management of cranial injury in the developing world.

Traumatic brain injury (TBI) remains a leading cause of morbidity and mortality, with approximately 69million individuals affected globally each year, particularly in low- and middle-income countries (LMICs) where neurosurgical resources are limited. The neurocognitive consequences of TBI range from life-threatening conditions to more subtle impairments such as cognitive deficits, impulsivity, and behavioral changes, significantly impacting patients' reintegration into society. LMICs bear about 70% of the global trauma burden, with causes of TBI differing from high-income countries (HICs). The lack of equitable neurosurgical care in LMICs exacerbates these challenges. Improving TBI care in LMICs requires targeted resource allocation, neurotrauma registries, increased education, and multidisciplinary approaches within trauma centers. Reports from successful neurotrauma initiatives in low-resource settings provide valuable insights into safe, adaptable strategies for managing TBI when "gold standard" protocols are unfeasible. This review discusses common TBI scenarios in LMICs, highlighting key epidemiological factors, diagnostic challenges, and surgical techniques applicable to resource-limited settings. Specific cases, including epidural hematoma, subdural hematoma, subarachnoid hemorrhage, and cerebrospinal fluid leaks, are explored to provide actionable insights for improving neurosurgical outcomes in LMICs.

Methodology for the Formulation of the Guidelines for the Management of Moderate to Severe Traumatic Brain Injury in Austere and Combat Environments

Care for the patient with traumatic brain injury (TBI) in austere or combat environments is challenging because resources are substantially limited as compared with care for these patients in a tertiary medical facility. Significant research has been and will continue to be performed on TBI care in these settings. This includes high-quality, evidence-based guidelines that are routinely updated to help guide the treating team as to best practices for a wide range of TBI presentations, complications, and outcomes. Much less is known regarding best practices for TBI care in a resource-limited environment, such as a facility in an austere environment without advanced imaging, dedicated neurointensive care, or definitive neurosurgical capabilities. The aim of this study was to identify the methodology that will be used for an upcoming in-person guideline conference, focusing on the care of patients with TBI in resource-limited austere and/or combat zones.

Optimizing Pediatric Traumatic Brain Injury Care in the Emergency Department: A Comprehensive Review of Current Practices and Evidence-Based Strategies

Optimizing Pediatric Traumatic Brain Injury Care in the Emergency Department: A Comprehensive Review of Current Practices and Evidence-Based Strategies

Chronic pain after traumatic brain injury: a collaborative care approach.

Chronic pain is common after traumatic brain injury (TBI), frequently limits daily activities, and is associated with negative outcomes such as decreased community participation. Despite the negative impact of chronic pain, few people with TBI receive effective treatment. This paper describes a collaborative care (CC) intervention, TBI Care, adapted specifically to treat chronic pain in people living with TBI, emphasizing expert clinician input, cognitive behavioral therapy (CBT) techniques, and other non-pharmacological approaches for decreasing pain interference. 79 participants engaged in the CC intervention from two academic medical rehabilitation clinics with weekly assessments of pain intensity, interference, and medication use. Participant feedback on the intervention was gathered by interview with the care manager (CM) at the last treatment session and/or booster session. Provider feedback was gathered by a confidential survey post intervention. Ninety percent of participants received at least 11 of the target 12 sessions with a care manager (CM), the majority occurring over the phone. Participants endorsed an average of 7 pain locations. All participants received pain education, skills in self-monitoring, goal setting/behavioral activation and relaxation training. Pain interference scores (impact on activity and enjoyment), tracked weekly by the CM, significantly decreased across sessions. 89% of participants received recommendations for CBT skills, 65% received referrals for additional treatments targeting pain interference, and 43% received care coordination. 75% of participants reported 6 or more medications/supplements at both the first and last session, with changes recommended primarily for headache treatment. Feedback from participants and providers was positive. TBI Care, a novel patient-centered CC approach, was flexibly delivered, tailored to the needs of those living with TBI and chronic pain, with a high level of participant engagement, and satisfaction among participants and providers. This approach, prioritizing pain self-management strategies and other non-pharmacological approaches, along with optimizing pharmacological treatment, led to significant reductions in self-reported pain interference and intensity during the intervention. Using a CC model in TBI is feasible and successfully improved access to evidence-based treatments for chronic pain as well as outcomes for pain interference and intensity. ClinicalTrials.gov, identifier NCT03523923.

