Assessment of cerebrovascular alterations induced by inflammatory response and oxidative-nitrative stress after traumatic intracranial hypertension and a potential mitigation strategy.

The rapid perfusion of cerebral arteries leads to a significant increase in intracranial blood volume, exposing patients with traumatic brain injury to the risk of diffuse brain swelling or malignant brain herniation during decompressive craniectomy. The microcirculation and venous system are also involved in this process, but the precise mechanisms remain unclear. A physiological model of extremely high intracranial pressure was created in rats. This development triggered the TNF-α/NF-κB/iNOS axis in microglia, and released many inflammatory factors and reactive oxygen species/reactive nitrogen species, generating an excessive amount of peroxynitrite. Subsequently, the capillary wall cells especially pericytes exhibited severe degeneration and injury, the blood-brain barrier was disrupted, and a large number of blood cells were deposited within the microcirculation, resulting in a significant delay in the recovery of the microcirculation and venous blood flow compared to arterial flow, and this still persisted after decompressive craniectomy. Infliximab is a monoclonal antibody bound to TNF-α that effectively reduces the activity of TNF-α/NF-κB/iNOS axis. Treatment with Infliximab resulted in downregulation of inflammatory and oxidative-nitrative stress related factors, attenuation of capillary wall cells injury, and relative reduction of capillary hemostasis. These improved the delay in recovery of microcirculation and venous blood flow.

Comparing the effects of mannitol and hypertonic saline in severe traumatic brain injury patients with elevated intracranial pressure: a systematic review and meta-analysis.

OBJECTIVES: Controlling elevated intracranial pressure following brain injury with hyperosmolar agents is one of the mainstay treatments in traumatic brain injury patients. In this study, we compared the effects of hypertonic saline (HS) and mannitol in reducing increased intracranial pressure. METHODS: A total of 637 patients from 15 studies were included in our meta-analysis. The primary outcomes were mortality, the length of stay in the hospital and ICU, and the Glasgow Outcome Scale at follow-up. RESULTS: The mortality in the mannitol group was not statistically different compared to the HS group (RR = 1.55; 95% CI = [0.98, 2.47], p = 0.06). The length of stay in the ICU was significantly shorter in the HS group (MD = 1.18, 95% CI = [0.44, 1.92], p < 0.01). In terms of favorable neurological outcomes, there was no significant difference between the two agents (RR = 0.92, 95% CI = [0.11, 7.96], p = 0.94). The duration of the effect was shorter in the mannitol group than in the HS group (MD = -0.67, 95% CI = [-1.00, -0.33], p < 0.01). DISCUSSION: The results showed that HS and mannitol had similar effects in reducing ICP. Although the HS was associated with a longer duration of effect and shorter ICU stay, other secondary outcomes including mortality rate and favorable neurological outcomes were similar between the two drugs. In conclusion, considering the condition of each patient individually, HS could be a reasonable option than mannitol to reduce ICP in TBI patients.

Comparison of mannitol and hypertonic saline solution for the treatment of suspected brain herniation during prehospital management of traumatic brain injury patients.

