Guideline

Traumatic brain injury treatment

Traumatic brain injury treatment

Acute activation of innate immune response in the brain, or neuroinflammation, protects this vital organ from a range of external pathogens and promotes healing after traumatic brain injury.

Secondary brain injury treatment

see Secondary brain injury treatment

Transfer

Traumatic brain injury transfer.

Management in Emergency Room

Blood pressure and oxygenation

Level II: monitor BP and avoid hypotension (SBP <90 mm Hg).

Level III: monitor oxygenation and avoid hypoxia (PaO2 <60mm Hg or O2 saturation <90%).

Hypotension

Hypotension (shock) is rarely attributable to head injury except:

● in terminal stages (i.e. with dysfunction of medulla and cardiovascular collapse)

● in infancy, where enough blood can be lost intracranially or into the subgaleal space to cause shock

● where enough blood has been lost from scalp wounds to cause hypovolemia (exsanguination)

Hypotension (defined as a single SBP < 90 mm Hg) doubles mortality, hypoxia (apnea or cyanosis in the field, or PaO2 <60 mm Hg on ABG) also increases mortality, and the combination of both triples mortality and increases the risk bad outcome. SBP<90 mm Hg may impair CBF and exacerbate brain injury and should be avoided.

Early use of paralytics and sedation (prior to ICP monitoring)

see Sedative for traumatic brain injury.

Intubation and hyperventilation

Indications for intubation in trauma:

1. depressed level of consciousness (patient cannot protect airway): usually GCS≤7

2. need for hyperventilation (HPV).

3. severe maxillofacial trauma: patency of airway tenuous or concern for inability to maintain patency with further tissue swelling and/or bleeding

4. need for pharmacologic paralysis for evaluation or management.

There are currently no established treatments for the underlying pathophysiology in TBI and while neurorehabilitation efforts are promising, there are currently is a lack of consensus regarding rehabilitation following TBI of any severity 1).

Ask for Alcohol consumption

see Alcohol withdrawal syndrome

see Wernicke’s encephalopathy.

Neuroprotection for Traumatic Brain Injury

Neuroprotection for Traumatic Brain Injury

Severe traumatic brain injury treatment

see Severe traumatic brain injury treatment.

Pediatric traumatic brain injury guidelines

Pediatric traumatic brain injury guidelines.

Traumatic brain injury treatment during the Covid-19 pandemic

Treating traumatic brain injuries (TBIs) during the Covid-19 pandemic requires careful considerations to ensure the safety and well-being of both patients and healthcare providers. Here are some important aspects to consider in TBI treatment during the pandemic:

Emergency care: In the event of a severe TBI, emergency medical services and hospitals continue to provide critical care. Protocols are in place to protect both patients and healthcare workers from potential exposure to the virus.

Hospital precautions: Hospitals have implemented infection control measures to minimize the risk of Covid-19 transmission. These measures include screening patients for symptoms, providing personal protective equipment (PPE) to staff, isolating Covid-19-positive patients, and maintaining enhanced cleaning and disinfection procedures.

Rehabilitation services: Rehabilitation is an essential component of TBI treatment. During the pandemic, rehabilitation facilities have implemented safety measures, such as reduced capacity, enhanced cleaning protocols, physical distancing measures, and telehealth options when appropriate.

Telehealth services: Telehealth has played a crucial role in providing ongoing care and support for TBI patients during the pandemic. Telehealth appointments allow healthcare providers to assess patients remotely, provide guidance, monitor progress, and offer therapy sessions when in-person visits are not feasible.

Mental health support: The Covid-19 pandemic has had a significant impact on mental health. It is crucial to address the emotional and psychological well-being of TBI patients, as they may face additional challenges and increased stress during these times. Teletherapy and virtual support groups can be valuable resources for providing mental health support.

Caregiver support: Caregivers play a vital role in supporting individuals with TBIs. They may face additional burdens and challenges during the pandemic. Providing caregiver support through virtual resources, educational materials, and online support groups can help them navigate these difficult circumstances.

Follow-up care: Regular follow-up appointments with healthcare providers are crucial for monitoring TBI recovery progress and addressing any ongoing concerns. Telehealth visits can be utilized for routine check-ups, medication management, and addressing non-emergency issues.

It is important to note that the specific guidelines and protocols for TBI treatment during the Covid-19 pandemic may vary depending on the location, healthcare facility, and individual circumstances.

1)

Marklund N, Bellander BM, Godbolt A, Levin H, McCrory P, Thelin EP. Treatments and rehabilitation in the acute and chronic state of traumatic brain injury. J Intern Med. 2019 Mar 18. doi: 10.1111/joim.12900. [Epub ahead of print] PubMed PMID: 30883980.

Stroke guidelines

Stroke guidelines

There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines. They identified areas of strong agreement across guidelines, and their global coverage.

