Traumatic Brain Injury: Science, Practice, Evidence and Ethics

Description

This book provides a comprehensive analysis of the contemporary management of all aspects of traumatic brain injury (TBI), combining the findings of several recent randomised controlled trials investigating the role of hypothermia, erythropoietin, intracranial pressure monitoring and decompressive craniectomy in the management of TBI. The book is divided into four sections: the first section covers the epidemiology of TBI, the changing global patterns of presentation, and the basic pathophysiology and classification, while the second discusses contemporary management of TBI, from pre-hospital care, emergency assessment, and medical and surgical management to rehabilitation and social reintegration. The third section then examines the evidence gained from recent clinical trials that have investigated the efficacy of management strategies involving intracranial pressure monitoring, multimodal monitoring, hypothermia, erythropoietin, thromboembolic prophylaxis and decompressive craniectomy. Lastly, the fourth section explores the ethical issues, both at the societal level and on an individual basis. Written by a broad range of experts, this book provides a valuable reference resource for neurosurgeons, intensivists, clinicians with ethical experience and pure bioethicists in their daily work. Preface Acknowledgements Contents Part I: Scientific Background 1: Epidemiology of Traumatic Brain Injury 1.1 Introduction 1.2 Defining Traumatic Brain Injury 1.3 Classifying Traumatic Brain Injury 1.4 The Incidence of Traumatic Brain Injury 1.5 The Severity of Traumatic Brain Injury 1.6 Financial Perspective 1.7 Risk Factors for TBI 1.8 Traumatic Brain Injury in HICs 1.9 Traumatic Brain Injury in LMICs 1.10 Traumatic Brain Injury in the Military 1.11 Preventive Strategies 1.12 Conclusions References 2: Pathophysiology of Traumatic Brain Injury 2.1 Introduction 2.2 Acute Pathophysiology 2.2.1 Consequences of Mechanical Force and Deformation 2.2.2 Ionic and Metabolic Disruption 2.2.3 Diffuse Axonal Injury 2.2.4 Vascular Disruption and Dysfunction 2.2.5 Inflammation 2.2.6 Altered Neural Circuitry 2.3 Chronic Pathophysiology 2.4 Conclusion References 3: Mechanics of Brain Tissue Deformation and Damage Following Trauma 3.1 Introduction 3.2 Overview of Healthy Brain Mechanics 3.2.1 Material Modelling of Brain Tissue 3.2.2 Macroscale Modelling of the Brain 3.3 Microscale Tissue Damage Induced by TBI 3.3.1 Direct Observations of Tissue Damage from Experiments 3.3.2 Inferring Tissue Damage from Experiments Combined with Modelling 3.3.3 Predicting and Modelling Tissue Damage 3.4 Macroscale Deformation in the Brain Induced by TBI 3.5 Future Directions 3.6 Conclusions References 4: Evidence Pyramid, Comparative Effectiveness Research, and Randomised Trials 4.1 Introduction: What Constitutes ‘Evidence’? 4.2 Background Information: Pros and Cons of Different Paradigms of Evidence 4.3 Illustrative Cases: The Story of Decompressive Craniectomy 4.4 Recent Developments: Comparative Effective Research 4.5 Future Directions 4.6 Conclusions References 5: Big Data Collection and Traumatic Brain Injury 5.1 Introduction 5.2 What Is Big Data in TBI? 5.3 Collection of Big Data 5.4 Use of Big Data in TBI 5.4.1 Classification of TBI 5.4.2 Acute TBI Management 5.4.3 ICP Monitoring 5.4.4 Intravenous (IV) Fluids and Medication Adjustments 5.4.5 Supportive Information to Guide Management 5.4.6 Management of Chronic TBI 5.4.7 Research Applications 5.5 Strengths