BACKGROUND AND IMPORTANCE: Occurrence of mydriasis during the prehospital management of traumatic brain injury (TBI) may suggest severe intracranial hypertension (ICH) subsequent to brain herniation. The initiation of hyperosmolar therapy to reduce ICH and brain herniation is recommended. Whether mannitol or hypertonic saline solution (HSS) should be preferred is unknown. OBJECTIVES: The objective of this study is to assess whether HSS, compared with mannitol, is associated with improved survival in adult trauma patients with TBI and mydriasis. DESIGN/SETTING AND PARTICIPANTS: A retrospective observational cohort study using the French Traumabase national registry to compare the ICU mortality of patients receiving either HSS or mannitol. Patients aged 16 years or older with moderate to severe TBI who presented with mydriasis during prehospital management were included. OUTCOME MEASURES AND ANALYSIS: We performed propensity score matching on a priori selected variables [i.e. age, sex and initial Coma Glasgow Scale (GCS)] with a ratio of 1 : 3 to ensure comparability between the two groups. The primary outcome was ICU mortality. The secondary outcomes were regression of pupillary abnormality during prehospital management, pulsatility index and diastolic velocity on transcranial Doppler within 24 h after TBI, early ICU mortality (within 48 h), ICU and hospital length of stay. RESULTS: Of 31 579 patients recorded in the registry between 2011 and 2021, 1417 presented with prehospital mydriasis and were included: 1172 (82.7%) received mannitol and 245 (17.3%) received HSS. After propensity score matching, 720 in the mannitol group matched 240 patients in the HSS group. Median age was 41 years [interquartile ranges (IQR) 26-60], 1058 were men (73%) and median GCS was 4 (IQR 3-6). No significant difference was observed in terms of characteristics and prehospital management between the two groups. ICU mortality was lower in the HSS group (45%) than in the mannitol group (54%) after matching [odds ratio (OR) 0.68 (0.5-0.9), P  = 0.014]. No differences were identified between the groups in terms of secondary outcomes. CONCLUSION: In this propensity-matched observational study, the prehospital osmotherapy with HSS in TBI patients with prehospital mydriasis was associated with a lower ICU mortality compared to osmotherapy with mannitol.

Growth hormone therapy does not impact the development of intracranial hypertension in children with Chiari malformation.

OBJECTIVES: Patients with Chiari malformation (CM) are prone to a variety of neurological sequelae, including benign intracranial hypertension (BIH). In these patients, BIH is attributed to impaired cerebrospinal fluid (CSF) flow due to anatomical abnormalities of the posterior fossa. Occasionally, patients with CM may require growth hormone therapy (GHT), which can increase the production of CSF. It is thought that patients with CM who undergo GHT are at high risk of BIH-associated symptoms (BIHAS). We describe the incidence of neurological symptoms in 34 patients with CM before and during GHT. METHODS: The database of a pediatric endocrinology center was queried for patients with CM who received GHT from 2010-22. Records were reviewed for adverse events. Demographic and radiological data were collected and analyzed. Patients with neoplastic disease, active inflammation, or acute trauma were excluded. CM diagnoses were independently assigned by a neuroradiology department. Patients were grouped based on the presence and nature of symptoms before and during GHT. Relationships between starting dose/BMI and occurrence of BIHAS/all GHT-associated symptoms were evaluated. RESULTS: GHT was not associated with new-onset or worsening of preexisting BIHAS in 33 out of 34 patients with CM. Five complex patients continued to have preexisting BIHAS, which did not worsen. Of the four patients who developed new-onset BIHAS during GHT, three patients' symptoms were attributed to other medical conditions. No patient permanently discontinued GHT due to BIHAS. CONCLUSIONS: Growth hormone therapy is likely a safe treatment in patients with Chiari malformation and is unlikely to cause BIHAS.

Isolated Intracranial Hypertension as a Presentation of Pediatric Lyme Borreliosis: A Case Report and Literature Review.

BACKGROUND: It is extremely rare for Lyme borreliosis to present solely with features of increased intracranial pressure. The treatment of pediatric Lyme neuroborreliosis with oral versus intravenous antibiotics remains controversial. METHODS: Case report and literature review. RESULTS: A 13-year-old male presented with five days of binocular diplopia, several weeks of headache, and a history of multiple tick bites six weeks prior. His examination showed a left eye abduction deficit and bilateral optic disc edema. Magnetic resonance imaging (MRI) of the brain with contrast showed tortuosity of the optic nerves, prominence of the optic nerve sheaths, and enhancement of the left fifth and bilateral sixth cranial nerves. Lumbar puncture showed an elevated opening pressure and a lymphocytic pleocytosis. Lyme IgM and IgG antibodies were positive in the serum and cerebrospinal fluid. The patient was treated with intravenous ceftriaxone for two days empirically followed by doxycycline by mouth for 19 days. Symptoms began improving after 48 hours. The strabismus resolved after two weeks, and the papilledema improved slowly with complete resolution at six months. CONCLUSIONS: Lyme neuroborreliosis can present as isolated intracranial hypertension in the pediatric population; it can be differentiated from idiopathic intracranial hypertension on MRI, and lumbar puncture and can be confirmed with serum antibody testing. Oral doxycycline can be considered for Lyme neuroborreliosis in children.

