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Editor—Mortality and morbidity from head injury seem to have fallen, presumably with use of organised trauma care systems and adequate critical care.1 In his editorial on treating head injuries Wasserberg said that evidence now shows an overall improvement in the outcome of head injury from treatment in a specialist unit that uses protocol driven treatment.2
This statement is not based on a randomised controlled trial but a retrospective survey showing that in the whole referral population the tendency to increased favourable outcome after institution of protocol driven treatment did not reach significance and the overall mortality did not change significantly.3 Only patients with severe head injury showed an increase in favourable outcome, without a difference in mortality. Wasserberg's statement therefore seems unsubstantiated.
All protocol driven treatments are based on successive introduction of hyperventilation, drainage of cerebrospinal fluid, infusion of mannitol, hypothermia, barbiturates, and (rarely) decompressive craniotomy—all treatments lowering intracranial pressure. Two studies cited by Raj and Narayan (by Roberts et al, reference 11, and Dickinson et al, reference 5) concluded on the basis of randomised controlled trials that it was impossible to refute either a moderate increase or a moderate decrease in the risk of death or disability from the use of hyperventilation, drainage of cerebrospinal fluid, mannitol, barbiturates, or corticosteroids.1
Wasserberg quotes a Cochrane review, concluding that no evidence exists that hypothermia is beneficial in head injury, forgetting that a recent randomised controlled trial was halted by the patient safety and monitoring board because the treatment was not effective and in fact worsened the prognosis in patients older than 45.4 As hypothermia did reduce raised intracranial pressure but outcome did not improve, surrogate markers of efficacy (such as intracranial pressure) have been deemed unreliable substitutes for clinical outcomes in determining the value of treatment.1
Protocol driven treatment and guidelines might be valuable tools in treating head injury, but, although guidelines for the management of severe head injury assembled by the United States Brain Trauma Foundation did take randomised trials into account, the methods used would not satisfy the criteria for scientific overviews (Roberts et al, reference 11).1
Step by step neurocritical research has been able to improve the control of raised intracranial pressure, but the conclusion that this improves mortality and morbidity after head injury is scientifically unproved and may prove false.
1.Raj K, Narayan RK. Hypothermia for traumatic brain injury: a good idea proved ineffective. N Engl J Med. 2001;344:602–603. doi: 10.1056/NEJM200102223440810. [DOI] [PubMed] [Google Scholar]
2.Wasserberg J. Treating head injuries. BMJ. 2002;325:454–455. doi: 10.1136/bmj.325.7362.454. . (31 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Patel HC, Menon DK, Tebbs S, Hawker R, Hutchinson PJ, Kirkpatrik PJ. Specialist neurocritical care and outcome from head injury. Intensive Care Med. 2002;28:547–553. doi: 10.1007/s00134-002-1235-4. [DOI] [PubMed] [Google Scholar]
4.Clifton GL, Miller ER, Choi SC, Levin HS, McCauley S, Smith KR, Jr, et al. Lack of effect of induction of hypothermia after acute brain injury. N Engl J Med. 2001;344:556–563. doi: 10.1056/NEJM200102223440803. [DOI] [PubMed] [Google Scholar]
BMJ. 2002 Dec 14;325(7377):1420.
Studies of efficacy of medical and surgical interventions are urgently needed
Editor—The editorial by Wasserberg highlights the lack of evidence on the effectiveness of currently used protocols in managing clinically significant head injury.1-1 The current large-scale study of corticosteroid treatment will be a welcome exception.1-2
The management of raised intracranial pressure also deserves proper trials. A systematic review in adults and children found that no class I data clarify the role of monitoring intracranial pressure in acute coma, traumatic or non-traumatic.1-3
In 1998 we conducted a retrospective audit of the management of paediatric head injury in the north of England. We audited the cases of 54 children with head trauma and Glasgow coma scores of 8 or less who were admitted to eight paediatric intensive care units for ventilatory management in 1994. Three of the units routinely monitored intracranial pressure, three rarely did so, and two did so selectively. In the 19 children who were monitored the use of interventions to lower intracranial pressure or increase cerebral perfusion pressure significantly increased, as did the duration of ventilation (median 7 days v 2 days, P<0.001). No obvious difference was seen in outcome (19 monitored: four died, six had a good outcome; 35 not monitored: nine died, 18 had a good outcome), but the numbers were far too small to detect any benefit or disadvantage below a level of 20%.
At the time of the audit, decompression was rarely considered and treatment of raised intracranial pressure relied on medical interventions. Surgical decompression is generally considered much earlier for compartment syndromes in the calf or abdomen and, although neurosurgical decompression seems logical, it is worrying that it is coming into use without any formal study of its effectiveness. As the management of raised intracranial pressure has implications for resources, formal studies of the efficacy of medical and surgical interventions are urgently needed.
Footnotes
Competing interests: None declared.
