Management of Severe Traumatic Brain Injury

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Collection Highlights

Manual of Traumatic Brain Injury Assessment and Management

2nd Edition Felise Zollman

Traumatic Brain Injury 2nd Edition Peter C. Whitfield

Traumatic Brain Injury: Rehabilitation, Treatment, and

Case Management, Fourth Edition Mark J. Ashley

Biomarkers for Traumatic Brain Injury 1st Edition Alan

H.B. Wu Ph.D. (Editor)
Blossoming Into Disability Culture Following Traumatic
Brain Injury The Lotus Arising 1st Edition Dee Phyllis
Genetti

Blossoming Into Disability Culture Following Traumatic

Brain Injury; The Lotus Arising 1st Edition Dee Phyllis
Genetti

Acquired Brain Injury An Integrative Neuro Rehabilitation

Approach Jean Elbaum

Finding consciousness : the neuroscience, ethics, and law

of severe brain damage First Edition Sinnott-Armstrong

Severe Asthma in Children and Adolescents Mechanisms and

Management Erick Forno
Management of
Severe Traumatic
Brain Injury
Evidence, Tricks, and Pitfalls
Terje Sundstrøm
Per-Olof Grände
Teemu Luoto
Christina Rosenlund
Johan Undén
Knut Gustav Wester
Editors
Second Edition
123
Management of Severe Traumatic
Brain Injury
Terje Sundstrøm • Per-Olof Grände
Teemu Luoto • Christina Rosenlund
Johan Undén • Knut Gustav Wester
Editors

Management of Severe
Traumatic Brain Injury
Evidence, Tricks, and Pitfalls

Second Edition
Editors
Terje Sundstrøm Per-Olof Grände
Department of Neurosurgery Department of Anaesthesia
Haukeland University Hospital and Intensive Care
Bergen Lund University Hospital
Norway Lund
Sweden
Department of Clinical Medicine
University of Bergen
Christina Rosenlund
Bergen
Department of Neurosurgery
Norway
Odense University Hospital
Odense
Teemu Luoto
Denmark
Department of Neurosurgery
Tampere University Hospital
Knut Gustav Wester
Tampere
Department of Clinical Medicine K1
Finland
University of Bergen
Bergen
Johan Undén
Norway
Department of Operation
and Intensive Care
Halmstad Hospital
Halmstad
Sweden

ISBN 978-3-030-39382-3    ISBN 978-3-030-39383-0 (eBook)

https://doi.org/10.1007/978-3-030-39383-0

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Foreword I

Traumatic brain injury (TBI) constitutes a vast global health problem, impact-
ing over 50 million people worldwide each year and costing the global econ-
omy $400 million USD. TBI has been described as “the most complex disease
in our most complex organ.” We now recognize that it is a process, not an
event. A disproportionate burden of death and disability exists in low- and
middle-income countries (LMICs). Concerted efforts are required to address
this global pandemic. Concerted efforts in the sense of both international col-
laborations and of interactions between basic neuroscience and clinical
research.
This second edition of the textbook Management of Severe Traumatic
Brain Injury: Evidence, tricks, and pitfalls constitutes an amazing concerted
effort, bringing together contributions from world-leading experts, linking
basic neuroscience to clinical research and practice, and presenting this in a
very clear and educational format. The Scandinavian Neurotrauma Committee
(SNC) deserves a huge compliment for this achievement. Importantly, this
textbook also bridges the neurotrauma gap between high-income countries
(HICs) and LMICs, true to the long-standing interest of Scandinavian neuro-
surgery in promoting educational activities in Africa. Over 90% of neu-
rotrauma occur in LMICs, whilst over 90% of TBI publications originate
from HICs. LMICs are severely underrepresented in TBI research. Surgery
for neurotrauma represents more than 40% of neurosurgical procedures per-
formed all over the world and more than 60% in developing areas of the
world. Acquiring detailed knowledge of TBI, its pathophysiology and man-
agement, should thus be a priority for all neurosurgeons and neurosurgical
trainees. This knowledge needs to extend far beyond a narrow focus on surgi-
cal management.
As past and current presidents of the Neurotrauma Committee of the
World Federation of Neurosurgical Societies, we greatly welcome this new
edition for its pragmatic approach, which will serve clinicians and research-
ers across the world. This book is relevant to basic scientists who wish to

v
vi Foreword I

understand more about clinical dilemmas, to neurosurgical trainees across the

world, and also to seasoned experts like ourselves who are sure to find some-
thing new!
The book should belong on the shelf of every neurosurgical department.


Edegem, Belgium Andrew I. R. Maas
Tariq
Peshawar, Pakistan Khan
Foreword II

The book is the result of a carefully concerted venture from the most dedi-
cated neurosurgeons, neurointensivists, neuroanaesthesiologists, trauma sur-
geons, neuroradiologists, rehabilitation physicians, and psychologist
throughout Scandinavia working on traumatic brain injury (TBI). Together,
and through the Scandinavian Neurotrauma Committee (SNC), they have
described the current knowledge—and sometimes the lack thereof—in a
structured and easily readable form. The book covers all topics from the epi-
demiology and organizational considerations of trauma management, via
evidence-based treatment strategies and monitoring, to long-term follow-up
and rehabilitation.
The first edition of this book was published in 2012. Although brain injury
research is clearly under-financed, the field is making rapid progress. The
SNC has published treatment guidelines for the management of minimal,
mild, and moderate head injuries, paediatric injuries, and the prehospital
management of severe TBI. This work has structured the treatment of these
patients throughout, and beyond, Scandinavia. Importantly, it has also fos-
tered a range of studies on implementation and follow-up of such guidelines,
giving rise to further improvements—as well as this second edition
Management of severe traumatic brain injury: Evidence, tricks, and pitfalls.
Overall, the SNC is a great example on how a regional multinational effort
can make an impact. The epidemiology of TBI is vastly different throughout
the globe, but the underlying challenges on organization, clinical decision-­
making, prevention of secondary damage, and rehabilitation remain very
similar.
This book covers the topic of severe head trauma in a well-written and
pedagogical way. It is a “must read” for all residents in neuro- or trauma sur-
gery, anaesthesiology, and intensive care medicine. It should also be an
important resource to all seasoned clinicians for updated information. The
layout of the book makes it a good everyday reference. This book should be
found in any and all units dealing with trauma patients.
I am very proud of the work performed by the SNC, and I am sure that you
will enjoy reading this book as much as I did.