Cerebral Lactate Uptake After Half-Molar Sodium Lactate Therapy in Traumatic Brain Injury: A Brief Report.

Exogenous sodium lactate has many advantages after traumatic brain injury, including intracranial pressure control and alternative energetic supply. It remains unclear, however, whether half-molar sodium lactate (HSL) is effectively incorporated in brain metabolism, which we can verify using the arteriovenous difference in lactate (AVDlac). Hence we compared the AVDlac in patients with severe traumatic brain injury receiving an equiosmolar bolus of sodium lactate or mannitol for intracranial hypertension (IH) treatment. We included 23 patients: 14 received HSL for 25 IH episodes, and nine received mannitol for 19 episodes (total of 44 IH episodes). We observed that the median variation in AVDlac was positive in the group that received HSL (Δ +0.1 [IQR -0.08-0.2] mmol/L), which suggests a net lactate uptake by the brain. On the other hand, it was negative in the group that received mannitol (Δ -0.0 [IQR -0.1 to 0.0] mmol/L), indicating a net lactate export. Finally, there were more positive AVDlac values in the group that received HSL and more negative AVDlac values in the group that received mannitol (Fisher exact p = 0.04). Our study reports the first evidence of a positive AVDlac, which corresponds to a net lactate uptake by the brain, in patients who received HSL for severe TBI. Our results constitute a bedside confirmation of the integration of lactate into the brain metabolism and pave the way for a wider dissemination of sodium lactate in the daily clinical care of patients with traumatic brain injury.

Safety and Effect on Intracranial Pressure of 3% Hypertonic Saline Bolus Via Peripheral Intravenous Catheter for Neurological Emergencies.

BACKGROUND: Elevated intracranial pressure (ICP) is a neurological emergency in patients with acute brain injuries. Such a state requires immediate and effective interventions to prevent potential neurological deterioration. Current clinical guidelines recommend hypertonic saline (HTS) and mannitol as first-line therapeutic agents. Notably, HTS is conventionally administered through central venous catheters (CVCs), which may introduce delays in treatment due to the complexities associated with CVC placement. These delays can critically affect patient outcomes, necessitating the exploration of more rapid therapeutic avenues. This study aimed to investigate the safety and effect on ICP of administering rapid boluses of 3% HTS via peripheral intravenous (PIV) catheters. METHODS: A retrospective cohort study was performed on patients admitted to Sisters of Saint Mary Health Saint Louis University Hospital from March 2019 to September 2022 who received at least one 3% HTS bolus via PIV at a rate of 999 mL/hour for neurological emergencies. Outcomes assessed included complications related to 3% HTS bolus and its effect on ICP. RESULTS: Of 216 3% HTS boluses administered in 124 patients, complications occurred in 8 administrations (3.7%). Pain at the injection site (4 administrations; 1.9%) and thrombophlebitis (3 administrations; 1.4%) were most common. The median ICP reduced by 6 mm Hg after 3% HTS bolus administration (p < 0.001). CONCLUSIONS: Rapid bolus administration of 3% HTS via PIV catheters presents itself as a relatively safe approach to treat neurological emergencies. Its implementation could provide an invaluable alternative to the traditional CVC-based administration, potentially minimizing CVC-associated complications and expediting life-saving interventions for patients with neurological emergencies, especially in the field and emergency department settings.

