A recent Kennedys' healthcare seminar considered advances in the treatment of brain injury and emphasised the importance of continued research trials.
Our speaker was Professor Peter Hutchinson, Honorary Consultant Neurosurgeon at Addenbrooke’s Hospital, Cambridge.
Early decision-making is important and much depends on the result of the CT scan. However, the issue of how best to manage and treat brain trauma (and in particular whether to operate) is not always clear.
It is hoped that clearer guidance will be established through trials: their importance should not be underestimated.
Each year, head injuries lead to one million patients attending accident and emergency departments in the UK. They are the commonest cause of death under the age of 40. Those who survive can be left with physical, psychological and social disabilities.
Historically, a patient with a head injury was taken to the nearest hospital and then transferred to a specialist centre. Now, there are major trauma centres (MTCs) nationally, to which a patient can be taken directly.
Ideally, the patient needs to be received by a MTC within 45 minutes of injury. There are four MTCs within the London area and so a 45 minute transfer is achievable. The difficulty arises in the regional areas, where a patient may be taken to their nearest hospital first for life-saving treatment and then transferred to a MCT.
Professor Hutchinson explained that the management of brain injury within an advanced trauma life support emergency department is very prescriptive:
- The patient undergoes a primary survey. The doctors assess the airway, breathing, circulation and the perceived disability. The Glasgow Coma Score (GCS) is used to assess the severity of the injury and will be between three and 15. A GCS of eight or below is severe and equates to ‘coma’.
- The patient will commence resuscitation and will be given oxygen if necessary. A secondary survey will be carried out, which involves examining the patient for other injuries.
- Once a patient is stable with good airway and satisfactory breathing they may be transferred for a CT scan. Given guidelines from the National Institute for Health and Care Excellence, around 30 to 50% of patients with head injuries are scanned.
The neurosurgical team must consider how best to proceed. A patient with a diffuse brain injury will need to go to an intensive therapy unit (ITU). The need for intracranial pressure monitoring will be considered. Professor Hutchinson explained that neuro-critical care and the ability to measure intracranial pressure has led to a marked improvement in outcome for these patients and is now fairly routine in the UK.
To try to maintain the intracranial pressure at less than 25mm Hg:
- The patient’s head will be elevated.
- Cerebrospinal fluid will be drained.
- They will be kept cool (helps sedate the brain, which reduces demand on it).
- Drugs will be administered to sedate them, increase blood pressure and improve blood flow (to drive it into the brain).
Some patients are very difficult to treat, however, and they may need to be placed into very deep sedation.
The question of surgery/operative management must also be considered. Haematomas generally need to be treated by surgery but surgery can also assist with diffuse injury by way of external ventricular drains and decompressive craniectomy.
Research trials are ongoing for the management of head injuries:
- Pharmacological trials have investigated whether drugs can assist in reducing swelling. However, there were poor outcomes for a variety of reasons.
- ‘Surgical trial in traumatic intracerebral haemorrhage’ (STITCH) sought to determine whether a policy of early surgery in patients with traumatic intracerebral haemorrhage improves the outcome compared to a policy of initial conservative treatment. The study recruited well but was stopped because only six patients were from the UK. However, the indications were that early surgery patients did better in terms of survival, although it was not clear whether overall quality of life was improved, given the early termination.
- Professor Hutchinson discussed a trial looking at early decompressive craniectomy as a pressure lowering method, known as DECRA. This study showed that mortality was the same but that the outcome for the patients in terms of disability was worse.
- A further trial, known as RESCUEicp, is also looking at decompressive craniectomy as a pressure lowering method, but with the surgery as a last-tier therapy. This study is currently being analysed.
Professor Hutchinson commented that studies are complex to run but the Royal College of Surgeons now have initiatives to promote and assist in these trials. The British Neurosurgery Trainee Research Collaborative also plays a role in engaging trainee doctors at an early stage.