Einar Osland Vik-Mo

The Scandinavian Neurosurgical
Society, Oslo, Norway

vii
In Memoriam Bertil Romner

Bertil Romner was one of the founders and a leading member of the
Scandinavian Neurotrauma Committee (SNC). He died of cancer when he
was 59 years old in August 2013. He was trained as a neurosurgeon at the
Department of Neurosurgery, Lund University Hospital, Sweden. He
defended his Ph.D. thesis in 1991, became associate professor in 1994 and
led the neurointensive care unit in Lund from 1996 to 2006. In 2006, he
became professor of neurosurgery at the University Hospital of Copenhagen,
Denmark. In 2010, he became professor of neurosurgery at the Lund
University, Sweden. From 1999 to his death, he held a second professorship
at the Arctic University of Norway in Tromsø, Norway.
Bertil will be remembered as an active scientist, supervisor, and inspirator.
He was a popular speaker with tremendous scenic talent and had a huge net-
work of collaborators and friends all over the world. He spent countless after-
noons together with members of his “research family,” and through his
leadership he raised the bar for scientific and clinical excellence. He was
internationally acclaimed for his contributions to neurosurgery and neuroin-
tensive care and published more than 150 articles. His main research field
was transcranial Doppler measurement of blood flow and, in more recent
years, noninvasive Doppler measurement of intracranial pressure. He also
made seminal contributions on treatment of subarachnoid hemorrhage, low-­
pressure hydrocephalus, and clinical use of and research on brain biomarkers,
such as S100B. Over the last years, his research was focused on management
of head injuries. Notably, he spear-headed the development of Scandinavian
guidelines for minimal, mild, and moderate head injuries published in 2013,
including for the first time a biomarker as an alternative to CT in the diagnos-
tic workup of head injuries. He was also the main organizer of several con-
gresses in Lund on clinical and research applications for biomarkers.
“I’m on my way,” Bertil often replied on the phone when he was late to a
meeting. He was always on the move. He constantly initiated new projects
and always participated with infectious enthusiasm. When matters became
difficult, he always said: “It’ll be solved” (“Det löser sig”). He was almost
always right.
Bertil truly enjoyed life. He had a great sense of humor and a strong social
competence. His warm personality and genuine consideration for others were
clearly reflected with patients, relatives, colleagues, and neighbors. In spite of
his disease, he refused to give up and kept on working full time as a professor,
both in clinic and research. Before he died, he said “I have so much undone.”

ix
x In Memoriam Bertil Romner

Through Bertil’s death, we have lost a dear friend and a dedicated clinician
and scientist. He has left a great void that is impossible to fill. We all really
miss him and honor his memory.
On behalf of the SNC.

Per-Olof
Lund, Sweden Grände
Copenhagen, Denmark Vagn Eskesen

Tromsø, Norway Tor Ingebrigtsen



Scandinavian Neurotrauma Committee

The Scandinavian Neurotrauma Committee (SNC; www.neurotrauma.nu)

was founded in 1998 after an initiative from the Scandinavian Neurosurgical
Society. The committee comprises dedicated neurosurgeons, neurologists,
intensivists, anaesthesiologists, radiologists, and paediatricians from
Denmark, Finland, Norway, and Sweden (population 27 million, 22 neuro-
surgical centers). The SNC is independent of industry funding and members
are supported by their respective institutions. The biannual Nordic
Neurotrauma Conference is hosted by the SNC.
The major objective of the SNC is to improve the management of neu-
rotrauma patients in the Nordic countries.

Members of the Scandinavian Neurotrauma Committee

Knut Gustav Wester (president)

Neurosurgeon
Bergen, Norway

Terje Sundstrøm
Neurosurgeon
Bergen, Norway

Mads Aarhus
Neurosurgeon
Oslo, Norway

Tor Brommeland
Neurosurgeon
Oslo, Norway

Anders Christian Feyling

Anaesthesiologist
Oslo, Norway

Kent Gøran Moen

Radiologist
Trondheim, Norway

xi
xii Scandinavian Neurotrauma Committee

Carsten Kock-Jensen
Neurosurgeon
Aarhus, Denmark

Bent Lob Dahl

Anaesthesiologist
Aarhus, Denmark

Stig Dyrskog
Anaesthesiologist
Aarhus, Denmark

Ramona Åstrand
Neurosurgeon
Copenhagen, Denmark

Christina Rosenlund
Neurosurgeon
Odense, Denmark

Olli Tenovuo
Neurologist
Turku, Finland

Teemu Luoto
Neurosurgeon
Tampere, Finland

Rahul Raj
Neurosurgeon
Helsinki, Finland

Bo-Michael Bellander
Neurosurgeon/Anaesthesiologist
Stockholm, Sweden

David Nelson
Anaesthesiologist
Stockholm, Sweden

Peter Reinstrup
Anaesthesiologist
Lund, Sweden

Johan Undén
Anaesthesiologist
Halmstad, Sweden
Scandinavian Neurotrauma Committee xiii