Effect of continuous hypertonic saline infusion on clinical outcomes in patients with traumatic brain injury.

Osmotic therapy has been recognized as an important treatment option for patients with traumatic brain injury (TBI). Nevertheless, the effect of hypertonic saline (HTS) remains unknown, as findings are primarily based on a large database. This study aimed to elucidate the effect of HTS on the clinical outcomes of patients with TBI admitted to the intensive care unit (ICU). We retrospectively identified patients with moderate-to-severe TBI from two public databases: Medical Information Mart for Intensive Care (MIMIC)-IV and eICU Collaborative Research Database (eICU-CRD). A marginal structural Cox model (MSCM) was used, with time-dependent variates designed to reflect exposure over time during ICU stay. Trajectory modeling based on the intracranial pressure evolution pattern allowed for the identification of subgroups. Overall, 130 (6.65%) of 1955 eligible patients underwent HTS. MSCM indicated that the HTS significantly associated with higher infection complications (e.g., urinary tract infection (HR 1.88, 95% CI 1.26-2.81, p = 0.002)) and increased ICU LOS (HR 2.02, 95% CI 1.71-2.40, p < 0.001). A protective effect of HTS on GCS was found in subgroups with medium and low intracranial pressure. Our study revealed no significant difference in mortality between patients who underwent HTS and those who did not. Increased occurrence rates of infection and electrolyte imbalance are inevitable outcomes of continuous HTS infusion. Although the study suggests slight beneficial effects, including better neurological outcomes, these results warrant further validation.

Systemic lupus erythematosus with chronic persistent intracranial hypertension: A case report.

OBJECTIVE: The aim is to investigate the clinical characteristics of systemic lupus erythematosus with intracranial hypertension. METHODS: The clinical characteristics of one case of systemic lupus erythematosus with chronic persistent intracranial hypertension were analyzed, and related literature was reviewed by searching Medline and Wanfang databases. RESULTS: Intracranial hypertension in SLE patients may occur at the onset or during the course of the disease. Our patient was diagnosed with IH 3 years after the onset of SLE. Headache and papilledema were the most common symptoms of intracranial hypertension, followed by nausea or vomiting, vision changes, and cerebral palsy. Our patient had a headache and cranial hypertension that lasted for years, but no papilledema was found. Corticosteroid is currently the mainstay of the treatment of IIH in patients with SLE, and immunosuppressive agents, acetazolamide, intravenous mannitol and furosemide are also used. However, our patient did not respond to these treatments and presents the characteristics of chronic persistent intracranial hypertension. CONCLUSION: Systemic lupus erythematosus with intracranial hypertension is a rare manifestation of SLE, which is not completely parallel to SLE activity. Headache and papilledema were the most common presenting symptoms. Different from previous reported cases, our patient had poor response to treatments, showing chronic and persistent characteristics.

Increased intracranial pressure in acute bacterial meningitis.

Acute bacterial meningitis (ABM) is associated with increased intracranial pressure (ICP) caused by bacterial invasion and the host response to infection. Antibiotic therapy is a sine qua non, and adjunct dexamethasone decreases mortality. The ICP increase may have a rapid course and death due to herniation is most often seen within the first week. Evidence regarding treatment of increased ICP in ABM is limited; this review summarises observational studies which point towards reduced mortality by applying a structured approach towards normalization of ICP in ABM.

