Commentary 6.1.1.



Karel Zítko and Vit Marecek

The meaning of non-surgical treatment of brain injury is the effort to ensure sufficient cerebral perfusion pressure (CPP) as precondition of sufficient cerebral blood flow (CBF)1-3. Non-surgical treatment of brain injury itself have to be based on the knowledge of pathologic events (morphology, physiology, biochemistry), that are in progress in brain tissue after injury.

Non-surgical treatment is generally applied in rising intensity4-7. It starts by variable combination of sedation and, as the case may be, skeletal muscle relaxation followed by osmotherapy, hyperventilation or ventricular drainage up to barbiturates and hypothermia. In case of evidence of posttraumatic intracranial expansion the surgical treatment of it is to be preferred. Non-surgical treatment is in that case only preparation for the operation and also a constituent of postoperative care afterwards.

The goals of pharmacological treatment of brain injury can be characterized as follows6:
- to optimize substrate delivery to the brain and prevent paroxysmal increases in intracranial pressure
  drugs: analgesics, sedatives, eventually skeletal muscle relaxants
- to prevent or treat brain swelling
  drugs: diuretics, barbiturates
- to decrease secondary brain damage
  drugs: neuroprotectives
- to treat symptoms associated with brain injury
  drugs: psychostimulants
- to prevent or treat complications of brain injury
  drugs: anticonvulsants, antibiotics

We invariably face the question of how much are non-surgical treatments of brain injury really effective and safe8.

1. Bouma GJ, Muizelaar JP, Choi SC, et al: Cerebral circulation and metabolism after severe traumatic brain injury: The eclusive role of ischemia. J Neurosurg 1991;75:685-693.
2. Bullock R, Chesnut RM, Clifton C, et al: Guidelines for the management of severe head injury. J Neurotrauma 1996; 13:643-734.
3. Maas AIR, Dearden M, Teasdale GM, et al: EBIC-Guidelines of severe head injury in adults. Acta Neurochir (Wien) 1997;139:286-294.
4. Drábková J: 2.mezinárodní neurotraumatologické sympózium. Glasgow,4.-9.7.1993. Ref Výb Anest Resuscit 1994;5:18-27.
5. Drábková J, Pokorný J, Getlík P, Ročeň M: Okamžitá a neodkladná péče při mozkolebečních poraněních. In Současné trendy kortikoterapie v akutních a v kritických stavech. Sborník ze symposia firmy UPJOHN, Praha 1993: 67-76.
6. Duhaime AC: Conventional drug therapies for head injury. In Narayan RK, Wilberger JE, Povlishock JT (eds.): Neurotrauma. McGraw-Hill; New York 1996: 365-374.
7. Drábková J: Závažná mozkolebeční poranění. Soudobé a budoucí aspekty. Ref Výb Anest Resuscit 1996;7:18-40.
8. Roberts I, Schierhout G, Alderson P: Absence of evidence for the effectiveness of five interventions routinely used in the intensive care management of severe head injury: a systematic review. J Neurol Neurosurg Psychiatry 1998;65: 729-733.

Last updated: 1999-09-06