Letter: Guidelines for the Management of Severe Traumatic Brain Injury Fourth Edition

To the Editor: We have read with great interest the new edition of the Brain Trauma Foundation guidelines for the management of severe traumatic brain injury (TBI).1 The authors should be congratulated for their efforts and for the proposal of the “Living Guidelines model” providing (“real-time”) update information to clinicians involved in the care of TBI. Regarding intracranial pressure (ICP), 2 new statements are presented: (1) “Management of severe TBI patients using information from ICP monitoring is recommended to reduce in-hospital and 2-week post-injury mortality” (level IIB) and (2) “Treating ICP > 22 mm Hg is recommended because values above this level are associated with increased mortality” (level IIB). Considering the first point, indications regarding which patient should be monitored are not reported anymore because not supported by evidence meeting current standard. Severe TBI is a heterogeneous condition with patients at high risk of intracranial hypertension (as indicated by clinical and radiological signs) and patients at low risk of elevated ICP such as in case of pure diffuse axonal injury (DAI), minimal intracranial pathology, or significant brain atrophy.2 These guidelines suggest a possible utility of ICP monitoring without indicating which category of patients may benefit more from it. In our opinion, this aspect will generate confusion among clinicians involved in the care of TBI. In this regard, we suggest to refer to 2 consensus conferences3,4 written after the publication of the Benchmark Evidence From South American Trials: Treatment of Intracranial Pressure trial.5 The main message of these consensus statements could be summarized in this way: (1) ICP should be monitored in all salvageable comatose patients with radiological features of intracranial hypertension, and (2) in patients with pure DAI or minimal intracranial pathology ICP should not be monitored anymore. Considering the second point (threshold for treatment), we are skeptical that a difference of 2 mm Hg of ICP could translate in daily clinical practice. ICP values should be individualized with the aid whenever possible of multimodal (neuro) monitoring,6 and intracranial hypertension should be considered in terms of insult severity and duration.7 Further, medical and surgical indications for “life-saving” extreme procedures (hypothermia, barbiturates, and cranial decompression) should be based on a combination of clinical, radiological, and neurophysiological parameters, not only on a “magic” ICP number. If we do not integrate ICP values in the context of different information, we diminish the utility of the monitoring and we cannot demonstrate its clinical value.5,8 The recent history of the use of corticosteroids in spinal cord injury should teach us about the value in clinical practice of evidence-based medicine “alone.” In a short time period, 2 important documents were published.9,10 Despite that they revised basically the same papers, they reached opposite conclusions: use of corticosteroids advised vs not recommended. This generated a great confusion in the neurosurgical community with a return to an individual-based approach.11 In the light of the above reported considerations, we suggest that a common sense-based approach (based on published practical suggestions) should be integrated into evidence-based recommendations. The final target of guidelines is, in our opinion, to help neurosurgeons and intensivists to cure their patients and not to keep at any cost an aseptic “formally correct” methodology. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.