and Limitations 5.6 Future Directions References Part II: Current Clinical Practice 6: Prehospital and Emergency Department Management of TBI 6.1 Introduction 6.2 Background Information and Pathophysiology 6.3 Current Evidence and Contemporary Practice 6.4 Pitfalls 6.5 Future Directions 6.6 Conclusions References 7: Monitoring the Injured Brain 7.1 Introduction 7.2 Current Evidence and Contemporary Practice 7.2.1 Clinical Evaluation 7.3 Intracranial Pressure Monitoring 7.3.1 Prediction: ICP Prediction of Poor Outcome and Threshold for Intervention 7.3.2 Perfusion: Optimal Cerebral Perfusion Pressure 7.3.3 Pathology: Early Detection of Mass Lesions 7.3.3.1 ICP Monitoring: Current Evidence 7.3.3.2 Cerebral Oxygenation Monitoring Jugular Bulb Venous Oxygen Saturation Monitoring (SjvO2) Brain Tissue Oxygen Tension Monitoring (PbtO2) 7.4 Near-Infrared Spectroscopy (NIRS) 7.5 Microdialysis (MD) 7.6 Brain Ultrasonography: B-Mode Transcranial ­Color-Coded Duplex (TCCD) and Transcranial Doppler (TCD) Sonography 7.7 Thermal Diffusion Flowmetry 7.8 Ultrasound of Optic Nerve Sheath Diameter 7.9 Neurophysiological Monitoring 7.10 Conclusions References 8: Contemporary Medical Management of Traumatic Brain Injury: High-Income Countries 8.1 Introduction 8.1.1 Neuroprotective Therapy 8.1.2 Multimodal Monitoring 8.1.3 Monro-Kellie Doctrine 8.2 Contemporary Medical Management of Severe Traumatic Brain Injury 8.2.1 Initial Medical Management in the ICU 8.3 Tier 1 8.3.1 Hyperosmolar Therapy 8.4 Tier 2 8.4.1 Hyperventilation 8.4.2 Neuromuscular Blocking Agents 8.4.3 Assessment of Autoregulation and Optimizing Cerebral Perfusion Pressure (CPP) 8.5 Tier 3 8.5.1 Hypothermia 8.5.2 Barbiturate Coma 8.5.3 Decompressive Craniectomy 8.6 Conclusions References 9: Contemporary Management of Traumatic Brain Injury: Low and Middle-Income Countries 9.1 Introduction 9.2 Background Information and Historical Aspects 9.3 Current Evidence, Contemporary Practice, and Ethical Issues 9.4 Future Directions 9.5 Addressing the Training Deficit in Neurotrauma Care 9.6 Societal Considerations 9.7 Conclusions References 10: Contemporary Surgical Management of Traumatic Brain Injury 10.1 Introduction 10.2 Assessment of Conscious Level 10.3 Surgical Procedures 10.3.1 Skull Fractures 10.3.1.1 Types of Fractures 10.3.1.2 Diagnostic Exams 10.3.1.3 Surgical Treatment 10.3.2 Posttraumatic Intracerebral Hematoma 10.3.2.1 Acute Extradural Hematoma Surgical Treatment Hyperacute Decompression 10.3.2.2 Acute Subdural Hematoma Surgical Treatment 10.3.2.3 Cerebral Contusions Surgical Treatment 10.3.3 Penetrating Brain injury 10.3.3.1 Radiological Evaluation 10.3.4 Traumatic Cerebrospinal Fistula 10.3.4.1 CSF Fistula: Presentation 10.3.4.2 CSF Fistula: Localization 10.3.4.3 Nonsurgical Treatment 10.3.4.4 Surgical Treatment Intracranial Surgical Approaches Endoscopic Endonasal Approaches 10.4 Conclusion References 11: Military Management of Traumatic Brain Injury 11.1 Introduction 11.2 History of Military Approach to TBI 11.2.1 Severe and Penetrating TBI 11.2.2 Mild TBI 11.3 Contemporary Practice 11.3.1 TBI Grading 11.3.2 Roles of Care 11.3.3 Severe and Penetrating TBI 11.3.4 Mild TBI 11.4 Future Directions 11.5 Conclusions References 12: Contemporary Management of Paediatric Head Injuries 12.1 Introduction 12.2 Anatomical and Pathophysiological Differences in Children Relevant to TBI 12.3 Characteristics of Primary TBI in Children 12.3.1 Skull Fractures 12.3.2 Intracranial Haematomas 12.3.3 Diffuse Axonal Injury (DAI) 12.4 Secondary TBI in