AANS Neurosurgeon | Volume 29, Number 1, 2020


Impact of Guidelines on the Management of Severe Traumatic Brain Injury

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Traumatic brain injury continues to be a major cause of significant morbidity and mortality universally, and managing patients with traumatic brain injury (TBI) remains challenging. In an effort to help standardize care among institutions, the Brain Trauma Foundation (BTF) began releasing evidence-based guidelines for the management of severe TBI in 1995. The latest iteration of the guidelines has culminated in the fourth edition published in 2016.1 In the modern era of evidence-based medicine (EBM), there has been an increased interest in developing and utilizing clinical practice guidelines (CPG) to direct patient care. There is certainly evidence that CPGs have improved care for patients with clinical issues including asthma, pneumonia, diabetes or psychiatric illnesses.2 Neurosurgeons have also demonstrated an interest in EBM and CPGs, as outlined by Fehlings and Nater.T3 There has also been an greater focus on the management of spinal trauma as demonstrated by the increasing number of publications from the BTF and the recently published guidelines on the management of spine injuries.4

Evidenced Based Medicine in Head Trauma

It has been shown that adherence to neurosurgical protocols can improve patient care and outcomes. At the local/institutional level, two hospitals that implemented protocols aimed at reducing their rates of ventriculostomy associated infection (VAI)5 both had lower VAI rates post-protocol. Some have suggested developing a universal standard for ventriculostomy care.6  Institutional protocols have successfully reduced surgical site infection (SSI) rates.7 On a more global level, the Centers for Disease Control and Prevention (CDC) released a set of guidelines for reducing SSIs first in 1999 and again in 2017.8 Clearly, neurosurgeons are interested in addressing intra-institutional issues; this local knowledge can be disbursed and compiled into standardized guidelines extra-institutionally.

Despite the evidence discussed above,  adherence to more widely dispersed guidelines published by the BTF and other groups remains inconsistent and varied. One study found poor adherence and implementation of the 2000 BTF guidelines (the second edition).9 Given the scope of the BTF guidelines, adherence fluxtuates depending  upon the institution,  the attending physician(s) and the specific guideline. For instance,  a review of multiple cohort studies, found strong adherence to guidelines on oxygenation, steroid use/avoidance and blood pressure control, but strikingly low adherence to the surgical guidelines (14 percent).10 On a similar note, a review of the Trauma Quality Improvement Program (TQIP) database found that intracranial pressure (ICP) monitors were placed in under 12 percent of the patients who met BTF guidelines for ICP monitoring.11 Education, resources and follow up can all help improve adherence to the guidelines. Hospitals participating in the Adam Williams Initiative and institutions with guideline-based protocols, neurosurgery residency programs and state of American College of Surgeons trauma center designation adhered more closely to BTF guidelines.11,12

Guidelines and ICP Monitoring

The guidelines for ICP monitoring have generated debate within the neurosurgical and neurocritical care communities. A review found that ICP monitoring was associated with increased systemic complications, infections and poorer functional independence.12 The review does not specify the kind of infectious complications these patients had or VAI rates. An earlier (2013) prospective analysis of 216 patients found higher compliance with BTF ICP monitoring guidelines and reduced in-hospital mortality for patients with ICP monitors.T13 Death from brain herniation was more common in patients without ICP monitors. One study  retrospectively reviewed 287 patients with severe diffuse TBI using propensity score matching.14 After accounting for differences between the patients who underwent ICP monitoring and those who did not, they found that ICP monitoring had a significant impact on the six-month favorable outcome for patients with a Glasgow Coma Score of 3 to 5.

Literature suggests that adherence to TBI guidelines is beneficial, and protocols to standardize approaches to TBI management have demonstrated improvements in mortality. In the 1990s one center instituted a protocol based on American Association of Neurologic Surgeons (AANS) guidelines.15 The patients treated after protocol implementation had a nine times greater odds of a good outcome relative to the patients treated before implementation. Another institution implemented a similar protocol based on BTF guidelines and improved outcomes and decreased length of stay.17 A more recent study looking at a U.S.-based hospital and a hospital in India found that an increase in guideline adherence was associated with decreased in-patient mortality, but that finding was not replicated at the U.S. site.18 Review of data from New York state found both increased adherence to BTF recommendations, especially those for ICP and CPP monitoring and thresholds associated with decreased two-week mortality from TBI from 2001 to 2009.19

Despite the evidence of the clear benefit of ICP monitoring for patients with TBI, the latest edition of the BTF guidelines fails to offer a Level I (highest) recommendation for this topic.  Typically, a subject will only be given a Level I recommendation if there is sufficient evidence meeting current standards, usually in the form of high-quality randomized control trials (RCTs). This may ultimately cause misperceptions for clinicians attempting to maintain adherence to the BTF guidelines that do not back well-accepted management protocols for patients with TBI. Critics argue that the difficulties encountered by the BTF guidelines stem from a reliance on high-cost stringent RCTs. Indeed, some proponents instead support  the future use of large-scale clinical registries to develop such guidelines.20 This may help eliminate the need to fund large-scale clinical trials and address the issue of adherence to the BTF guidelines.


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1. Carney N, Totten AM, O’Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80(1):6-15.

2. Almazrou Mazrou SH, Expected benefits of clinical practice guidelines: factors affecting their adherence and methods of implementation and dissemination. J Health Spec 2013;1:141-7

3. Fehlings MG, Nater A. Development and implementation of guidelines in neurosurgery. Neurosurgery Clinics 2015 Apr;26(2):271-282.