Solución salina hipertónica versus otros agentes reductores de la presión intracraneal en personas con lesión cerebral traumática aguda / Hypertonic saline versus other intracranial pressure–lowering agents for people with acute traumatic brain injury

Se revisaron las pruebas de la efectividad y la seguridad de las infusiones (en las que se administra una sustancia a través de una vena) de solución salina hipertónica (SSH) [solución salina concentrada (cloruro de sodio)] en comparación con otros tipos de infusión para disminuir la presión intracraneal (PIC, la presencia de presión alta dentro y alrededor del cerebro) en el tratamiento de la lesión cerebral traumática aguda. Fundamento. Las LCT agudas (lesiones repentinas y graves en el cerebro, a menudo debidas a accidentes) son una de las principales causas de muerte y discapacidad en el mundo, especialmente en niños y jóvenes. La hipertensión intracraneal es común después de un daño cerebral. Esto se debe a que el cráneo es un compartimento rígido que contiene 3 partes: tejido cerebral blando, sangre y líquido cefalorraquídeo. Si aumenta el volumen de uno de los componentes, por ejemplo los hematomas (acumulaciones de sangre) dentro del tejido blando del cerebro, el volumen de uno o más del resto de componentes debe disminuir. Si no, la PIC aumentará. Si esta aumenta más allá de ciertos límites, se produce un desequilibrio y el flujo sanguíneo al cerebro disminuye peligrosamente. Esta PIC elevada puede causar efectos graves que incluyen daños cerebrales y muerte. La terapia hiperosmolar es un tratamiento importante para la PIC elevada. Un tipo de terapia hiperosmolar consiste en una infusión de solución salina concentrada (hipertónica) (sal de mesa/cloruro sódico) en la sangre; también pueden utilizarse otros tratamientos, como el manitol (una forma de azúcar). Estos tratamientos pueden reducir la PIC al disminuir el volumen de agua dentro y entre las células cerebrales. (AU)

Hipertensión intracraneal secundaria a trombosis de senos venosos / Intracranial hypertension secondary to a venous sinus thrombosis

No disponible

Desprendimiento de retina neurosensorial macular asociado al uso de topiramato / Macular neurosensory retinal detachment associated with topiramate use

Mujer de 36 años diagnosticada de hipertensión intracraneal idiopática tratada con acetazolamida y topiramato, que presenta desprendimientos neurosensoriales retinianos. La paciente fue seguida durante 2 años estableciéndose una relación entre los desprendimientos neurosensoriales y el topiramato, con recurrencias tras la introducción del topiramato y mejoría tras la retirada del mismo. Estos hechos señalan al topiramato como posible responsable del cuadro. El topiramato podría ser responsable de la aparición de desprendimientos neurosensoriales de la retina y mácula. Aunque los casos de efusión cilio coroidea producidos por este fármaco son bien conocidos, sus efectos secundarios sobre la retina son menos frecuentes. Ya que se trata de un fármaco de amplio uso, tanto neurólogos como oftalmólogos deberían ser conscientes de sus posibles efectos secundarios

A 36 year-old woman with idiopathic intracranial hypertension was treated with topiramate and acetazolamide. The patient was followed-up for 2 years, with a relationship between neurosensory detachments and topiramate being established, with recurrences after the introduction of topiramato and improvement after its withdrawal. These findings point topiramate as a possible cause of the clinical picture. Topiramate may cause retinal and macular neurosensory detachments. Although the ciliochoroidal effusion cases caused by this drug are well-known, its retinal side effects are less common. As it is a widely used drug, neurologists and ophthalmologists should be aware of its possible ocular side effects

Lactato de sodio 0, 5 molar: ¿el agente osmótico que buscamos? / Half-molar sodium-lactate: The osmotic agent we are looking for?

