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Prophylactic hypothermia for traumatic brain injury: a quantitative systematic review

Published online by Cambridge University Press:  21 May 2015

James L. Fox ,
Erik N. Vu ,
Mary Doyle-Waters ,
Jeffrey R. Brubacher ,
Riyad Abu-Laban  and
Zengxuan Hu
James L. Fox*
Affiliation:
Department of Emergency Medicine, University of British Columbia, Vancouver, BC
Erik N. Vu
Affiliation:
Department of Emergency Medicine, University of British Columbia, Vancouver, BC Department of Critical Care, University of British Columbia, Vancouver, BC
Mary Doyle-Waters
Affiliation:
Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vanvouver, BC
Jeffrey R. Brubacher
Affiliation:
Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vanvouver, BC
Riyad Abu-Laban
Affiliation:
Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vanvouver, BC
Zengxuan Hu
Affiliation:
Department of Surgery, Vancouver General Hospital, Vancouver, BC
*
Department of Emergency Medicine, Vancouver General Hospital, 855 West 12th Ave., Vancouver BC V5Z 1M9; jlrfox@gmail.com

Abstract

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Introduction:

During the past 7 years, considerable new evidence has accumulated supporting the use of prophylactic hypothermia for traumatic brain injury (TBI). Studies can be divided into 2 broad categories: studies with protocols for cooling for a short, predetermined period (e.g., 24–48 h), and those that cool for longer periods and/or terminate based on the normalization of intracranial pressure (ICP). There have been no systematic reviews of hypothermia for TBI that include this recent new evidence.

Methods:

This analysis followed the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and the QUOROM (quality of reporting of meta-analyses) statement. We developed a comprehensive search strategy to identify all randomized controlled trials (RCTs) comparing therapeutic hypothermia with standard management in TBI patients. We searched Embase, MEDLINE, Web of Science, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, ProceedingsFirst and PapersFirst. Additional relevant articles were identified by hand-searching conference proceedings and bibliographies. All stages of study identification and selection, quality assessment and analysis were conducted according to prospectively defined criteria. Study quality was determined by assessment of each study for the use of allocation concealment and outcome assessment blinding. Studies were divided into 2 a priori–defined subgroups for analysis based on cooling strategy: short term (≤ 48 h), and long term or goal-directed (> 48 h and/or continued until normalization of ICP). Outcomes included mortality and good neurologic outcome (defined as Glasgow Outcome Scale score of 4 or 5). Pooling of primary outcomes was completed using relative risk (RR) and reported with 95% confidence intervals (CIs).

Results:

Of 1709 articles, 12 studies with 1327 participants were selected for quantitative analysis. Eight of these studies cooled according to a long-term or goal-directed strategy, and 4 used a short-term strategy. Summary results demonstrated lower mortality (RR 0.73, 95% CI 0.62–0.85) and more common good neurologic outcome (RR 1.52, 95% CI 1.28–1.80). When only short-term cooling studies were analyzed, neither mortality (RR 0.98, 95% CI 0.75–1.30) nor neurologic outcome (RR 1.31, 95% CI 0.94–1.83) were improved. In 8 studies of long-term or goal-directed cooling, mortality was reduced (RR 0.62, 95% CI 0.51–0.76) and good neurologic outcome was more common (RR 1.68, 95% CI 1.44–1.96).

Conclusion:

The best available evidence to date supports the use of early prophylactic mild-to-moderate hypothermia in patients with severe TBI (Glasgow Coma Scale score ≤ 8) to decrease mortality and improve rates of good neurologic recovery. This treatment should be commenced as soon as possible after injury (e.g., in the emergency department after computed tomography) regardless of initial ICP, or before ICP is measured. Most studies report using a temperature of 32°–34°C. The maximal benefit occurred with a long-term or goal-directed cooling protocol, in which cooling was continued for at least 72 hours and/or until stable normalization of intracranial pressure for at least 24 hours was achieved. There is large potential for further research on this therapy in prehospital and emergency department settings.

