GUIDELINES   Open access

Journal of Neurosurgical Sciences 2021 June;65(3):219-38

DOI: 10.23736/S0390-5616.21.05383-2

Copyright © 2021 THE AUTHORS

This is an open access article distributed under the terms of the CC BY-NC-ND 4.0 license which allows users to copy and distribute the manuscript, as long as this is not done for commercial purposes and further does not permit distribution of the manuscript if it is changed or edited in any way, and as long as the user gives appropriate credits to the original author(s) and the source (with a link to the formal publication through the relevant DOI) and provides a link to the license.

language: English

Management of intracranial hypertension following traumatic brain injury: a best clinical practice adoption proposal for intracranial pressure monitoring and decompressive craniectomy. Joint statements by the Traumatic Brain Injury Section of the Italian Society of Neurosurgery (SINch) and the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

Corrado IACCARINO ¹, Laura LIPPA ² ✉, Marina MUNARI ³, Carlo A. CASTIONI ⁴, Chiara ROBBA ⁵, Anselmo CARICATO ⁶, Angelo POMPUCCI ⁷, Stefano SIGNORETTI ⁸, Gianluigi ZONA ^{9, 10}, Frank A. RASULO ^{11, 12} on behalf of the Traumatic Brain Injury Section of the Italian Society of Neurosurgery (SINch) and the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) 

¹ Division of Neurosurgery, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena University Hospital, Modena, Italy; ² Department of Neurosurgery, Ospedali Riuniti di Livorno, Livorno, Italy; ³ Department of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy; ⁴ Department of Anesthesia and Intensive Care, IRCCS Istituto delle Scienze Neurologiche Bellaria Hospital, Bologna, Italy; ⁵ Department of Anesthesia and Intensive Care, IRCCS San Martino University Hospital, Genoa, Italy; ⁶ Department of Anesthesia and Critical Care, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy; ⁷ Department of Neurosurgery, S. Maria Goretti Hospital, Latina, Italy; ⁸ Division of Emergency-Urgency, Unit of Neurosurgery, S. Eugenio Hospital, Rome, Italy; ⁹ Department of Neurosurgery, IRCCS San Martino University Hospital, Genoa, Italy; ¹⁰ Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy; ¹¹ Department of Anesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University Hospital, Brescia, Italy; ¹² Department of Surgical and Medical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy

No robust evidence is provided by literature regarding the management of intracranial hypertension following severe traumatic brain injury (TBI). This is mostly due to the lack of prospective randomized controlled trials (RCTs), the presence of studies containing extreme heterogeneously collected populations and controversial considerations about chosen outcome. A scientific society should provide guidelines for care management and scientific support for those areas for which evidence-based medicine has not been identified. However, RCTs in severe TBI have failed to establish intervention effectiveness, arising the need to make greater use of tools such as Consensus Conferences between experts, which have the advantage of providing recommendations based on experience, on the analysis of updated literature data and on the direct comparison of different logistic realities. The Italian scientific societies should provide guidelines following the national laws ruling the best medical practice. However, many limitations do not allow the collection of data supporting high levels of evidence for intracranial pressure (ICP) monitoring and decompressive craniectomy (DC) in patients with severe TBI. This intersociety document proposes best practice guidelines for this subsetting of patients to be adopted on a national Italian level, along with joint statements from “TBI Section” of the Italian Society of Neurosurgery (SINch) endorsed by the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Presented here is a recap of recommendations on management of ICP and DC supported a high level of available evidence and rate of agreement expressed by the assemblies during the more recent consensus conferences, where members of both groups have had a role of active participants and supporters. The listed recommendations have been sent to a panel of experts consisting of the 107 members of the “TBI Section” of the SINch and the 111 members of the Neuroanesthesia and Neurocritical Care Study Group of the SIAARTI. The aim of the survey was to test a preliminary evaluation of the grade of predictable future adherence of the recommendations following this intersociety proposal. The following recommendations are suggested as representing best clinical practice, nevertheless, adoption of local multidisciplinary protocols regarding thresholds of ICP values, drug therapies, hemostasis management and perioperative care of decompressed patients is strongly recommended to improve treatment efficiency, to increase the quality of data collection and to provide more powerful evidence with future studies. Thus, for this future perspective a rapid overview of the role of the multimodal neuromonitoring in the optimal severe TBI management is also provided in this document. It is reasonable to assume that the recommendations reported in this paper will in future be updated by new observations arising from future trials. They are not binding, and this document should be offered as a guidance for clinical practice through an intersociety agreement, taking in consideration the low level of evidence.

KEY WORDS: Traumatic brain injuries; Decompressive craniectomy; Consensus development conference; Guideline