Case-Based Modules > Case 5 > Conclusion
Great job! The purpose of this case was to walk you through a real case of a patient with refractory intracranial hypertension from his TBI, emphasizing a stairstep approach to treatment.
Pearl 1: Take a stairstep approach to ICP management, starting with the easiest and most benign interventions, then working your way up.
(Stocchetti and Maas 2014)
Note how hyperventilation is less favored (later step in the staircase) as compared with hyperosmolar therapy, and even CSF drainage. CSF drainage is also something to consider early on, which may run contrary to common belief.
Pearl 2: Patients who already have a bone flap off can still develop intracranial hypertension.
While a decompressive craniectomy can provide significant improvement in ICPs, unfortunately, there are some patients who will still struggle with elevated ICPs. You can breathe a quick sigh of relief, but you'll have to stay vigilant.
It's true that at some point, the fidelity of the readings may suffer as your ICP readings drift (there's no recalibration). However, that really requires clinical contextualization, and early on, elevated values should be taken seriously and treated appropriately.
Suggested Reading from this Case:
- Andrews PJ, Sinclair HL, RodrÃguez A, et al. Therapeutic hypothermia to reduce intracranial pressure after traumatic brain injury: the Eurotherm3235 RCT. Health Technol Assess. 2018;22(45):1-134. doi:10.3310/hta22450
- Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. The Lancet. 2019;394(10210):1713-1723. doi:10.1016/s0140-6736(19)32233-0
- Frontera JA, Gilmore EJ, Johnson EL, et al. Guidelines for Seizure Prophylaxis in Adults Hospitalized with Moderate-Severe Traumatic Brain Injury: A Clinical Practice Guideline for Health Care Professionals from the Neurocritical Care Society. Neurocrit Care. 2024;40(3):819-844. doi:10.1007/s12028-023-01907-x
- Guidelines for the management of severe TBI, 4th edition. Brain Trauma Foundation. Sep 2016.
- Stocchetti N, Maas AI. Traumatic intracranial hypertension. N Engl J Med. 2014;371(10):972. doi:10.1056/NEJMc1407775
- Zimmermann LL, Tran DS, Lovett ME, Mangat HS, Poblete RA. Emergency neurological life support: traumatic brain injury protocol version 5.0. ENLS. Apr 2022.