Children 12.5 Non-Accidental Injury (NAI) 12.6 Birth Injuries 12.7 Management of Traumatic Brain Injury 12.7.1 Mild TBI 12.7.2 Moderate and Severe TBI 12.7.2.1 Initial Management of Paediatric Patients in the ICU 12.7.3 Tier 1 12.7.4 Tier 2 12.7.5 Tier 3 Therapies 12.7.5.1 Hypothermia 12.7.5.2 Barbiturate Coma 12.7.5.3 Decompressive Craniectomy 12.8 Future Directions 12.9 Conclusions References 13: Sports-Related Traumatic Brain Injury 13.1 Introduction 13.2 Background Information and History 13.3 Management and Long-Term Consequences of SRC 13.3.1 SRC Recognition and Diagnosis 13.3.2 Early Removal from Play and Graduated Return-to-Play (or School) Protocol 13.3.3 Concussion Recovery and the “Post-Concussion Syndrome” 13.3.4 Long-Term Consequences 13.4 Future Directions 13.4.1 Controversies 13.4.2 Prevention 13.4.3 Fluid Biomarkers 13.4.4 Acute Treatment 13.4.5 Neuroimaging 13.4.5.1 Magnetic Resonance Imaging (MRI) 13.4.5.2 Positron Emission Tomography 13.4.6 When Should a Career Be Terminated? 13.5 Conclusions References 14: Rehabilitation After Traumatic Brain Injury 14.1 Introduction 14.1.1 Historical Perspective of TBI Rehabilitation 14.2 Classification of Disability and Health 14.3 Rehabilitation Pathways and Services 14.3.1 Rehabilitation Prescriptions 14.4 The Multidisciplinary Approach 14.4.1 Physiotherapy 14.4.2 Occupational Therapy 14.4.3 Speech and Language Therapy 14.4.4 Neuropsychology 14.4.5 Rehabilitation Medicine Physicians 14.4.6 Goal Setting 14.4.7 Brain Injury and the Mental Capacity Act 14.4.8 Cognitive Impairment and Recovery After Traumatic Brain Injury 14.4.9 Vocational Rehabilitation After Brain Injury 14.5 Emerging Trends in Rehabilitation 14.5.1 Deep Brain Stimulation 14.5.2 Augmented Reality 14.5.3 Brain-Computer Interface 14.6 Conclusion References Part III: Evidence 15: Predicting Outcome Following Traumatic Brain Injury 15.1 Introduction 15.2 Background Information on Prognostic Factors of TBI 15.3 Recent Developments 15.4 Future Directions 15.5 Conclusions References 16: Biomarkers in Traumatic Brain Injury 16.1 Introduction: The Need for Biomarkers in TBI Medicine 16.2 Challenges in Developing Biomarkers for Clinical Use in TBI 16.3 The Role of Biomarkers in Specific Clinical Situations 16.3.1 Identifying Patients with Mild Traumatic Brain Injury 16.3.2 Assessing the Need for Imaging After Mild Traumatic Brain Injury 16.3.3 Outcome Prediction 16.3.4 Monitoring the Injured Brain 16.4 Current Evidence 16.5 Protein Biomarkers 16.6 Neuronal Cell Body Biomarkers 16.6.1 Neuron-Specific Enolase (NSE) 16.6.2 Ubiquitin C-Terminal Hydrolase-L1 (UCH-L1) 16.7 Axonal and Axon Terminal Biomarkers 16.7.1 Neurofilament Light Polypeptide (NF-L) 16.7.2 Tau 16.8 Astroglial Biomarkers 16.8.1 Glial Fibrillary Acidic Protein (GFAP) 16.8.2 S100 Calcium-Binding Protein B (S100B) 16.9 Metabolomic and Lipidomic Biomarkers 16.10 Future Directions and Conclusions References 17: Erythropoietin, Progesterone, and Amantadine in the Management of Traumatic Brain Injury: Current Evidence 17.1 Introduction 17.2 Erythropoietin 17.3 Progesterone 17.4 Amantadine 17.5 Future Directions References 18: Tranexamic Acid in the Management of Traumatic Brain Injury 18.1 Introduction 18.2 Coagulation and Coagulopathy in Traumatic Brain Injury 18.3 Tranexamic Acid 18.4 Tranexamic Acid: Current Evidence for Efficacy 18.5 The CRASH-3 Trial 18.6 The Subgroup Analysis 18.7 CRASH-3 Trial Interpretation 18.8 Future Directions 18.9 Conclusions References 19: Hypothermia in the Management of Traumatic Brain Injury 