La hipertensión intracraneana (HIC) es el factor modificable con mayor impacto pronóstico predictivo negativo en el paciente neurocrítico. La terapia osmótica constituye la medida específica de primer nivel más importante para controlar la HIC. El manitol al 20% y el cloruro de sodio hipertónico al 3, 7,5, 10 y 23% son los agentes osmóticos más comúnmente utilizados en la práctica clínica. En los últimos años ha sido incorporado el lactato de sodio 0,5M como agente osmótico. El lactato como anión acompañante del sodio evita la hipercloremia y sus efectos adversos (acidosis hiperclorémica, inflamación sistémica, insuficiencia renal aguda); asimismo, el lactato puede ser utilizado por la neuroglia como sustrato energético para el cerebro dañado. El lactato de sodio 0,5M tendría además un efecto más potente y prolongado mediante un descenso de la osmolaridad intracelular e inhibición de los mecanismos de control del volumen neuronal. Trabajos pioneros en pacientes con traumatismo craneoencefálico grave han mostrado un efecto más pronunciado que el manitol en el control de la HIC. Asimismo, en este grupo de pacientes parece ser beneficioso en la prevención de HIC. Sin embargo, estos resultados prometedores necesitan ser corroborados en futuras investigaciones

Intracranial hypertension (ICH) is the most important modifiable factor with predictive negative value in brain injury patients. Osmotherapy is the most important first level specific measure in the treatment of ICH. Mannitol 20%, and 3, 7.5, 10, and 23% hypertonic sodium chloride are the most commonly used osmotic agents in the neurocritical care setting. Currently, controversy about the best osmotic agent remains elusive. Therefore, over the past few years, half-molar sodium lactate has been introduced as a new osmotic agent to be administered in the critically ill. Lactate is able to prevent hyperchloremia, as well as its adverse effects such as hyperchloremic acidosis, systemic inflammation, and acute kidney injury. Furthermore, lactate may also be used by glia as energy substrate in brain injury patients. Half-molar sodium lactate would also have a more potent and long-lasting effect decreasing intracellular osmolarity and by inhibiting neuronal volume control mechanisms. Pioneering researches in patients with traumatic brain injury have shown a more significant effect than mannitol on the control of ICH. In addition, in this group of patients this solution appears to be beneficial in preventing episodes of ICH. However, future research is necessary to corroborate or not these promising results

Disminución rápida de la presión arterial en pacientes con hemorragia intracerebral aguda / No disponible

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Papiledema asociado a síndrome de Poems / Papilledema as an indicator of Poems syndrome

Caso clínico: Se describe el caso de una pacientede 54 años con papiledema bilateral asociado a síndromede POEMS. En el estudio se determinó lapresencia de hipertensión intracraneal y se instaurótratamiento con acetazolamida.Discusión: La manifestación oftalmológica delPOEMS suele ser el papiledema, cuya etiologíapuede ser infiltrativa, por hipertensión intracraneal,inflamatoria y por aumento de la permeabilidadvascular. El correcto estudio y tratamiento del edemade papila, según su diferente etiología, permitiráel control de la clínica visual del paciente

Case report: We present the case of a 54-year-oldwoman with papilledema associated to POEMSsyndrome. The presence of intracranial hypertensionwas detected and treatment started with acetazolamide.Discussion: The most common ophthalmologicalpathology in POEMS syndrome is papilledema, theetiology of which could be infiltrative, intracranialhypertension, inflammation or an increase of thevascular permeability. The correct diagnosis andtreatment of papilledema, depending on its etiology,should permit an acceptable visual outcome to beachieved

Hipertensión endocraneana secundaria a edema cerebral y la utilización de soluciones salinas hipertónicas y manitol en su tratamiento / Intracranial hypertension secondary to cerebral edema, and the use of saline hypertonic and mannitol

Este artículo es una revisión de la información de los últimos años, relacionados con las terapias utilizadas en el manejo y tratamiento de hipertensión endocraneana. Se inicia recordando los conceptos básicos de la neurofisiología y neuropatología; en los que se han basado los fundamentos, para las guías terapéuticas. También se comparan las opciones terapéuticas que brinden mejores y más efectivos resultados en el manejo de esta patología. Se explican algunas de las medidas generales del manejo del edema cerebral, dando énfasis en las ventajas y desventajas de los tratamientos tradicionales versus los que se han incorporado en los últimos años. Todo esto basados en el manejo de Soluciones Hiperosmolares versus la utilización de manitol.

