Abstract
Dear Editor:
Management guidelines for severe traumatic brain injury (STBI) (Brain Trauma Foundation, 1996) have been in place in the United States since 1995. Since that time, the Society of Neurosurgery in Taiwan has made efforts to educate neurosurgeons in Taiwan about these guidelines, encourage integration of these concepts into clinical practice, and to lobby the National Health Institute to pay for STBI treatment. Due to differences in cultural background and traditional practice customs, we found several discrepancies during this period of transition to widespread use of the guidelines in Taiwan, and thus saw a need for locally developed guidelines for use in Asia.
In July 2008, more than 300 neuroscience experts in Asia participated in the first Asia-Oceania Neurotrauma Society (AONTS) congress. Specialists discussed differences in the management of STBI and differences among the guidelines published in China, Korea, Japan, and Taiwan. Novel consensus agreements were proposed for four key topics, including the management of intracranial pressure (ICP) (Bratton et al., 2007) and cerebral perfusion pressure (CPP) (Chang et al., 2009; Lin et al., 2008; Sviri et al., 2009), and the use of decompressive craniectomy (DC) (Howard et al., 2008; Timofeev et al., 2008) and sedatives (Chiu et al. 2006).
New consensus guidelines recommend that ICP should be considered as a treatment concept rather than just a monitoring tool. For those patients indicated for ICP monitoring, external ventriculostomies are the best choice for the most accurate and cost-effective management. They also allow the dual functions of monitoring and cerebrospinal fluid (CSF) drainage. In addition, ICP data as measured by ventriculostomy are more representative of the overall intracranial condition than intraparenchymal, subdural, or extradural insertion (Bratton et al., 2007).
The consensus recommendation for CPP is that it should be maintained at ≥60 mm Hg for most patients. However, it is advisable to maintain CPP > 70 mm Hg for extremely severe TBI patients, such as patients with Glasgow Coma Scale (GCS) scores of 3–5 (Lin et al., 2008), despite the high complication rates associated with the inotropic drugs used to maintain CPP. In this subgroup, the recovery of cerebral autoregulation is also poor compared to patients with GCS scores ≥6 (Sviri et al., 2009). Maintaining these higher CPP values provides improved survival rates and long-term prognosis for these patients. Decompressive craniectomies are thought to be clinically effective in lowering ICP in those with refractory intracranial hypertension (Timofeev et al., 2008), and prophylactic DC may also be useful in those requiring urgent evacuation of intracranial hemorrhage and other conditions. Thus DCs should be considered and used soon after primary therapy is complete, and in some cases sooner (Howard et al., 2008). The guidelines for the use of sedatives recommend the use of short-term sedation, and analgesics are indicated for acute and ventilated STBI patients with adequate monitoring.
We plan to build on these initial four consensus guidelines proposed by the first AONTS congress, and more advanced prospective studies of STBI will be conducted in Asia to help refine them.