Per-Olof Grände
Anaesthesiologist
Lund, Sweden

Niklas Marklund
Neurosurgeon
Lund, Sweden

Zandra Olivecrona
Neurosurgeon
Örebro, Sweden

Johan Ljungqvist
Neurosurgeon
Gothenburg, Sweden

Olga Calcagnile
Paediatrician
Gothenburg, Sweden
Introduction

Traumatic brain injury (TBI) is an important public health problem. In

Europe, TBI has been estimated to annually account for 82,000 deaths and
2.1 million hospital discharges (Majdan et al. 2016). Many survivors suffer
long-term disabilities incurring significant personal and societal costs.
TBI incidence rates are increasing in elderly people, especially in high-­
income countries (HICs) (Roozenbeek et al. 2013). The situation in low- and
middle-income countries (LMICs) is particularly concerning, with a signifi-
cant increase in the number of TBIs coupled with substantial resource limita-
tions, poorly developed trauma management systems, and lack of qualified
medical personnel (Rubiano et al. 2015).
Many different TBI guidelines have been developed, all aiming to improve
the quality of care in and between prehospital services, primary hospitals,
neurosurgical departments, neurointensive care units, and rehabilitation facil-
ities. The Brain Trauma Foundation (BTF; www.braintrauma.org) has been
instrumental in this work. Their first evidence-based guidelines were pub-
lished in 1995 and have been updated several times, most recently in 2017.
The Scandinavian Neurotrauma Committee (SNC) published their first
guidelines for the management of minimal, mild, and moderate head injuries
in adults in 2000 (Ingebrigtsen et al. 2000a, b; Romner et al. 2000a, b). These
guidelines were extensively updated in 2013 (Undén et al. 2013), and sepa-
rate paediatric guidelines were published in 2016 (Åstrand et al. 2016). In
collaboration with the BTF, the SNC published guidelines for the prehospital
management of severe traumatic head injury in 2008 (Bellander et al. 2008;
Juul et al. 2008; Sollid et al. 2008).
The groundwork for the first edition of this book was started in 2007. The
major goal was to create a comprehensive, yet practical, manual for severe
TBI management throughout the entire chain of care. In this perspective, it
was of significant importance to recruit recognized professionals from most
centers in the Nordic countries, and from most of the involved specialties in
neurotrauma care. The first edition—Management of Severe Traumatic Brain
Injury: Evidence, Tricks, and Pitfalls—was published in 2012. It was a wel-
come addition to the TBI literature and has been actively used in many clinics
to improve TBI management. Two years ago, in conjunction with the first
Nordic Neurotrauma Conference, the SNC therefore decided to embark on
the second edition.

xv
xvi Introduction

The second edition is a major update on severe TBI. Most of the previous
chapters have undergone substantial revisions and 24 new chapters have been
added, reflecting both advances and key challenges within the field. The first
edition included 59 authors from 36 departments at 19 hospitals or universi-
ties in 5 countries. Notably, almost all of the authors from the first edition
have also contributed to this second edition, and more than 40 new authors
have participated.
The authors performed literature searches, not only with reference to the
BTF guidelines from 1995 and later revisions, but also within other areas of
the medical field, which is reflected in the index of this book. Based upon the
literature, clinical recommendations were made (influenced by grading sys-
tems such as the United States Preventive Services Task Force, the National
Health Services (UK) Centre for Reviews and Dissemination, the Cochrane
Collaboration and the GRADE guidelines (Guyatt et al. 2011)). In order to
achieve a high degree of clinical practicality, the classifications were refined
through an independent review process and consensus discussion in the SNC
group.
Levels of recommendation:

–– Level I recommendation: Based upon properly designed (prospective) ran-

domized controlled trials (the gold standard of clinical practice).
–– Level II recommendation: Prospectively collected data or retrospective
analyses concerning relevant studies and based on clearly reliable data in
well-defined populations. This includes prospective trials that did not meet
the strict criteria for Level I recommendations, as well as non-randomized
studies, observational studies, case-control studies, and cohort studies.
–– Level III recommendation: Descriptive studies, consensus reports, and
expert opinions.

Most of the provided recommendations are Level II or III. As a whole, the

scientific foundation for management of severe TBI is extensive, but rarely
grounded on high-quality evidence. These recommendation levels allow the
reader to appreciate the scientific background behind the recommendation
whilst also providing a practical and clinically useful message (in particular
in the absence of high-quality evidence).
Each chapter has been given a standardized setup, with the exception of a
few chapters where this approach was not practical. The reader is given initial
Recommendations. An Overview gives a short summary of the relevant litera-
ture with emphasis on more recent studies, also including older, but impor-
tant, research. A section with Tips, Tricks, and Pitfalls provides practical
advice and expert views. The relevant literature is reviewed in the Background
section. When applicable, a final section entitled Specific Paediatric Concerns
is provided.
The SNC hope that this updated book will prove useful for those faced
with the clinical and scientific problems of severely brain-injured patients.
Introduction xvii

The aim is to help establish a systematic and sustainable healthcare system,

including all aspects of TBI, from injury to long-term recovery.
This book would not have been possible without the initiative and support
from the SNC. We are grateful to all the authors for their enthusiasm and hard
work. We would like to thank all the section editors for their consistency and
imperative scientific input. We are also deeply indebted to all of the above
affiliated institutions for financial support and facilitation. Finally, we would
like to extend our sincerest appreciation to Springer International Publishing
AG for their invaluable editorial assistance.

Terje Sundstrøm
Per-Olof Grände
Teemu Luoto
Christina Rosenlund
Johan Undén
Knut Gustav Wester