Bridging the gap: enhancing TBI care in Pakistan's primary and secondary healthcare settings.

Traumatic Brain Injury (TBI) in Pakistan is predominantly caused by road traffic accidents, falls, and violence, resulting in approximately 300,000 new cases annually. Significant gaps exist in awareness, resources, and accessibility for effective TBI management, especially in primary care settings. To improve care, strategies include training healthcare providers, nationwide awareness campaigns, strengthening healthcare infrastructure, and establishing referral systems. Collaboration between government, NGOs, and international partners is crucial for enhancing TBI management.

Utilization of the Modified Brain Injury Guidelines by Neurosurgeons to Improve Traumatic Brain Injury Patient Throughput at a Level I Trauma Center: A Retrospective Observational Study

ObjectiveThe Modified Brain Injury Guidelines (mBIG) were developed to improve care of traumatic brain injury (TBI) patients. The objective of this study was to assess if utilization of the mBIG by neurosurgeons would improve TBI patient throughput at a level one trauma center, particularly for patients meeting mBIG 1 criteria. MethodsThis represents a retrospective observational study at one level one trauma center. The mBIG were adopted in November 2021. Outcome and safety data for patients 18 years and older meeting mBIG 1 criteria treated 18 months before (pre-mBIG) and after implementation (post-mBIG) were compared. Patients meeting criteria for mBIG 2 or mBIG 3 classification were excluded. In contrast to the mBIG, neurosurgery was involved in the care of all patients. Results170 patients were included (77 pre-mBIG, 93 post-mBIG). 53 patients (57%) post-mBIG were discharged from the emergency department (ED) after a period of observation, compared to 3 (4%) pre-mBIG (p=<0.01). Patients not discharged post-mBIG were most often admitted for care of other injuries (85%). Repeat neuroimaging was less frequent post-mBIG (15% vs. 62%, p=<0.01). 0 patients in either cohort needed operative neurosurgical interventions, medical therapy for intracranial hypertension, or neurologically deteriorated. 0 patients post-BIG had radiographic injury progression. The rate of ED re-presentation within 30 days was no different (p=0.14). ConclusionsThe mBIG 1 criteria were safe and effective at improving low risk TBI patient throughput at a level one trauma center. Neurosurgical involvement may be beneficial to the mBIG while still facilitating significant resource savings.

Assessing outcomes in traumatic brain injury: Helsinki score versus Glasgow coma scale.

The precision of assessment and prognosis in traumatic brain injury (TBI) is paramount for effective triage and informed therapeutic strategies. While the Glasgow Coma Scale (GCS) remains the cornerstone for TBI evaluation, it overlooks critical primary imaging findings. The Helsinki Score (HS), a novel tool designed to incorporate radiological data, offers a promising approach to predicting TBI outcomes. This study aims to evaluate the prognostic efficacy of HS in comparison to GCS across a substantial TBI patient cohort. This retrospective study encompassed TBI patients treated at our institution between 2008 and 2019, specifically those with an admission GCS of 14 or lower. We assessed both the initial GCS and the HS derived from primary CT scans. Key outcome metrics included the Glasgow Outcome Scale (GOS) and mortality rates at hospital discharge and at 6 and 12-month intervals post-discharge. Predictive performances of GCS and HS were analyzed through Receiver Operating Characteristic (ROC) curves and Kendall tau-b correlation coefficients against each outcome. The study included 544 patients, with an average age of 62.2 ± 21.5 years, median initial GCS of 14, and a median HS of 3. The mortality rate at discharge stood at 8.6%, with a median GOS of 4. Both GCS and HS demonstrated significant correlations with mortality and GOS outcomes (p < 0.05). Notably, HS showed a markedly superior correlation with mortality (τb = 0.36) compared to GCS (τb = -0.11) and with GOS outcomes (τb = -0.40 for HS vs. τb = 0.33 for GCS). ROC analyses affirmed HS's enhanced predictive accuracy over GCS for both mortality (AUC of 0.79 for HS vs. 0.62 for GCS) and overall outcomes (AUC of 0.77 for HS vs. 0.71 for GCS). The findings validate the HS in a large German cohort and suggest that radiological assessments alone, as exemplified by HS, can surpass the traditional GCS in predicting TBI outcomes. However, the HS, despite its efficacy, lacks the integration of clinical evaluation, a vital component in TBI management. This underscores the necessity for a holistic approach that amalgamates both radiological and clinical insights for a more comprehensive and accurate prognostication in TBI care.