Comparación de la eficacia del pentobarbital y el tiopental en el control de la hipertensión intracraneal refractaria. Resultados preliminares en una serie de 20 pacientes / Comparison of the effectiveness of pentobarbital and thiopental in patients with refractory intracranial hypertension. Preliminary report of 20 patients

Objetivo. Comparar la eficacia del pentobarbital y tiopental en el control de la hipertensión intracraneal (HIC) refractaria a las medidas de primer nivel, según las Guías de Práctica Clínica de la "Brain Trauma Foundation", en pacientes con traumatismo craneoencefálico (TCE) grave. Material y métodos. Estudio prospectivo de cohorte, aleatorizado, de intervención terapéutica comparativa entre dos fármacos: pentobarbital y tiopental. La muestra fue seleccionada a partir de los pacientes que sufrieron un TCE grave (Glasgow Coma Scale GCS, postresucitación, 20 mmHg) refractaria al tratamiento convencional, de acuerdo con las Guías de Práctica Clínica de la "Brain Trauma Foundation". Además de comprobar la eficacia en el control de la PIC, también se recogieron los efectos secundarios del tratamiento. Resultados. Se presentan los resultados de los primeros 20 pacientes reclutados, de los cuales diez recibieron tiopental y diez pentobarbital. No hubo diferencias estadísticamente significativas en las características basales de los pacientes (edad, sexo, índices de gravedad y comorbilidades). Tampoco hubo diferencias respecto al GCS de ingreso (tiopental seis puntos; pentobarbital siete puntos; P=0,26) ni en la tomografía craneal computarizada de ingreso, según la clasificación del "Traumatic Coma Data Bank". En el grupo de tiopental se controló la PIC en cinco casos y en el grupo de pentobarbital en dos pacientes (P=0,16). Cinco pacientes tratados con tiopental fallecieron y ocho en el grupo de pentobarbital (P=0,16). No hubo diferencias significativas entre ambos grupos respecto a la incidencia de hipotensión arterial (P=1) o complicaciones infecciosas. Conclusiones. los resultados preliminares de este estudio indican que el tiopental podría ser más eficaz que el pentobarbital en el control de la HIC refractaria a las medidas de primer nivel. Dichos resultados confirman la evidencia experimental que indica que los mecanismos neuroprotectores de ambos fármacos son distintos y justifican el continuar aumentando el tamaño muestral de nuestro estudio para poder definir mejor la eficacia de ambos fármacos

Objective. To assess the effectiveness of pentobarbital and thiopental to control raised intracranial pressure (ICP), refractory to first level measures, in patients with severe traumatic brain injury. Material and methods. Prospective, randomized study to compare the effectiveness between two treatments: pentobarbital and thiopental. The patients will be selected from those admitted to the Intensive Care Unit with a severe traumatic brain injury (postresuscitation Glasgow Coma Scale equal or less than 8 points) and raised ICP (ICP>20 mmHg) refractory to first level measures according to the Brain Trauma Foundation guidelines. The adverse effects of both treatments were also collected. Results. We present the results of the first 20 patients included. Ten received pentobarbital and the other ten thiopental. There were no statistically significance differences in patients’characteristics (age, sex, severity of the trauma at admission and comorbilities). There were no differences between both groups neither in the Glasgow Coma Scale at admission (thiopental six points; pentobarbital seven points; P=0.26) nor in the admission Cranial Tomography, according to the Traumatic Coma Data Bank classification. Thiopental treatment controlled raised ICP in five cases and pentobarbital in two cases (P=0.16). Five patients in the thiopental group died and eight in the pentobarbital group (P=0.16). There were no statistically differences between both groups regarding to the presence of hypotension (P=1) or infectious complications. Conclusions. These preliminary results indicate that thiopental could be more effective than pentobarbital in patients with refractory intracranial hypertension. These results support previous experimental findings that show that both treatments are not equal and justify to continue this study