Treatment of Closed-Head Injury

It is a great honor for me to edit this issue of Seminars in Neurosurgery. The overall incidence of traumatic brain injury (TBI) has declined in recent years, as has the overall morbidity of head injuries. Unfortunately, TBI continues to be a major public health problem and the primary cause of death in those who suffer traumatic injury. The past decade has witnessed the development of guidelines for the management of TBI in the prehospital and critical care settings. These efforts have been a great step forward in standardizing the management of these often complex patients.

Because of its prevalence, it is likely that all neurosurgeons will encounter TBI at some point in clinical practice. The presentations may vary: acute versus chronic, mild versus severe, adult versus pediatric. Accordingly, it is vital that every neurosurgeon, whether that practitioner commonly cares for trauma or not, stay current in the management of TBI. The goal of this issue of Seminars in Neurosurgery is to update certain aspects of TBI management that appear to be changing faster than other facets of care for the patient with head injury.

The issue commences with an outstanding discussion of pre-hospital TBI management by author Manley. Pre-hospital management is a facet of care over which neurosurgeons often have minimal control but which may profoundly affect the outcome from head injury. Thereafter, Glastonbury and Gean review the current techniques for neuroimaging in the setting of TBI. Such a review is timely because the technology for computed tomography (CT) and magnetic resonance (MR) has changed tremendously over the last decade. Such a review is also paramount for the neurosurgeon because most decide on the appropriate neuroimaging study after initial resuscitation.

Taking the next step to critical care management, Tse has contributed an excellent review of neurological monitoring and management of intracranial hypertension. The ability to monitor intracranial pressure with the goal of reducing intracranial hypertension and elevating cerebral perfusion pressure in the critical care setting is important for every critical care practitioner to review and understand. The Tse contribution summarizes first-tier therapy for the treatment of intracranial hypertension. Banks and Matz follow with a discussion of the techniques, indications, and contraindications of second-tier therapy. Second-tier therapy is often undertaken when ICP becomes refractory to initial medical management (first-tier therapy). It is important for the neurosurgeon to be familiar with all of the techniques and their limitations.

The next two contributions discuss the management of trauma away from the adult, tertiary-care setting. Severe TBI is commonly managed in the community setting. The contribution by Eichbaum discusses the differences in protocol necessary for management of TBI in the community setting and reviews which resources are necessary to assemble a community-based trauma program. Wellons and Tubbs provide a timely review of pediatric TBI, whose management may be vastly different from that of adult TBI. In many instances, trauma neurosurgeons may have to treat both ends of the spectrum, and the contribution by Wellons and Tubbs recapitulates pediatric management.

Two often-overlooked aspects of TBI are vascular injury and mild head injury. Because of recent developments in MR and CT angiography, I have provided an update regarding their relevance in noninvasively diagnosing vascular injury. The subsequent review discusses the diagnostic criteria and management paradigm for mild TBI and concussion. This topic is especially relevant in the management of young adults playing contact sports.

With medical care becoming increasingly specialized, new specialties have arisen. One of these is neurointensive care. The contribution by Jarquin-Valdivia, Bonovich, and Hemphill delineates the role of the neurointensivist in the management of TBI. This article also summarizes the options and protocols available for optimal function of a critical care unit.

The issue ends with two articles on research. The penultimate article provides a review of the prior clinical TBI trials and discusses the reasons for their failures and the direction future clinical research may take. Finally, Lewén, Nilsson, and Enblad discuss the basic science of TBI. They examine the prior pharmacological pathways targeted for TBI research and the future directions in which experimental research may go in the hope of providing therapy for this devastating disease. The focus of these last two articles is not meant to be technical. Rather, they were assembled to provide a better understanding regarding TBI research for the general neurosurgeon and related practitioners.

The authors of these articles and I hope that the readers will benefit from our insights and comments and that this edition yields a timely review of the treatment of closed-head injury.