References

Åstrand R, Rosenlund C, Undén J. Scandinavian Neurotrauma Committee

(SNC). Scandinavian guidelines for initial management of minor and
moderate head trauma in children. BMC Med. 2016;14:33.
Bellander BM, Sollid S, Kock-Jensen C, Juul N, Eskesen V, Sundstrøm T,
Wester K, Romner B. Prehospital management of patients with severe
head injuries. Scandinavian guidelines according to Brain Trauma
Foundation. Lakartidningen. 2008;105:1834–38.
Guyatt GH, Oxman AD, Schünemann HJ, Tugwell P, Knottnerus A. GRADE
guidelines: a new series of articles in the Journal of Clinical Epidemiology.
J Clin Epidemiol. 2011;64:380–2.
Ingebrigtsen T, Rise IR, Wester K, Romner B, Kock-Jensen C. Scandinavian
guidelines for management of minimal, mild and moderate head injuries.
Tidsskr Nor Laegeforen. 2000a;120:1985–90.
Ingebrigtsen T, Romner B, Kock-Jensen C. Scandinavian guidelines for ini-
tial management of minimal, mild, and moderate head injuries. J Trauma.
2000b;48:760–6.
Juul N, Sollid S, Sundstrøm T, Kock-Jensen C, Eskesen V, Bellander BM,
Wester K, Romner B. Scandinavian guidelines on the pre-hospital man-
agement of traumatic brain injury. Ugeskr Laeger. 2008;170:2337–41.
Majdan M, Plancikova D, Brazinova A, Rusnak M, Nieboer D, Feigin V,
Maas A. Epidemiology of traumatic brain injuries in Europe: a cross-­
sectional analysis. Lancet Public Health. 2016;1:e76–83.
Romner B, Ingebrigtsen T, Kock-Jensen C. Scandinavian guidelines for man-
agement of head injuries. Evidence-based management of minimal, mild
and moderate head injuries. Ugeskr Laeger. 2000a;162:3839–45.
xviii Introduction

Romner B, Ingebrigtsen T, Kock-Jensen C. Scandinavian guidelines for man-

agement of head injuries. Evidence-based management of minimal, mild
and moderate head injuries. Lakartidningen. 2000b;97:3186–92.
Roozenbeek B, Maas AI, Menon DK. Changing patterns in the epidemiology
of traumatic brain injury. Nat Rev Neurol. 2013;9:231–6.
Rubiano AM, Carney N, Chesnut R, Puyana JC. Global neurotrauma research
challenges and opportunities. Nature. 2015;527:S193–7.
Sollid S, Sundstrøm T, Kock-Jensen C, Juul N, Eskesen V, Bellander BM,
Wester K, Romner B. Scandinavian guidelines for prehospital manage-
ment of severe traumatic brain injury. Tidsskr Nor Laegeforen.
2008;128:1524–7.
Undén J, Ingebrigtsen T, Romner B, Scandinavian Neurotrauma Committee
(SNC). Scandinavian guidelines for initial management of minimal, mild
and moderate head injuries in adults: an evidence and consensus-based
update. BMC Med. 2013;11:50.
Contents

Part I Traumatic Brain Injury as a Public Health Problem

1 Epidemiological Aspects������������������������������������������������������������������   3

Marek Majdan, Tor Ingebrigtsen, and Olli Tenovuo
2 Challenges in Low- and Middle-­Income Countries ��������������������   9
Tsegazeab Laeke, Knut Gustav Wester, Morten Lund-­Johansen,
and Terje Sundstrøm
3 Challenges in the Elderly���������������������������������������������������������������� 15
Teemu Luoto and Thoralph Ruge
4 Challenges in Children�������������������������������������������������������������������� 21
Olga Calcagnile, Ulrika Sandvik, and Erik Edström
5 Biomechanics and Prevention �������������������������������������������������������� 25
Svein Kleiven

Part II Classification and Assessment

6 Pathophysiology of Severe Traumatic Brain Injury �������������������� 35

Niklas Marklund and Olli Tenovuo
7 Classification of Head Injury���������������������������������������������������������� 51
Ramona Åstrand and Johan Undén
8 Primary Clinical Assessment���������������������������������������������������������� 61
Jacob Bertram Springborg

Part III Prehospital Management

9 Prehospital Guidelines�������������������������������������������������������������������� 69
Riikka Takala
10 What the Neurosurgeon and the Trauma Team
Want to Know: What, Who, When, and Where?�������������������������� 77
Mads Gilbert and Knut Gustav Wester
11 Transportation���������������������������������������������������������������������������������� 83
Magnus Olivecrona and Zandra Olivecrona

xix
xx Contents

Part IV Admission, Diagnostics and Planning

12 The Trauma Team Concept������������������������������������������������������������ 91

Christina Rosenlund and Rico Frederik Schou
13 Trauma Protocol (ABCDE)������������������������������������������������������������ 95
Christina Rosenlund and Rico Frederik Schou
14 Hospital Response to Mass Casualty Incidents ���������������������������� 101
Pål Aksel Næss and Christine Gaarder
15 Cervical Spine Injury���������������������������������������������������������������������� 105
Tor Brommeland and Hege Linnerud
16 Blast-Induced Brain Injury������������������������������������������������������������ 109
Niklas Marklund
17 Radiological Evaluation of Head Trauma�������������������������������������� 115
Christian Rahbek, Ronni Mikkelsen, and Vibeke Fink-Jensen
18 Radiological Evaluation of Cervical Spine Trauma���������������������� 123
Christian Rahbek, Ronni Mikkelsen, and Vibeke Fink-Jensen
19 Blood Samples���������������������������������������������������������������������������������� 129
Bo-Michael Bellander and Rasmus Philip Nielsen
20 To Treat or Not to Treat in the Acute Setting
(Withholding) and Withdrawal of Treatment ������������������������������ 135
Magnus Olivecrona
21 Potential Organ Donor: Organ Donor Management�������������������� 145
Pia Löwhagen Hendén
22 Ethical Aspects and Communication �������������������������������������������� 153
Christina Rosenlund

Part V Acute Surgical Treatment

23 Basic Trauma Craniotomy�������������������������������������������������������������� 159

Terje Sundstrøm, Eirik Helseth, and Knut Gustav Wester
24 Surgical Management of Traumatic Intracranial
Haematomas ������������������������������������������������������������������������������������ 163
Terje Sundstrøm, Eirik Helseth, and Knut Gustav Wester
25 Surgical Management of Penetrating Brain Injuries ������������������ 173
Terje Sundstrøm, Eirik Helseth, and Knut Gustav Wester
26 Decompressive Craniectomy���������������������������������������������������������� 177
Jussi P. Posti and Pål A. Rønning
27 Skull Fractures �������������������������������������������������������������������������������� 187
Pål André Rønning and Tor Brommeland
28 Vessel Injuries���������������������������������������������������������������������������������� 191
Pål André Rønning and Tor Brommeland
Contents xxi