Keywords

brain injurieshypothermiainducedreviewtraumatic brain injuryprophylactic hypothermiasystematic review
Type
State of the Art • À la fine pointe
Information
Canadian Journal of Emergency Medicine , Volume 12 , Issue 4 , July 2010 , pp. 355 - 364
Copyright
Copyright © Canadian Association of Emergency Physicians 2010

References

REFERENCES

1.Bernard, SA, Gray, TW, Buist, MD, et al.Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557–63.Google Scholar
2.Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346:549–56.Google Scholar
3.Cheung, KW, Green, RS, Magee, KD. Systematic review of randomized controlled trials of therapeutic hypothermia as a neuroprotectant in post-cardiac arrest patients. CJEM 2006; 8:329–37.Google Scholar
4.Alderson, P, Gadkary, C, Signorini, DF. Therapeutic hypothermia for head injury. Cochrane Database Syst Rev 2004;CD001048.Google Scholar
5.Henderson, WR. Hypothermia in the management of traumatic brain injury — a systematic review. Intensive Care Med 2003;29:1637–44.CrossRefGoogle ScholarPubMed
6.McIntyre, LA, Fergusson, DA, Hebert, PC, et al.Prolonged therapeutic hypothermia after traumatic brain injury in adults: a systematic review. JAMA 2003;289:2992–9.Google Scholar
7.Bratton, SL, Chestnut, RM, Ghajar, J, et al.Guidelines for the management of severe traumatic brain injury. III. Prophylactic hypothermia. J Neurotrauma 2007;24(Suppl 1):S21-5.Google Scholar
8.Zhi, D, Zhang, S, Lin, X. Study on therapeutic mechanism and clinical effect of mild hypothermia in patients with severe head injury. Surg Neurol 2003;59:381–5.Google Scholar
9.Coles, JP, Fryer, TD, Smielewski, P, et al.Defining ischemic burden after traumatic brain injury using 15O PET imaging of cerebral physiology. J Cereb Blood Flow Metab 2004;24:191–201.Google Scholar
10.Inoue, Y, Shiozaki, T, Tasaki, O, et al.Changes in cerebral blood flow from the acute to the chronic phase of severe head injury. J Neurotrauma 2005;22:1411–8.CrossRefGoogle Scholar
11.Werner, C, Engelhard, K. Pathophysiology of traumatic brain injury. Br JAnaesth 2007;99:4–9.CrossRefGoogle ScholarPubMed
12.Tokutomi, T, Morimoto, K, Miyagi, T, et al.Optimal temperature for the management of severe traumatic brain injury: effect of hypothermia on intracranial pressure, systemic and intracranial hemodynamics, and metabolism. Neurosurgery 2003;52:102–11, discussion 11–2.Google Scholar
13.Jiang, JY, Lyeth, BG, Kapasi, MZ, et al.Moderate hypothermia reduces blood-brain barrier disruption following traumatic brain injury in the rat. Acta Neuropathol 1992;84:495–500.Google Scholar
14.Chatzipanteli, K, Alonso, OF, Kraydieh, S, et al.Importance of posttraumatic hypothermia and hyperthermia on the inflammatory response after fluid percussion brain injury: biochemical and immunocytochemical studies. J Cereb Blood Flow Metab 2000;20:531–42.Google Scholar
15.Whalen, MJ, Carlos, TM, Clark, RS, et al.The relationship between brain temperature and neutrophil accumulation after traumatic brain injury in rats. Acta Neurochir Suppl 1997;70:260–1.Google Scholar
16.Fay, T. Observations on generalized refrigeration in cases of severe cerebral trauma. Assoc Res Nerv Ment Dis Proc 1943;24:611–19.Google Scholar
17.Clifton, GL, Allen, S, Barrodale, P, et al.A phase II study of moderate hypothermia in severe brain injury. J Neurotrauma 1993;10:263–71, discussion 73.Google Scholar
18.Marion, DW, Obrist, WD, Carlier, PM, et al.The use of moderate therapeutic hypothermia for patients with severe head injuries: a preliminary report. J Neurosurg 1993;79:354–62.Google Scholar
19.Clifton, GL, Miller, ER, Choi, SC, et al.Lack of effect of induction of hypothermia after acute brain injury. N Engl J Med 2001;344:556–63.CrossRefGoogle ScholarPubMed
20.Stocchetti, N, Colombo, A, Ortolano, F, et al.Time course of intracranial hypertension after traumatic brain injury. J Neurotrauma 2007;24:1339–46.Google Scholar
21.Polderman, KH, Tjong Tjin Joe, R, Peerdeman, SM, et al.Effects of therapeutic hypothermia on intracranial pressure and outcome in patients with severe head injury. Intensive Care Med 2002;28:1563–73.Google Scholar
