Estado actual y perspectivas futuras en el manejo de la hipertensión intracraneal posterior a traumatismo craneoencefálico: craniectomía descompresiva, hipotermia terapéutica y barbitúricos / Current status and outlook for the management of intracranial hypertension after traumatic brain injury: decompressive craniectomy, therapeutic hypothermia, and barbiturates

Introducción: El aumento de la presión intracraneal se ha asociado a un pronóstico neurológicodesfavorable y a un incremento en la mortalidad en pacientes con traumatismo craneoencefálico grave. Tradicionalmente, las terapias para disminuir la presión intracraneal se administranutilizando un enfoque progresivo, reservando el uso de opciones más agresivas para los casossin respuesta a intervenciones de primer nivel, o de hipertensión intracraneal refractaria. Desarrollo: El valor terapéutico de las intervenciones de rescate para la hipertensión intracraneal, así como el momento adecuado para su uso ha sido debatido constantemente en laliteratura. En esta revisión, discutiremos las principales opciones de tratamiento para la hipertensión intracraneal refractaria posterior a un traumatismo craneoencefálico grave en adultos.Tenemos la intención de llevar a cabo una revisión en profundidad de los ensayos controladosaleatorios más representativos sobre las diferentes intervenciones terapéuticas de rescate,incluyendo la craniectomía descompresiva, hipotermia terapéutica y barbitúricos. Además,discutiremos las perspectivas futuras de estas opciones de tratamiento. Conclusiones: La evidencia parece mostrar que se puede reducir la mortalidad al utilizar estasintervenciones de rescate como terapia de último nivel, sin embargo, este beneficio vieneacompanado de una discapacidad severa. La decisión de realizar o no estas intervencionesdebe ser individualizada y centrada en el paciente. El desarrollo e integración de diferentesvariables fisiológicas a través de monitorización multimodal es de suma importancia para poderproporcionar información pronóstica más sólida a los pacientes que enfrentan este tipo dedecisiones.(AU)

Introduction: Increased intracranial pressure has been associated with poor neurological out-comes and increased mortality in patients with severe traumatic brain injury. Traditionally,intracranial pressure-lowering therapies are administered using an escalating approach, withmore aggressive options reserved for patients showing no response to first-tier interventions,or with refractory intracranial hypertension. Development: The therapeutic value and the appropriate timing for the use of rescue treat-ments for intracranial hypertension have been a subject of constant debate in literature. Inthis review, we discuss the main management options for refractory intracranial hypertensionafter severe traumatic brain injury in adults. We intend to conduct an in-depth revision of themost representative randomised controlled trials on the different rescue treatments, includingdecompressive craniectomy, therapeutic hypothermia, and barbiturates. We also discuss futureperspectives for these management options. Conclusions: The available evidence appears to show that mortality can be reduced whenrescue interventions are used as last-tier therapy; however, this benefit comes at the cost ofsevere disability. The decision of whether to perform these interventions should always bepatient-centred and made on an individual basis. The development and integration of differentphysiological variables through multimodality monitoring is of the utmost importance to providemore robust prognostic information to patients facing these challenging decisions.(AU)

Current status and outlook for the management of intracranial hypertension after traumatic brain injury: decompressive craniectomy, therapeutic hypothermia, and barbiturates.

INTRODUCTION: Increased intracranial pressure (ICP) has been associated with poor neurological outcomes and increased mortality in patients with severe traumatic brain injury (TBI). Traditionally, ICP-lowering therapies are administered using an escalating approach, with more aggressive options reserved for patients showing no response to first-tier interventions, or with refractory intracranial hypertension. DEVELOPMENT: The therapeutic value and the appropriate timing for the use of rescue treatments for intracranial hypertension have been a subject of constant debate in literature. In this review, we discuss the main management options for refractory intracranial hypertension after severe TBI in adults. We intend to conduct an in-depth revision of the most representative randomised controlled trials on the different rescue treatments, including decompressive craniectomy, therapeutic hypothermia, and barbiturates. We also discuss future perspectives for these management options. CONCLUSIONS: The available evidence appears to show that mortality can be reduced when rescue interventions are used as last-tier therapy; however, this benefit comes at the cost of severe disability. The decision of whether to perform these interventions should always be patient-centred and made on an individual basis. The development and integration of different physiological variables through multimodality monitoring is of the utmost importance to provide more robust prognostic information to patients facing these challenging decisions.

Current status and outlook for the management of intracranial hypertension after traumatic brain injury: decompressive craniectomy, therapeutic hypothermia, and barbiturates. / Estado actual y perspectivas futuras en el manejo de la hipertensión intracraneal posterior a traumatismo craneoencefálico: craniectomía descompresiva, hipotermia terapéutica y barbitúricos.

INTRODUCTION: Increased intracranial pressure has been associated with poor neurological outcomes and increased mortality in patients with severe traumatic brain injury. Traditionally, intracranial pressure-lowering therapies are administered using an escalating approach, with more aggressive options reserved for patients showing no response to first-tier interventions, or with refractory intracranial hypertension. DEVELOPMENT: The therapeutic value and the appropriate timing for the use of rescue treatments for intracranial hypertension have been a subject of constant debate in literature. In this review, we discuss the main management options for refractory intracranial hypertension after severe traumatic brain injury in adults. We intend to conduct an in-depth revision of the most representative randomised controlled trials on the different rescue treatments, including decompressive craniectomy, therapeutic hypothermia, and barbiturates. We also discuss future perspectives for these management options. CONCLUSIONS: The available evidence appears to show that mortality can be reduced when rescue interventions are used as last-tier therapy; however, this benefit comes at the cost of severe disability. The decision of whether to perform these interventions should always be patient-centred and made on an individual basis. The development and integration of different physiological variables through multimodality monitoring is of the utmost importance to provide more robust prognostic information to patients facing these challenging decisions.

Increased cerebrospinal fluid levels of cytokines monocyte chemoattractant protein-1 (MCP-1) and macrophage inflammatory protein-1ß (MIP-1ß) in patients with amyotrophic lateral sclerosis. / Incremento de las citoquinas proteína quimiotáctica de monocitos-1 (MCP-1) y proteína inflamatoria macrofágica-1ß (MIP-1ß) en líquido cefalorraquídeo de pacientes con esclerosis lateral amiotrófica.

INTRODUCTION: Neuroinflammation has recently been described in amyotrophic lateral sclerosis (ALS). However, the precise role of such proinflammatory cytokines as monocyte chemoattractant protein-1 (MCP-1) and macrophage inflammatory protein-1ß (MIP-1ß) in ALS has not yet been determined. In this study, we determined cerebrospinal fluid (CSF) MCP-1 and MIP-1ß levels and assessed their association with the duration and severity of ALS. METHODS: Concentrations of MCP-1 and MIP-1ß were determined in the CSF of 77 patients diagnosed with ALS and 13 controls. Cytokine levels were analysed in relation to ALS duration (<12months vs. >12months) and severity (<30points vs. >30points on the ALS Functional Rating Scale administered at hospital admission). RESULTS: Higher CSF MIP-1ß (10.68pg/mL vs. 4.69pg/mL, P<.0001) and MCP-1 (234.89pg/mL vs. 160.95pg/mL, P=.011) levels were found in the 77 patients with ALS compared to controls. There were no differences in levels of either cytokine in relation to disease duration or severity. However, we did observe a significant positive correlation between MIP-1ß and MCP-1 in patients with ALS. CONCLUSIONS: The increase in MIP-1ß and MCP-1 levels suggests that these cytokines may have a synergistic effect on ALS pathogenesis. However, in our cohort, no association was found with either the duration or the clinical severity of the disease.