29 Insertion of Intracranial Monitoring Devices ������������������������������ 195

Zandra Olivecrona and Bo-Michael Bellander
30 Maxillofacial Fractures������������������������������������������������������������������� 203
Ann Hermansson
31 Considerations in Patients with Concomitant
Cervical Spine Injury���������������������������������������������������������������������� 207
Tor Brommeland and Terje Sundstrøm
32 Soft Tissue Injuries�������������������������������������������������������������������������� 211
Daniel Isacson and Daniel Nowinski
33 Surgery Outside Neurosurgical Units�������������������������������������������� 219
Per Enblad
34 Planning of Cranial and Extracranial Surgery
in Multitraumatised Patients���������������������������������������������������������� 225
Aqeel Chaudhry and Thomas Geisner

Part VI Perioperative Anaesthesia

35 Choice of Anaesthesia, Drugs and Medications���������������������������� 233

Christian Sigvald Langfrits and Bent Lob Dahl
36 Blood Pressure, CO2, and Oxygen Saturation������������������������������ 239
Kristian Dahl Friesgaard and Bent Lob Dahl
37 Intracranial Pressure Reduction���������������������������������������������������� 245
Bent Lob Dahl and Kristian Dahl Friesgaard

Part VII Monitoring in Neurointensive Care

38 Secondary Clinical Assessment������������������������������������������������������ 255

Jacob Bertram Springborg and Christina Rosenlund
39 A Wake-Up Test in the Neurointensive Care Management
of Severe TBI: Pros and Cons �������������������������������������������������������� 259
Niklas Marklund
40 Intracranial Pressure (ICP): Theoretical
and Practical Aspects���������������������������������������������������������������������� 267
Peter Reinstrup
41 Brain Tissue Oxygen Monitoring �������������������������������������������������� 279
Troels Halfeld Nielsen and Jon Axel Forsse
42 Monitoring Microdialysis���������������������������������������������������������������� 283
Peter Reinstrup and Carl-Henrik Nordström
43 Jugular Bulb Measurements (SJVO2)�������������������������������������������� 291
Bo-Michael Bellander and Peter Reinstrup
44 Cerebral Blood Flow (CBF) and Cerebral Metabolic
Rate (CMR)�������������������������������������������������������������������������������������� 297
Peter Reinstrup, Eric L. Bloomfield, and Elham Rostami
xxii Contents

45 Transcranial Doppler (TCD)���������������������������������������������������������� 309

Peter Reinstrup and Jan Frennström
46 Near-Infrared Spectroscopy (NIRS) or Cerebral Oximetry�������� 319
Peter Reinstrup
47 Clinical Neurophysiology: Evoked Potentials ������������������������������ 323
Birger Johnsen
48 Clinical Neurophysiology: Continuous EEG Monitoring������������ 327
Birger Johnsen
49 Imaging of Severe Traumatic Brain Injury in the
Neurointensive Care Unit���������������������������������������������������������������� 331
Leif Hovgaard Sørensen and Kent Gøran Moen
50 Serum Protein Biomarkers in the Management of Severe
Traumatic Brain Injury������������������������������������������������������������������ 343
Eric Peter Thelin, David W. Nelson, Johan Undén,
Ramona Åstrand, and Bo-Michael Bellander
51 Cardiopulmonary Aspects�������������������������������������������������������������� 357
Karen-Lise Kobberø Welling, Malin Rundgren,
and Kirsten Møller
52 Renal Aspects������������������������������������������������������������������������������������ 377
Jens Aage Kølsen-Petersen
53 Neuroendocrine Aspects������������������������������������������������������������������ 381
Marianne Klose and Ulla Feldt-Rasmussen

Part VIII Treatment in Neurointensive Care

54 Guidelines for Treatment of Patients with Severe

Traumatic Brain Injury������������������������������������������������������������������ 395
Per-Olof Grände and Niels Juul
55 The Lund Therapy: A Physiological Approach���������������������������� 403
Per-Olof Grände and Peter Reinstrup
56 Pharmacological Neuroprotection�������������������������������������������������� 409
Niklas Marklund
57 Subacute Surgery in Neurointensive Care������������������������������������ 421
Terje Sundstrøm, Eirik Helseth, and Knut Gustav Wester
58 Management of Extracranial Injuries ������������������������������������������ 425
Nikolaj Preus Hatting and Rico Frederik Schou
59 CSF Drainage ���������������������������������������������������������������������������������� 429
Lars-Owe D. Koskinen
60 Hyperventilation������������������������������������������������������������������������������ 433
Niels Juul
Contents xxiii

61 Osmotherapy������������������������������������������������������������������������������������ 437
Jens Aage Kølsen-Petersen
62 Barbiturates for ICP Management������������������������������������������������ 449
Mads Rasmussen
63 Management of Fluids and Electrolytes���������������������������������������� 453
Per-Olof Grände and Niels Juul
64 Sedation: Including Pain Treatment and Withdrawal
Symptoms������������������������������������������������������������������������������������������ 461
Geir Olav Dahle
65 Nutrition�������������������������������������������������������������������������������������������� 467
Anne Berit Guttormsen, Bram Johan de Hoog,
and Jennie Witte Hernæs
66 Management of CNS-Related Infection ���������������������������������������� 473
Christian A. Helland, Steinar Skrede,
and Jens Kjølseth Møller
67 Management of Extracranial Infections���������������������������������������� 485
Jan-Erik Berdal
68 Temperature Management�������������������������������������������������������������� 493
Per-Olof Grände and Peter Reinstrup
69 Seizures �������������������������������������������������������������������������������������������� 497
Elisabeth Ronne-Engström and Jon Axel Forsse
70 Paroxysmal Sympathetic Hyperactivity���������������������������������������� 503
Christina Rosenlund
71 Prophylaxis Against Venous Thromboembolism (VTE)
in Patients with Traumatic Brain Injury (TBI)���������������������������� 509
Ulf Schott and Morten Zebitz Steiness
72 Coagulopathy (Bleeding Tendency)������������������������������������������������ 515
Bo-Michael Bellander, Alexander Fletcher-­Sandersjöö,
and Martin Engström
73 Corticosteroids �������������������������������������������������������������������������������� 533
Jens Jakob Riis
74 Management of Acute Psychiatric Problems�������������������������������� 537
Arne Einar Vaaler

