NEJM：颅内压监护创伤性脑损伤受质疑

　　一项发表在《新英格兰》杂志上的研究表明，颅内压监测（严重脑外伤的标准护理）与基于影像和临床检查的诊断与治疗相比并无明显不同。Randall Chesnut是华盛顿大学医学院的一名神经外科医生，在西雅图的港景医学中心工作，并且是这项研究的主要研究者。他说，在脑外伤的治疗领域中，这项研究具有变革意义，我们之前的治疗都是由颅内压的数值来指导的，而并不是按照疾病的病理生理学来治疗。该研究是第一个有关脑外伤的国际性随机对照试验，它是由美国卫生研究所资助。这种类型的研究在拉美还是首例。

　　当出现脑外伤时，控制患者的颅内压低于20 mm（毫米汞柱）是首要治疗，即使此时患者需要实施开颅手术。颅内压上升说明中枢神经系统（神经的）和血管（血管的）组织正在受到压迫，并且可能会导致永久性脑损伤和死亡。

 对于创伤性脑损伤患者而言，常规的标准护理仅仅就是实施开颅手术，这是由华盛顿大学的一组研究人员和玻利维亚及厄瓜多尔的六所医院的同事共同制定的。一个主要问题是20mm（毫米汞柱）并不是一个决定治疗标准的神奇数字，患者需要的是一个更为复杂的治疗方案。　

与脑损伤相关的拓展阅读：

• 颅内压监护创伤性脑损伤受质疑
• 睡眠呼吸暂停综合征患者脑损伤有性别差异
• Diabetes:新型降糖药或可减少卒中后脑损伤
• LANCET NEUROL：创伤性脑损伤发病率高于官方公布的6倍
• 高血压脑损伤始于年轻时
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A Trial of Intracranial-Pressure Monitoring in Traumatic Brain Injury

BACKGROUND

Intracranial-pressure monitoring is considered the standard of care for severe traumatic brain injury and is used frequently, but the efficacy of treatment based on monitoring in improving the outcome has not been rigorously assessed.

METHODS

We conducted a multicenter, controlled trial in which 324 patients 13 years of age or older who had severe traumatic brain injury and were being treated in intensive care units (ICUs) in Bolivia or Ecuador were randomly assigned to one of two specific protocols: guidelines-based management in which a protocol for monitoring intraparenchymal intracranial pressure was used (pressure-monitoring group) or a protocol in which treatment was based on imaging and clinical examination (imaging–clinical examination group). The primary outcome was a composite of survival time, impaired consciousness, and functional status at 3 months and 6 months and neuropsychological status at 6 months; neuropsychological status was assessed by an examiner who was unaware of protocol assignment. This composite measure was based on performance across 21 measures of functional and cognitive status and calculated as a percentile (with 0 indicating the worst performance, and 100 the best performance).

RESULTS

There was no significant between-group difference in the primary outcome, a composite measure based on percentile performance across 21 measures of functional and cognitive status (score, 56 in the pressure-monitoring group vs. 53 in the imaging–clinical examination group; P=0.49). Six-month mortality was 39% in the pressure-monitoring group and 41% in the imaging–clinical examination group (P=0.60). The median length of stay in the ICU was similar in the two groups (12 days in the pressure-monitoring group and 9 days in the imaging–clinical examination group; P=0.25), although the number of days of brain-specific treatments (e.g., administration of hyperosmolar fluids and the use of hyperventilation) in the ICU was higher in the imaging–clinical examination group than in the pressure-monitoring group (4.8 vs. 3.4, P=0.002). The distribution of serious adverse events was similar in the two groups.

CONCLUSIONS

For patients with severe traumatic brain injury, care focused on maintaining monitored intracranial pressure at 20 mm Hg or less was not shown to be superior to care based on imaging and clinical examination.