19.1 Introduction 19.2 History of Therapeutic Hypothermia 19.3 The Pathophysiology of Traumatic Brain Injury 19.3.1 The Monro-Kellie Doctrine 19.3.2 Neuroprotection and the Heterogeneity Paradox 19.4 Hypothermia: Clinical Evidence 19.5 Future Directions 19.5.1 Management Strategies 19.5.2 Complications References 20: Decompressive Craniectomy in the Management of Traumatic Brain Injury 20.1 Introduction 20.2 Background Information 20.2.1 History 20.2.2 Pathophysiology 20.3 Practical Aspects: Surgical Techniques, Indications and Patient Selection 20.3.1 Hemicraniectomy 20.3.2 Bifrontal Decompressive Craniectomy 20.3.3 Indications 20.3.4 Patient Selection 20.4 After Decompressive Craniectomy 20.4.1 Specific Aspects of Care After Decompressive Craniectomy 20.4.2 Complications 20.4.3 Cranial Reconstruction 20.5 Current Evidence Base 20.5.1 DECRA Trial 20.5.2 RESCUEicp Trial 20.5.3 Other Trials of Decompressive Craniectomy 20.5.4 Summarising the Current Evidence Base and Its Limitations 20.5.4.1 Patient Values and Preference 20.6 Conclusions References 21: Cranioplasty Following Traumatic Brain Injury 21.1 Introduction 21.2 Cranioplasty: Clinical Indications 21.2.1 Restoration of Cosmesis 21.2.2 Regaining Protection of the Cerebral Tissue 21.2.3 Re-establishment of Normal Cerebral Hydrodynamics 21.3 Cranioplasty: Surgical Technique 21.3.1 Surgical Timing 21.3.2 Management of Temporal Muscle 21.3.3 Materials Used for Reconstruction 21.3.3.1 Autologous Bone 21.3.3.2 Titanium 21.3.4 Methyl Methacrylate 21.3.5 Ceramics and Others 21.4 Current Evidence 21.5 Complications of Cranioplasty 21.5.1 Sudden Death 21.5.2 Postoperative Collections 21.5.3 Infection 21.5.4 Bone Resorption 21.6 Future Directions 21.7 Conclusions References 22: Thromboembolic Prophylaxis in Traumatic Brain Injury 22.1 Introduction 22.2 Background Information and Pathophysiology 22.3 Current Evidence and Recommendations 22.4 Future Directions 22.5 Conclusions References 23: Long-Term Neurological Consequences of Traumatic Brain Injury 23.1 Introduction 23.2 Long-Term Behavioral Issues 23.2.1 Long-Term Physical Symptoms Following TBI 23.2.2 Long-Term Cognitive Symptoms Following TBI 23.2.3 Long-Term Emotional Symptoms Following TBI 23.3 Long-Term Neurodegenerative Problems 23.3.1 Dementia Following TBI: Historical Evidence and Case Studies 23.3.2 Chronic Traumatic Encephalopathy 23.3.3 Impaired Cognition in Later Life: Epidemiological Evidence 23.3.4 Cognitive Decline of TBI: Future Developments 23.3.5 Conclusion References 24: Post-Traumatic Epilepsy 24.1 Introduction 24.2 Epidemiology 24.3 Pathophysiology 24.3.1 Oxidative Stress 24.3.1.1 Excitotoxic Mechanism 24.3.2 History and Examination 24.3.3 Investigations 24.3.4 Magnetic Resonance Imaging 24.4 Current Evidence 24.4.1 Specific Antiepileptic Medications 24.4.2 Non-pharmacological Interventions 24.5 Future Directions 24.6 Conclusion References 25: Brain Death: Current Evidence and Guidelines 25.1 Introduction 25.2 Definition of Death 25.3 Pathophysiology and Mechanisms of Brain Death 25.4 Essential Prerequisites for the Diagnosis of BD/DNC 25.5 BD/DNC: The Clinical Diagnosis 25.6 Ancillary Tests 25.7 Pediatric Considerations 25.8 The Role of Communication and of Education and Training 25.9 Conclusions References Part IV: Ethical Considerations 26: Introduction to Bioethics 26.1 Introduction 26.2 The History of Bioethics 26.2.1 Virtue Ethics: Greek 26.2.2 Virtue Ethics: Christian 26.2.3 Natural Law 26.2.4 Deontology and Kantian Ethics 26.2.5 Utilitarianism and Consequentialism 