To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1st January 2011, evaluate quality (AGREE II), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced).

Searches identified 15400 titles, 911 texts were retrieved, 203 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing aetiological diagnosis, management of hypertension, weight, diabetes, lipids, lifestyle modification; and for ischemic stroke: management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, antithrombotics in non-cardioembolic stroke. For rehabilitation there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task specific training, fitness training, and specific interventions for post-stroke impairments.Most recommendations were from high income countries, and most did not consider comorbidity, resource implications and implementation. Patient and public involvement was limited.

The review identified a number of areas of stroke care in there was strong consensus. However there was extensive repetition and redundancy in guideline recommendations. Future guidelines groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation 1).

American Heart Association Guidelines for the Early Management of Patients With Acute Ischemic Stroke

American Heart Association Guidelines for the Early Management of Patients With Acute Ischemic Stroke.

European Stroke Organisation Guidelines

https://eso-stroke.org/guidelines/eso-guideline-directory/

The fifth edition of the National Clinical Guideline for Stroke 2016

https://www.strokeaudit.org/Guideline/Full-Guideline.aspx

Stroke Foundation – Australia

https://strokefoundation.org.au/what-we-do/for-health-professionals/clinical-guidelines

1)

Mead GE, Sposato LA, Silva GS, Yperzeele L, Wu S, Kutlubaev MA, Cheyne J, Wahab K, Urrutia VC, Sharma VK, Sylaja PN, Hill K, Steiner T, Liebeskind DS, Rabinstein AA. Systematic review and synthesis of global stroke guidelines for the World Stroke Organization. Int J Stroke. 2023 Feb 1:17474930231156753. doi: 10.1177/17474930231156753. Epub ahead of print. PMID: 36725717.

Central nervous system tumor guidelines

Central nervous system tumor guidelines

NCCN Guidelines

The NCCN Guidelines for Central nervous system tumor focus on the management of the following adult CNS cancers: glioma (WHO grade 1, WHO grade 2-3 Oligodendroglioma IDH-mutant and 1p/19q-codeleted, WHO grade 2-4 Astrocytoma IDH-mutants, WHO grade 4 glioblastoma), intracranial and spinal ependymomas, medulloblastoma, limited and extensive brain metastases, leptomeningeal metastases, non-AIDS-related Primary central nervous system lymphomas, metastatic spine tumors, meningiomas, and primary spinal cord tumors. The information contained in the algorithms and principles of management sections in the NCCN Guidelines for CNS Cancers is designed to help clinicians navigate through the complex management of patients with CNS tumors. Several important principles guide surgical management and treatment with radiotherapy and systemic therapy for adults with brain tumors. The NCCN CNS Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel’s most recent recommendations regarding molecular profiling of gliomas 1)

AANS/CNS SECTION ON TUMORS

Evidence-based, clinical practice guidelines in the management of central nervous system tumors (CNS) continue to be developed and updated through the work of the Joint Section on Tumors of the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS).

The guidelines are created using the most current and clinically relevant evidence using systematic methodologies, which classify available data and provide recommendations for clinical practice.

This update summarizes the Tumor Section Guidelines developed over the last five years for non-functioning pituitary adenomas, low-grade gliomas, vestibular schwannomas, and metastatic brain tumors 2).

National Cancer Institute

https://www.cancer.gov/types/brain/hp/adult-brain-treatment-pdq

European Society for Medical Oncology

https://www.esmo.org/guidelines/guidelines-by-topic/neuro-oncology

1)

Horbinski C, Nabors LB, Portnow J, Baehring J, Bhatia A, Bloch O, Brem S, Butowski N, Cannon DM, Chao S, Chheda MG, Fabiano AJ, Forsyth P, Gigilio P, Hattangadi-Gluth J, Holdhoff M, Junck L, Kaley T, Merrell R, Mrugala MM, Nagpal S, Nedzi LA, Nevel K, Nghiemphu PL, Parney I, Patel TR, Peters K, Puduvalli VK, Rockhill J, Rusthoven C, Shonka N, Swinnen LJ, Weiss S, Wen PY, Willmarth NE, Bergman MA, Darlow S. NCCN Guidelines® Insights: Central Nervous System Cancers, Version 2.2022. J Natl Compr Canc Netw. 2023 Jan;21(1):12-20. doi: 10.6004/jnccn.2023.0002. PMID: 36634606.
2)

Redjal N, Venteicher AS, Dang D, Sloan A, Kessler RA, Baron RR, Hadjipanayis CG, Chen CC, Ziu M, Olson JJ, Nahed BV. Guidelines in the management of CNS tumors. J Neurooncol. 2021 Feb;151(3):345-359. doi: 10.1007/s11060-020-03530-8. Epub 2021 Feb 21. PMID: 33611702.