Part IX Rehabilitation and Follow-Up

75 Rehabilitation After Severe TBI ���������������������������������������������������� 547

Nada Andelic, Solrun Sigurdardottir, and Olli Tenovuo
76 Long-Term Follow-Up �������������������������������������������������������������������� 557
Olli Tenovuo, Nada Andelic, and Solrun Sigurdardottir
xxiv Contents

Part X Outcome and Prognosis

77 General Overview���������������������������������������������������������������������������� 565

Eirik Vikane and Teemu Luoto
78 Somatic Consequences�������������������������������������������������������������������� 569
Johan Ljungqvist
79 Neuropsychiatric Consequences ���������������������������������������������������� 575
Salla Koponen
80 Neuropsychological Perspectives���������������������������������������������������� 581
Aniko Bartfai and Eirik Vikane
81 Neurosurgical Challenges���������������������������������������������������������������� 591
Jussi P. Posti
82 Minimally Conscious and Vegetative State������������������������������������ 605
Alison K. Godbolt
83 Specific Paediatric Concerns���������������������������������������������������������� 613
Olga Calcagnile, Catherine Aaro Jonsson,
and Ingela Kristiansen
84 Socioeconomic Consequences �������������������������������������������������������� 623
Olli Tenovuo, Marek Majdan, and Nada Andelic
85 Subacute MR Imaging: Traumatic Axonal Injury,
Brainstem Lesions and Prognostic Factors ���������������������������������� 629
Toril Skandsen, Kent Gøran Moen, and Anne Vik
86 Neurodegeneration and Dementia following
Traumatic Brain Injury������������������������������������������������������������������ 637
Niklas Marklund

Part XI Research in Severe TBI

87 Neurointensive Care Unit as a Platform for Advanced

Clinical Research����������������������������������������������������������������������������� 647
Per Enblad, Tim Howells, and Lars Hillered
88 Current State of the Art in Neurotrauma Research �������������������� 659
Andrew I. R. Maas, David K. Menon, and Niklas Marklund
Index���������������������������������������������������������������������������������������������������������� 685
Contributors

Catherine Aaro Jonsson Child and Youth Rehabilitation, Östersunds

Hospital, Östersund, Sweden
Nada Andelic Department of Physical Medicine and Rehabilitation, Oslo
University Hospital Ullevål, Oslo, Norway
Research Centre for Habilitation and Rehabilitation Models and Services,
Faculty of Medicine, Institute of Health and Society, University of Oslo,
Oslo, Norway
Ramona Åstrand Department of Neurosurgery, Rigshospitalet, Copenhagen
University Hospital, Copenhagen, Denmark
Aniko Bartfai Division of Rehabilitation Medicine, Department of Clinical
Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
Bo-Michael Bellander Department of Clinical Neuroscience, Karolinska
Institutet, Stockholm, Sweden
Department of Neurosurgery, Karolinska University Hospital, Stockholm,
Sweden
Jan-Erik Berdal Infectious Diseases Department, Akershus University
Hospital, Nordbyhagen, Norway
Eric L. Bloomfield Department of Anesthesiology, Mayo Clinic, Rochester,
MN, USA
Tor Brommeland Department of Neurosurgery, Oslo University Hospital
Rikshospitalet, Oslo, Norway
Department of Neurosurgery, Oslo University Hospital Ullevål, Oslo, Norway
Olga Calcagnile Department of Paediatric Medicine, Halland Regional
Hospital, Halmstad, Sweden
Aqeel Chaudhry Department of Neurosurgery, Haukeland Trauma Center,
Haukeland University Hospital, Bergen, Norway
Bent Lob Dahl Department of Anesthesia and Intensive Care, Silkeborg
Regional Hospital, Silkeborg, Denmark
Geir Olav Dahle Department of Anaesthesia and Intensive Care, Haukeland
University Hospital, Bergen, Norway

xxv
xxvi Contributors

Bram Johan de Hoog Department of Anaesthesia and Intensive Care,

Haukeland University Hospital, Bergen, Norway
Erik Edström Department of Clinical Neuroscience, Karolinska Institute,
Stockholm, Sweden
Department of Neurosurgery, Karolinska University Hospital, Stockholm,
Sweden
Per Enblad Section of Neurosurgery, Department of Neuroscience/
Neurosurgery, Uppsala University Hospital, Uppsala University, Uppsala,
Sweden
Martin Engström Department of Health Care, Region Halland, Halmstad,
Sweden
Vagn Eskesen University Clinic of Neurosurgery, Copenhagen University
Hospital, Copenhagen, Denmark
Ulla Feldt-Rasmussen Department of Medical Endocrinology, Copenhagen
University Hospital, Copenhagen, Denmark
Vibeke Fink-Jensen Department of Neuroradiology, Aarhus University
Hospital, Aarhus, Denmark
Alexander Fletcher-Sandersjöö Department of Neurosurgery, Karolinska
University Hospital, Solna, Sweden
Jon Axel Forsse Department of Neurosurgery, Odense University Hospital,
Odense, Denmark
Jan Frennström Department of Neurosurgery, Skåne University Hospital,
Lund, Sweden
Kristian Dahl Friesgaard Department of Anesthesiology and Intensive
Care, Aarhus University Hospital, Aarhus, Denmark
Christine Gaarder Department of Traumatology, Oslo University Hospital
Ullevål, Oslo, Norway
Faculty of Medicine, University of Oslo, Oslo, Norway
Thomas Geisner Department of Vascular Surgery, Haukeland Trauma
Center, Haukeland University Hospital, Bergen, Norway
Mads Gilbert The Clinic of Emergency Medicine, University Hospital of
North Norway, Tromsø, Norway
The Anaesthesia and Critical Care Research Group, Institute of Clinical
Medicine, The Arctic University of Norway, Tromsø, Norway
Alison K. Godbolt University Department of Rehabilitation Medicine, and
Department of Clinical Sciences, Karolinska Institute, Danderyd Hospital,
Stockholm, Sweden
Per-Olof Grände Department of Anaesthesia and Intensive Care, Lund
University and Lund University Hospital, Lund, Sweden
Anne Berit Guttormsen Department of Anaesthesia and Intensive Care,
Haukeland University Hospital, Bergen, Norway
Contributors xxvii

