Intended for healthcare professionals

Practice Uncertainties

Which treatments are safe and effective to reduce intracranial pressure following severe traumatic brain injury?

BMJ 2022; 378 doi: (Published 03 August 2022) Cite this as: BMJ 2022;378:e061960
  1. Gavin D Perkins, professor of critical care medicine1,
  2. Daniel Horner, consultant in emergency and intensive care medicine2,
  3. Michael J Naisbitt, consultant in intensive care medicine2
  1. 1Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Warwick, UK
  2. 2Northern Care Alliance NHS Foundation Trust, UK
  1. Correspondence to G Perkins G.D.Perkins{at}

What you need to know

  • A tiered approach using multiple interventions to reduce raised intracranial pressure and maintain adequate cerebral perfusion pressure is reasonable in severe traumatic brain injury

  • The effectiveness and safety of several common interventions is not known, because of a paucity of data from adequately powered, randomised controlled trials

  • Use your clinical judgment to balance the possible benefits and potential risks of treatments, and explore with patients and their loved ones what an acceptable outcome is, to guide decision making

Forceful impact to the head can impair mental status and lead to neurobehavioural deficits. Most traumatic brain injuries (TBIs) are mild,1 but about 20% of patients have severe injury defined by a Glasgow coma scale (GCS) score ≤8 at presentation. Severe TBI has an incidence of 70 per 100 000 persons worldwide.23

Multiple pathologies often combine to cause more harm than the initial head injury. Injuries may be focal or diffuse and over time can coalesce through inflammation. These physiological changes can increase the volume of intracranial contents, leading to rising intracranial pressure (ICP) and secondary injury to brain tissue. Sustained rise in ICP above normal range (7 to 15 mm Hg) can result in progressive cerebral ischaemia, herniation syndromes, or death.4 In a retrospective single centre cohort study (459 patients with severe TBI), an elevated ICP >22 mm Hg for >37 minutes was associated with worsening functional outcomes.5 In an international cohort study (2113 patients), 21.3% of patients with severe TBI had died and 43.1% had a permanent need for help with activities of daily living or absence of awareness of self or environment6 at six months.3

Early resuscitation and emergency care of severe TBI aim to reduce cerebral oxygen demand, optimise perfusion to the brain, and limit secondary injury. Several routine critical care interventions …

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