Figure 33.1. Algorithm for the management of moderate TBI patients recommended by the Scandinavian Neurotrauma Committee.

DAI = diffuse axonal injury; SAH = subarachnoid hemorrhage.

33.6 Intracranial Pressure Monitoring

Intracranial pressure (ICP) monitoring is not indicated on a routine basis in moderate TBI. The physician, however, may opt to monitor ICP in certain patients with mass lesions.

33.7 Results

This heterogeneous patient group is remarkably variable in relation to long-term neurological recovery and outcomes. Early predictive factors of poor outcome include: GCS score, CT findings, coagulopathy, subarachnoid bleeding, and skull-base fracture.

While technological progress has improved patient survival in the last two decades, it has also lead to multiple disabilities in survivors. The Glasgow Outcome Scale (GOS) is widely used to globally assess TBI patient outcomes. Some limitations (wide categories, scarce sensitivity to subtle recovery changes, excessive worth attached to physical disability vis-à-vis cognitive and behavioural alterations, etc.), however, have been described. Several authors recommend the Disability Rating Scale (DRS) or the Extended Glasgow Outcome Scale (GOS-E) to assess delayed (6-month) outcomes in moderate TBI patients because of the higher sensitivity these tools have.

Many moderate TBI patients show some degree of neuropsychological impairment, memory, fine coordination or speech alterations. Even when cognitive functions improve in the first few years, memory deficits can persist.

33.8 Final Considerations

Moderate TBI patients are a heterogeneous group whose evolution and outcomes are almost impossible to predict, making it difficult to set up clear intervention guidelines. Hospitalization and baseline life support are universally accepted procedures, as is CT on admission. Predicting which patients will require intervention (ICP monitoring, neurosurgery, or both), however, has not been possible, except in the event of deterioration. A large multicentre trial is needed to improve the management of this group of patients.

General References

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Neuroscience Critical Care: Two Experts’ Point of View Acute Spinal Cord Injury: Pathophysiology and Intensive Care Management Monitoring Cerebral Blood Flow and Cerebral Autoregulation: Basic Principles, Techniques, Common Patterns and Interpretation of Results Endocrinology of Acute Brain Injury Monitoring Brain Chemistry by Microdialysis During Neurointensive Care Acute Paraplegias and Quadriplegias of Non-traumatic Cause

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