References
1-1.Wasserberg J. Treating head injuries. BMJ. 2002;325:454–455. doi: 10.1136/bmj.325.7362.454. . (31 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
1-2. CRASH Trial Pilot Study Group Collaborative Group. The MRC CRASH trial: study design, baseline data and outcome in 1000 randomised patients in the pilot phase. J Accid Emerg Med (in press). [DOI] [PMC free article] [PubMed]
Editor—I share Wasserberg's frustration with the lack of benefit of neuroprotective drugs in treating head injury despite the initial high hopes from laboratory results and in animal studies.2-1 A more promising pharmacological intervention seldom used in the United Kingdom is the neurostimulant group of drugs, which proved useful in managing some of the long term cognitive impairments secondary to traumatic brain injury.
Speed of information processing could be improved with methylphenidate, and short term memory problems showed some improvement with donepezil.2-2,2-3 Most of the evidence comes from small trials or single subject design studies, but that did not stop the use of neurostimulants from becoming standard practice in the United States for selected patients with such cognitive problems.2-2
Researchers in neurological rehabilitation have always found it difficult to organise large randomised trials or analyse results of smaller trials for various reasons, such as the difficulty of randomising patients because of their heterogeneity and the use of different outcome measures. The main difficulty, however, comes from the fact that rehabilitation outcome depends on complex interactions between medical, therapeutic, and psychosocial factors.
These difficulties in research methods are unlikely to be resolved in the near future. If we as doctors continue to wait for clear unequivocal proof of the effectiveness of a particular intervention in rehabilitating patients with brain injury, patients might miss out on a chance of a real difference in their quality of life.
Footnotes
Competing interests: None declared.
References
2-1.Wasserberg J. Treating head injury. BMJ. 2002;325:454–455. doi: 10.1136/bmj.325.7362.454. . (31 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
2-2.Whyte J, Vaccaro M, Grieb-Neff P, Hart T. Psychostimulants use in the rehabilitation of individuals with traumatic brain injury. J Head Trauma Rehabil. 2002;4:284–299. doi: 10.1097/00001199-200208000-00003. [DOI] [PubMed] [Google Scholar]
2-3.Masanic CA, Bayley MT, Van Reekum R, Simard M. Open label study of donepezil in traumatic brain injury. Arch Phys Med Rehabil. 2001;82:896–901. doi: 10.1053/apmr.2001.23833. [DOI] [PubMed] [Google Scholar]
BMJ. 2002 Dec 14;325(7377):1420.
Psychiatric aspects of head injury need to be taken into consideration
Editor—Wasserberg's editorial on treating head injuries provides a constructively critical view on managing this common major health problem, particularly in young adults,3-1 but awareness of the psychiatric sequelae of both major and minor head injuries needs to be increased urgently to complete the picture.
The effects of head injury on mental functions have mostly been studied in patients with severe trauma, which results in several neurological and psychological sequelae, including cognitive impairment, personality change, psychoses, affective disorders, and suicide.3-2 Studies of the consequences of minor head injury are much rarer, although such patients often complain of psychiatric difficulties.3-3 The wide range of symptoms commonly reported after minor trauma include headache, dizziness, hypersensitivity to noise, fatigue, impaired concentration, memory difficulty, irritability, anxiety, and depression.3-2
The psychiatric presentation often comes to light a few weeks or months after the event. The trauma may first present as comparatively subtle affective or behavioural changes. The patient, while providing the history, may not associate the complaints with the traumatic event.
Dinan and I found that the prevalence of depression (Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III)) in patients with minor head injury was 15.7% two to 12 months after the trauma. The problems of all these patients were undetected and untreated.3-4 The prolactin responses to challenges with buspirone and fenfluramine were significantly blunted, which implies serotonin dysfunction after trauma. This dysfunction returned to normal with clinical recovery after treatment with amitriptyline, although we found that depression after head injury was resistant to standard antidepressant treatment.3-5
Footnotes
Competing interests: None declared.
References
3-1.Wasserberg J. Treating head injuries. BMJ. 2002;325:454–455. doi: 10.1136/bmj.325.7362.454. . (31 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
3-2.Lishman WA. Head injury. In: Lishman WA, editor. Organic psychiatry. Oxford: Blackwell; 1988. pp. 199–201. [Google Scholar]
3-3.Schoenhuber R, Gentilini M. Anxiety and depression after mild head injury: a case control study. J Neurol Neurosurg Psychiatry. 1988;722:725–751. doi: 10.1136/jnnp.51.5.722. [DOI] [PMC free article] [PubMed] [Google Scholar]
3-4.Mobayed M, Dinan T. Buspirone/prolactin response in post head injury depression. J Affect Dis. 1990;19:237–241. doi: 10.1016/0165-0327(90)90100-m. [DOI] [PubMed] [Google Scholar]
3-5.Dinan T, Mobayed M. Treatment resistance of depression after head injury: a preliminary study of amitriptyline response. Acta Psychiatr Scand. 1992;85:292–295. doi: 10.1111/j.1600-0447.1992.tb01472.x. [DOI] [PubMed] [Google Scholar]