Time from injury to operative intervention in traumatic intracranial hematoma: A systematic literature review and meta-analysis.

The outcomes in traumatic intracranial hematoma (TICH) have not improved significantly despite advances in trauma care. A modifiable factor in TICH management is time to operation room (TOR). TOR has become a key marker in Traumatic brain injury care despite a lack of contemporary evidence. This study aimed to determine the timing of TICH evacuation and its association with mortality and neurological outcomes. A systematic review of PubMed, OVID MEDLINE, CINAHL, and Web of Science. Included studies reported data on adult patients with acute TICH who underwent surgical evacuation. The primary outcome was TOR and its association with mortality or functional neurological recovery. From 1838 articles screened, 17 were included. Eight studies reported TOR as a continuous variable, ranging between 3 and 7.1h. Three studies found better outcomes with shorter TOR, five found no difference, and one found worse outcomes with shorter TOR. Five articles were included in meta-analysis of mortality in patients undergoing operative decompression less than or greater than 4h from injury which found lower mortality in the >4-h group, OR=1.53. Longitudinal regression analysis showed no difference in TOR over the 33-year span of articles included. There is limited data available on TOR in TICH, with equivocal results on the effect of timing on outcomes. TOR has not decreased over the last 4decades. The unvalidated 4-h cut-off seems to be associated with better survival. Contemporary assessment of this potentially important performance indicator is required.

Who is seeking information about traumatic brain injury? Characterizing online course participants.

Accessible, up-to-date information on traumatic brain injury (TBI) can be challenging to find and is needed to address TBI knowledge gaps and improve outcomes for people who experience a TBI. The Understanding TBI Massive Open Online Course (TBI MOOC) was developed to increase TBI knowledge across a diverse global audience. We sought to characterize the TBI MOOC participant cohort, to understand the reach of the course among this target audience. Examining the characteristics of TBI MOOC enrollees showed that participants came from a wide range of demographic backgrounds, had a variety of TBI experiences and had multiple reasons for enrolling in the MOOC. The majority of course participants shared some characteristics with other groups of health information seekers. Four distinct demographic profiles were identified among TBI MOOC participants (education seekers, TBI-aware participants, TBI care providers and retirees) using a novel approach combining chi-squared tests and network modularity. Participants assigned to the TBI-aware and retiree profiles were most likely to complete all modules of the MOOC, and the TBI-aware profile was more highly represented in more recent iterations of the MOOC. Together, these data indicate that the TBI MOOC provided information to a wide range of people, and particularly engaged participants with personal or family experience of TBI. However, engagement with this course was minimal among some hard-to-reach populations, including men and people with low levels of education, indicating that additional strategies are needed to ensure equity in health promotion.

Current Aspects of Intensive Medical Care for Traumatic Brain Injury - Part 2 - Secondary Treatment Strategies, Long-term Outcome, Neuroprognostics and Chronification

This two-part article deals with the intensive medical care of traumatic brain injury. Part 1 addresses the primary treatment strategy, haemodynamic management and multimodal monitoring, Part 2 secondary treatment strategies, long-term outcome, neuroprognostics and chronification. Traumatic brain injury is a complex clinical entity with a high mortality rate. The primary aim is to maintain homeostasis based on physiological targeted values. In addition, further therapy must be geared towards intracranial pressure. In addition to this, there are other monitoring options that appear sensible from a pathophysiological point of view with appropriate therapy adjustment. However, there is still a lack of data on their effectiveness. A further aspect is the inflammation of the cerebrum with the "cross-talk" of the organs, which has a significant influence on further intensive medical care.