Department of Clinical Medicine, University of Bergen, Bergen, Norway

Nikolaj Preus Hatting Department of Neuroanesthesiology and
Neurointensive Care, Odense University Hospital, Odense, Denmark
Christian A. Helland Department of Neurosurgery, Haukeland University
Hospital, Bergen, Norway
Department of Clinical Medicine, University of Bergen, Bergen, Norway
Eirik Helseth Institute of Clinical Medicine, University of Oslo, Oslo,
Norway
Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
Ann Hermansson ENT Department, University Hospital, Lund, Sweden
Department of Otorhinolaryngology, Lund University Hospital, Lund,
Sweden
Jennie Witte Hernæs Eating Disorders Unit, Skaraborgs Hospital, Skövde,
Sweden
Lars Hillered Department of Neuroscience, Neurosurgery, Uppsala
University, Uppsala, Sweden
Tim Howells Department of Neuroscience, Neurosurgery, Uppsala
University, Uppsala, Sweden
Tor Ingebrigtsen Department of Clinical Medicine, Faculty of Health
Sciences, UiT the Arctic University of Norway, Tromsø, Norway
Department of Neurosurgery, Ophthalmology and ENT, University Hospital
of North Norway, Tromsø, Norway
Daniel Isacson Department of Plastic and Maxillofacial Surgery, Uppsala
University Hospital, Uppsala, Sweden
Birger Johnsen Department of Clinical Neurophysiology, Aarhus University
Hospital, Aarhus, Denmark
Niels Juul Department of Anaesthesia, Aarhus University Hospital, Aarhus,
Denmark
Tariq Khan Department of Neurosurgery, Northwest School of Medicine,
Peshawar, Pakistan
Svein Kleiven Division of Neuronic Engineering, KTH Royal Institute of
Technology, Huddinge, Sweden
Marianne Klose Department of Medical Endocrinology, Copenhagen
University Hospital, Copenhagen, Denmark
Jens Aage Kølsen-Petersen Department of Anaesthesia, Aarhus University
Hospital, Aarhus, Denmark
Salla Koponen Department of Psychiatry, Hospital District of Helsinki and
Uusimaa, Helsinki, Finland
xxviii Contributors

Lars-Owe D. Koskinen Department of Clinical Science-Neurosciences/

Neurosurgery, Umeå University and Umeå University Hospital, Umeå,
Sweden
Ingela Kristiansen Department of Women’s and Children’s Health, Uppsala
University and Uppsala University Childrens’ Hospital, Uppsala, Sweden
Tsegazeab Laeke Department of Clinical Medicine, University of Bergen,
Bergen, Norway
Department of Neurosurgery, Addis Ababa University, Addis Ababa, Ethiopia
Christian Sigvald Langfrits Department of Anesthesia and Intensive Care,
Aalborg University Hospital, Aalborg, Denmark
Hege Linnerud Department of Neurosurgery, Oslo University Hospital
Ullevål, Oslo, Norway
Johan Ljungqvist Department of Neurosurgery, Sahlgrenska University
Hospital, Gothenburg, Sweden
Institute of Neuroscience and Physiology, Sahlgrenska Academy University
of Gothenburg, Gothenburg, Sweden
Pia Löwhagen Hendén Department of Anesthesiology and Intensive Care,
Sahlgrenska University Hospital, Gothenburg, Sweden
Morten Lund-Johansen Department of Clinical Medicine, University of
Bergen, Bergen, Norway
Department of Neurosurgery, Haukeland University Hospital, Bergen,
Norway
Teemu Luoto Department of Neurosurgery, Tampere University Hospital
and Tampere University, Tampere, Finland
Andrew I. R. Maas Department of Neurosurgery, Antwerp University
Hospital and University of Antwerp, Edegem, Belgium
Marek Majdan Department of Public Health, Faculty of Health Sciences
and Social Work, Trnava University, Trnava, Slovak Republic
Niklas Marklund Department of Clinical Sciences Lund, Neurosurgery,
Lund University, Skåne University Hospital, Lund, Sweden
David K. Menon Division of Anaesthesia, University of Cambridge,
Cambridge, UK
Neurosciences Critical Care Unit, Addenbrooke’s Hospital, Cambridge, UK
Ronni Mikkelsen Department of Neuroradiology, Aarhus University
Hospital, Aarhus, Denmark
Department of Biomedicine, Aarhus University, Aarhus, Denmark
Kent Gøran Moen Faculty of Medicine and Health Sciences, Department
of Neuromedicine and Movement Science, Norwegian University of Science
and Technology (NTNU), Trondheim, Norway
Department of Radiology, Nord-Trøndelag Hospital Trust, Levanger Hospital,
Levanger, Norway
Contributors xxix