4. Chi JH, Eichholz KM, Anderson PA, Arnold PM, Dailey AT, Dhall SS, Harrop JS, Hoh DJ, Qureshi S, Rabb CH, Raksin PB, Kaiser MG, O’Toole JE. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Novel Surgical Strategies. Neurosurgery. 2019 Jan 1;84(1):E59-E62.

5. Tavakoli S, Peitz G, Ares W, Hafeez S, Grandhi R. Complications of invasive intracranial pressure monitoring devices in neurocritical care. Neurosurg Focus. 2017 Nov;43(5):E6.

6. Hepburn-Smith M, Dynkevich I, Spektor M, Lord A, Czeisler B, Lewis A. Establishment of an External Ventricular Drain Best Practice Guideline: The Quest for a Comprehensive, Universal Standard for External Ventricular Drain Care. J Neurosci Nurs. 2016 Feb;48(1):54-65.

7. Fattahi A, Jahanbakhshi A, Taheri M, Mehrizi A, Chavoshinejad M. Our experience with using a uniform prophylactic protocol in neurosurgery: surgical-site infection did not occur in 272 operations. Br J Neurosurg. 2018 Aug;32(4):396-399.

8. Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, Reinke CE, Morgan S, Solomkin JS, Mazuski JE, Dellinger EP, Itani KMF, Berbari EF, Segreti J, Parvizi J, Blanchard J, Allen G, Kluytmans JAJW, Donlan R, Schecter WP; Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017 Aug 1;152(8):784-791.

9. Hesdorffer DC, Ghajar J, Iacono L. Predictors of compliance with the evidence-based guidelines for traumatic brain injury care: a survey of United States trauma centers. J Trauma. 2002 Jun;52(6):1202-9.

10. Khormi YH, Gosadi I, Campbell S, Senthilselvan A, O’Kelly C, Zygun D. Adherence to Brain Trauma Foundation Guidelines for Management of Traumatic Brain Injury Patients and Its Effect on Outcomes: Systematic Review. J Neurotrauma. 2018 Jul 1;35(13):1407-1418.

11. Aiolfi A, Benjamin E, Khor D, Inaba K, Lam L, Demetriades D. Brain Trauma Foundation Guidelines for Intracranial Pressure Monitoring: Compliance and Effect on Outcome. World J Surg. 2017 Jun;41(6):1543-1549. doi: 10.1007/s00268-017-3898-6. Erratum in: World J Surg. 2017 Jun;41(6):1542.

12. Hesdorffer D, Ghajar J, Iacono L. Predictors of Compliance with the Evidence-Based Guidelines for Traumatic Brain Injury Care: A Survey of United States Trauma Centers. J Trauma. 2002 Jun;52(6):1202-1209.

13. Saherwala AA, Bader MK, Stutzman SE, Figueroa SA, Ghajar J, Gorman AR, Minhajuddin A, Olson DM. Increasing Adherence to Brain Trauma Foundation Guidelines for Hospital Care of Patients With Traumatic Brain Injury. Crit Care Nurse. 2018 Feb;38(1):e11-e20.

14. Talving P, Karamanos E, Teixeira PG, Skiada D, Lam L, Belzberg H, Inaba K, Demetriades D. Intracranial pressure monitoring in severe head injury: compliance with Brain Trauma Foundation guidelines and effect on outcomes: a prospective study. J Neurosurg. 2013 Nov;119(5):1248-54.

15. Palmer S, Bader MK, Qureshi A, Palmer J, Shaver T, Borzatta M, et al. The Impact on Outcomes in a Community Hospital Setting of Using the AANS Traumatic Brain Injury Guidelines. The Journal of Trauma: Injury, Infection, and Critical Care. 2001;50(4):657–64.

16. Yuan Q, Wu X, Cheng H, Yang C, Wang Y, Wang E, Qiu B, Fei Z, Lan Q, Wu S, Jiang Y, Feng H, Liu J, Liu K, Zhang F, Jiang R, Zhang J, Tu Y, Wu X, Zhou L, Hu J. Is Intracranial Pressure Monitoring of Patients With Diffuse Traumatic Brain Injury Valuable? An Observational Multicenter Study. Neurosurgery. 2016 Mar;78(3):361-8; discussion 368-9.

17. Fakhry SM, Trask AL, Waller MA, Watts DD; IRTC Neurotrauma Task Force. Management of brain-injured patients by an evidence-based medicine protocol improves outcomes and decreases hospital charges. J Trauma. 2004 Mar;56(3):492-9; discussion 499-500.

18. Gupta D, Sharma D, Kannan N, Prapruettham S, Mock C, Wang J, Qiu Q, Pandey RM, Mahapatra A, Dash HH, Hecker JG, Rivara FP, Rowhani-Rahbar A, Vavilala MS. Guideline Adherence and Outcomes in Severe Adult Traumatic Brain Injury for the CHIRAG (Collaborative Head Injury and Guidelines) Study. World Neurosurg. 2016 May;89:169-79.

19. Gerber L, Chiu Y, Carney N., Härtl R. and Ghajar J. Marked reduction in mortality in patients with severe traumatic brain injury. J Neurosurgery. 2013;119(6):1583-1590.

20. Hoque DM, Kumari V, Ruseckaite R, Romero L, Evans SM. Impact of clinical registries on quality of patient care and health outcomes: protocol for a systematic review. BMJ Open. 2016 Apr;6(4):e010654. doi:10.1136/bmjopen-2015-010654


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