A Study Comparing Modified Lund Concept and Cerebral Perfusion Pressure-targeted Therapy in Secondary Brain Ischaemia.
Condition: Brain Injuries; Subarachnoid Hemorrhage
MeSH terms: Brain Injuries; Subarachnoid Hemorrhage; Brain Ischemia; Hemorrhage; Ischemia
Study type: Interventional

Summary: 
      Secondary brain ischaemia (SBI) usually develops after aneurysmal subarachnoid haemorrhage
      (SAH) and severe traumatic brain injury (TBI). The current management strategies are based on
      intracranial pressure-targeted therapy (ICP-targeted) with cerebral microdialysis monitoring
      (modified Lund concept) or cerebral perfusion pressure-targeted therapy (CPP-targeted). We
      present a randomised controlled study to compare the two management strategies.

      The hypotheses of the study were:

        -  SBI developed after aneurysmal SAH and severe TBI share the same crucial characteristics
           and any treatment applied will essentially treat the same underlying pathophysiology.

        -  ICP-targeted therapy with cerebral microdialysis monitoring according to the modified
           Lund concept is superior to CPP-targeted therapy in managing comatose patients with SBI
           after aneurysmal SAH and severe TBI.

      Sixty comatose operated patients with SBI following aneurysmal SAH and severe TBI were
      randomized into ICP-targeted therapy with cerebral microdialysis monitoring and CPP-targeted
      therapy groups. Mortality rates in both groups were calculated and biochemical signs of
      cerebral ischaemia were analysed using cerebral microdialysis. Outcome for cerebral
      microdialysis was measured as poor outcome (Glasgow Outcome Scale score 1, 2 and 3) or good
      outcome (Glasgow Outcome Scale score 4 and 5).
    


Intervention name(s): Modified Lund concept; Cerebral perfusion pressure-targeted therapy
Intervention type(s): Procedure; Procedure
Intervention description(s): After surgical evacuation of intracranial mass lesion and clipping of aneurysm the objectives were achieved:
Reduction of cerebral energy metabolism with fentanyl (2-5 µg/kg/h) and thiopenthal (0.5-3 mg/kg/h);
Maintenance of colloid osmotic pressure with administration of red cell and albumin/plasma transfusions to maintain Hb/s 125-140 g/L and Alb/s ≈40 g/L;
Reduction of capillary hydrostatic pressure with α2-agonist clonidine (0.4-0.8 µg/kg, 1 x 4-6 iv.) and maintaining normovolaemia;
Reduction of mean arterial pressure and neuroprotection with Nimodipine infusion 5 ml per hour for 21 days and Urapidil 200 mg /200 ml, 7-10 ml/h.
Control of ICP, which can be in majority of patients, kept at values below 15 mmHg.; ICP monitoring using an external ventricular drain and CSF drainage as a first measure if ICP was increased (over 15-20 mmHg);
Maintenance of CPP over 70-80 mmHg (Triple 'H' therapy = 3L/24 hours including 1L of colloids - 5% albumin; drugs = dopamine, dobutamine);
No hyperventilation if ICP was under 20-25 mmHg and hyperventilation as a third measure if ICP was increased;
Osmotherapy (20% manitol, bolus 150-350 ml or 10% manitol, 50 ml/h for 10 hours and standard electrolytes [Na, Cl and K]);
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: traumatic brain injury; subarachnoid hemorrhage; secondary brain ischemia; microdialysis; modified Lund concept; cerebral perfusion pressure; intracranial pressure