Jens Kjølseth Møller Department of Clinical Microbiology, Vejle Hospital,

Vejle, Denmark
Kirsten Møller Department of Neuroanaesthesiology, The Neuroscience
Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
Department of Clinical Medicine, University of Copenhagen, Copenhagen,
Denmark
Pål Aksel Næss Department of Traumatology, Oslo University Hospital
Ullevål, Oslo, Norway
Faculty of Medicine, University of Oslo, Oslo, Norway
David W. Nelson Department of Physiology and Pharmacology, Section of
Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm,
Sweden
Rasmus Philip Nielsen Department of Anaesthesiology, Regional Hospital
West Jutland, Herning, Denmark
Troels Halfeld Nielsen Department of Neurosurgery, Odense University
Hospital, Odense, Denmark
Carl-Henrik Nordström Department of Neurosurgery, Odense University
Hospital, Odense, Denmark
Daniel Nowinski Department of Plastic and Maxillofacial Surgery, Uppsala
University Hospital, Uppsala, Sweden
Department of Surgical Sciences, Plastic Surgery, Uppsala University,
Uppsala, Sweden
Magnus Olivecrona Department of Medical Sciences, Faculty of Medicine,
Örebro University, Örebro, Sweden
Section for Neurosurgery, Department of Anaesthesia and Intensive Care,
University Hospital, Örebro, Sweden
Zandra Olivecrona Department of Medical Sciences, Faculty of Medicine,
Örebro University, Örebro, Sweden
Section for Neurosurgery, Department of Anaesthesia and Intensive Care,
University Hospital, Örebro, Sweden
Jussi P. Posti Clinical Neurosciences, Department of Neurosurgery and
Turku Brain Injury Centre, Turku University Hospital and University of
Turku, Turku, Finland
Christian Rahbek Department of Neuroradiology, Aarhus University
Hospital, Aarhus, Denmark
Mads Rasmussen Department of Anaesthesia and Intensive Care, Section
of Neuroanaesthesia, Aarhus University Hospital, Aarhus, Denmark
Peter Reinstrup Department of Intensive and Perioperative Care, Skånes
University Hospital, Lund, Sweden
Department of Anaesthesia and Intensive Care, Lund University and Lund
University Hospital, Lund, Sweden
xxx Contributors

Jens Jakob Riis Department of Neurosurgery, Aalborg University Hospital,

Aalborg, Denmark
Elisabeth Ronne-Engström Department of Neuroscience, Neurosurgery,
Uppsala University, Uppsala, Sweden
Pål A. Rønning Department of Neurosurgery, Oslo University Hospital,
Oslo, Norway
Christina Rosenlund Department of Neurosurgery, Odense University
Hospital, Odense, Denmark
Elham Rostami Department of Neurosurgery, Uppsala University Hospital,
Uppsala, Sweden
Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
Thoralph Ruge Department of Emergency and Internal Medicine, Skåne
University Hospital, Lund, Sweden
Department of Internal Medicine, Skåne University Hospital, Lund, Sweden
Department of Clinical Sciences, Lund University, Malmö, Sweden
Malin Rundgren Neurointensive Care Unit, Department of Intensive and
Preoperative Care, Skåne University Hospital, Lund, Sweden
Department of Clinical Sciences, Anesthesiology and Intensive Care
Medicine, Skåne University Hospital, Lund University, Lund, Sweden
Ulrika Sandvik Department of Clinical Neuroscience, Karolinska Institute,
Stockholm, Sweden
Department of Neurosurgery, Karolinska University Hospital, Stockholm,
Sweden
Ulf Schott Department of Anaesthesia and Intensive Care, Institution of
Clinical Sciences, Lund University, Lund, Sweden
Rico Frederik Schou Department of Neuroanesthesia and Neurocritical
Care, Odense University Hospital, Odense, Denmark
Section of Neuroanesthesia and Neurointensive Care, Department of
Anesthesia and Intensive Care Medicine, Odense University Hospital,
Odense, Denmark
Solrun Sigurdardottir Department of Research, Sunnaas Rehabilitation
Hospital, Bjørnemyr, Norway
Toril Skandsen Faculty of Medicine and Health Sciences, Department of
Neuromedicine and Movement Science, Norwegian University of Science
and Technology (NTNU), Trondheim, Norway
Department of Physical Medicine and Rehabilitation, St. Olav’s Hospital,
Trondheim University Hospital, Trondheim, Norway
Steinar Skrede Department of Medicine, Section of Infectious Diseases,
Haukeland University Hospital, Bergen, Bergen, Norway
Contributors xxxi

Leif Hovgaard Sørensen Department of Neuroradiology, Aarhus University

Hospital, Aarhus, Denmark
Jacob Bertram Springborg Department of Neurosurgery, University Clinic
of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
Morten Zebitz Steiness Spine Section, Department of Neurosurgery,
Aalborg University Hospital, Aalborg, Denmark
Terje Sundstrøm Department of Neurosurgery, Haukeland University
Hospital, Bergen, Norway
Department of Clinical Medicine, University of Bergen, Bergen, Norway
Riikka Takala Perioperative Services, Intensive Care Medicine and Pain
Management, Turku University Hospital, Turku, Finland
Olli Tenovuo Turku Brain Injury Centre, Turku University Hospital, Turku,
Finland
Department of Clinical Medicine, University of Turku, Turku, Finland
Department of Clinical Medicine, Turku Brain Injury Centre, Turku
University Hospital, University of Turku, Turku, Finland
Eric Peter Thelin Department of Clinical Neuroscience, Karolinska
Institutet, Stockholm, Sweden
Division of Neurosurgery, Department of Clinical Neurosciences, University
of Cambridge, Cambridge, UK
Johan Undén Department of Anaesthesia and Intensive Care, Hallands
Hospital, Halmstad, Sweden
Department of Operation and Intensive Care, Hallands Hospital, Halmstad,
Sweden
Lund University, Lund, Sweden
Arne Einar Vaaler Department of Mental Health, Norwegian University of
Science and Technology (NTNU), Trondheim, Norway
Eirik Vikane Department of Physical Medicine and Rehabilitation,
Haukeland University Hospital, Bergen, Norway
Anne Vik Department of Neuromedicine and Movement Science, Norwegian
University of Science and Technology (NTNU), Trondheim, Norway
Department of Neurosurgery, St. Olav’s Hospital, Trondheim University
Hospital, Trondheim, Norway
Einar Osland Vik-Mo Department of Neurosurgery, Oslo University
Hospital Rikshospitalet, Oslo, Norway
Karen-Lise Kobberø Welling Neurointensive Care Unit, Section 6021,
Department of Neuroanaesthesiology, The Neuroscience Centre,
Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
Knut Gustav Wester Department of Clinical Medicine K1, University of
Bergen, Bergen, Norway
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