26.2.6 Feminist Ethics 26.2.7 Contemporary Ethical Frameworks 26.3 Conclusion References 27: Consent for Neurosurgery in Cases of Traumatic Brain Injury 27.1 Introduction 27.2 Consent 27.2.1 Capacity to Consent to Treatment 27.2.2 Consent Must Be Voluntary and Free from Undue Influence 27.2.3 Consent Should Be Accompanied by the Provision of Information Regarding Material Risks 27.2.4 The Ethical and Legal Limits of Consent 27.2.5 Disputes over Treatment 27.2.6 A Clinical Example 27.3 Discussion 27.4 Conclusion References 28: Team-Based Decision-Making in Traumatic Brain Injury 28.1 Introduction 28.2 History of Shared Decision-Making 28.3 Agency for Healthcare Research and Quality (AHRQ) SHARE Approach to SDM 28.4 SDM Foundation 28.5 SDM Challenges 28.6 SDM Conflicts 28.6.1 Conflicts for Physicians 28.6.2 Conflicts for Family Members 28.7 SDM Drivers 28.8 SDM Types 28.9 Conclusion References 29: Traumatic Brain Injury and Resource Allocation 29.1 Introduction 29.2 Contextual Considerations on Resource Limits 29.3 How Do Limited Resources Apply to Traumatic Brain Injury (TBI)? 29.4 Framework for Priority Setting in Clinical Care 29.5 How Does Resource Allocation Affect TBI? References 30: Research Ethics in Clinical Trials 30.1 Introduction 30.2 Clinical Trials in Neurotrauma 30.2.1 The Role of Corticosteroids in the Management of TBI 30.2.2 The Role of Therapeutic Hypothermia in the Management of Traumatic Brain Injury 30.3 Hypothermia: Clinical Studies 30.3.1 The Role of Decompressive Craniectomy in Severe Traumatic Brain Injury 30.3.1.1 The DECompressive CRAniectomy (DECRA) Trial 30.3.1.2 The Randomised Evaluation of Surgery with Elevation of Intracranial Pressure (RESCUEicp) Trial 30.3.2 The Role of ICP Monitoring in the Management of TBI 30.3.3 The Role of Tranexamic Acid in TBI 30.4 Conclusion References 31: Artificial Intelligence and Healthcare Ethics 31.1 Introduction 31.2 Background 31.3 Ethical Outlook 31.4 Pathway for Ethical Healthcare 31.4.1 Transparency, Responsibility, and Reproducibility 31.4.2 Autonomy in AI (Scope of Human Intervention) 31.4.3 Privacy and Security 31.4.4 Social Impact 31.4.5 Machines with Morality 31.4.6 Deployment and AI Safety 31.5 Conclusions References 32: Ethical Issues in Paediatric Traumatic Brain Injury 32.1 Introduction 32.2 Background Information 32.3 Current Evidence 32.4 Communication and Consent in Paediatric Neurotrauma 32.5 Brain Death 32.6 Conclusions References 33: Withholding and Withdrawing Treatment 33.1 Introduction 33.2 Withdrawing Medical Therapy: Historical Aspects 33.3 Withdrawing and Withholding Medical Therapy: Traumatic Brain Injury 33.4 Treatment Decisions for Incapacitated Patients 33.4.1 Consent 33.4.2 Medical Futility 33.4.3 Medical Futility: An Alternative Approach 33.4.4 Medical Futility: Does Life Have Intrinsic Value? 33.5 Withholding and Withdrawing Life-Sustaining Treatment: Is There a Difference? 33.5.1 Acts and Omissions 33.6 The Equivalence Test 33.7 Practical Decision-Making 33.8 Mitigating Conflict 33.9 Conclusion References 34: Long-Term Outcome Following Traumatic Brain Injury 34.1 Introduction 34.2 Favorable Outcome but Not Necessarily Acceptable 34.3 Unfavorable Outcome but Not Necessarily Unacceptable 34.3.1 The Disability Paradox 34.3.2 The Salutogenic Model 34.4 Unfavorable and Unknown 34.4.1 Disorders of Consciousness: Diagnosis 34.4.2 Disorders of Consciousness: Experimental Intervention 34.4.3 The Rule of Rescue 34.4.4 Disorders of Consciousness: Surgical Intervention 34.5 Conclusions References