22.Higgins, JPT, Green, S, eds. Cochrane handbook for systematic reviews of interventions 4.2.6 [updated September 2006]. In: The Cochrane library. Chichester (UK): John Wiley & Sons, Ltd.; 2006.Google Scholar
23.Moher, D, Cook, DJ, Eastwood, S, et al.Improving the quality of reports of meta-analyses of randomized controlled trials: the QUOROM statement. Lancet 1999;354:1896–900.CrossRefGoogle ScholarPubMed
24.Jiang, JY, Xu, W, Li, WP, et al.Effect of long-term mild hypothermia or short-term mild hypothermia on outcome of patients with severe traumatic brain injury. J Cereb Blood Flow Metab 2006;26:771–6.CrossRefGoogle ScholarPubMed
25.Hirayama, T, Katayama, Y, Kano, T, et al.Impact of moderate hypothermia on therapies for intracranial pressure control in severe traumatic brain injury. In: Nagai, H, Ishii, S, Maeda, M, editors. Intracranial pressure IX: 9th International Symposium. Nagaya (Japan): Springer-Verlag; 1994. p. 233–6.Google Scholar
26.Marion, DW, Penrod, LE, Kelsey, SF, et al.Treatment of traumatic brain injury with moderate hypothermia. N Engl J Med 1997;336:540–6.Google Scholar
27.Aibiki, M, Maekawa, S, Yokono, S. Moderate hypothermia improves imbalances of thromboxane A2 and prostaglandin I2 production after traumatic brain injury in humans. Crit Care Med 2000;28:3902–6.Google Scholar
28.Jiang, J, Yu, M, Zhu, C. Effect of long-term mild hypothermia therapy in patients with severe traumatic brain injury: 1-year follow-up review of 87 cases. J Neurosurg 2000;93:546–9.Google Scholar
29.Chen, L, Piao, Y, Zeng, F, et al.Moderate hypothermia therapy for patients with severe head injury. Chin J Traumatol 2001;4:164–7.Google Scholar
30.Yan, Y, Tang, W. Changes of evoked potentials and evaluation of mild hypothermia for treatment of severe brain injury. Chin J Traumatol 2001;4:8–13.Google Scholar
31.Qiu, WS, Liu, WG, Shen, H, et al.Therapeutic effect of mild hypothermia on severe traumatic head injury. Chin J Traumatol 2005;8:27–32.Google Scholar
32.Smrcka, M, Vidlak, M, Maca, K, et al.The influence of mild hypothermia on ICP, CPP and outcome in patients with primary and secondary brain injury. Acta Neurochir Suppl 2005;95:273–5.CrossRefGoogle ScholarPubMed
33.Liu, WG, Qiu, WS, Zhang, Y, et al.Effects of selective brain cooling in patients with severe traumatic brain injury: a preliminary study. JInt Med Res 2006;34:58–64.Google Scholar
34.Aibiki, M, Maekawa, S, Ogura, S, et al.Effect of moderate hypothermia on systemic and internal jugular plasma IL-6 levels after traumatic brain injury in humans. J Neurotrauma 1999;16:225–32.Google Scholar
35.Adelson, PD, Ragheb, J, Kanev, P, et al.Phase II clinical trial of moderate hypothermia after severe traumatic brain injury in children. Neurosurgery 2005;56:740–54.Google Scholar
36.Jiang, JY, Yang, XF. Current status of cerebral protection with mild-to-moderate hypothermia after traumatic brain injury. Curr Opin Crit Care 2007;13:153–5.Google Scholar
37.Zweifler, RM, Voorhees, ME, Mahmood, MA, et al.Induction and maintenance of mild hypothermia by surface cooling in non-intubated subjects. J Stroke Cerebrovasc Dis 2003;12:237–43.CrossRefGoogle ScholarPubMed
38.Resnick, DK, Marion, DW, Darby, JM. The effect of hypothermia on the incidence of delayed traumatic intracerebral hemorrhage. Neurosurgery 1994;34:252–5, discussion 5–6.Google Scholar
39.Bernard, SA, Mac, CJB, Buist, M. Experience with prolonged induced hypothermia in severe head injury. Crit Care 1999;3:167–72.Google Scholar
40.Harris, OA, Muh, CR, Surles, MC, et al.Discrete hypothermia in the management of traumatic brain injury. J Neurosurg 2009;110:1256–64.CrossRefGoogle ScholarPubMed
41.Clifton, GL. Effects of hypothermia upon outcomes after acute traumatic brain injury (NABISH:HIIR). ClinicalTrials.gov ID: NCT00178711.Google Scholar
42.Adelson, PD. Pediatric Traumatic Brain Injury Consortium: hypothermia. ClinicalTrials.gov ID: NCT00222742.Google Scholar
43.Maekawa, T. Therapeutic strategy for severe head trauma patients with mild hypothermia and estimation of medical expenses in Japan. Clinicaltrials.gov ID: NCT00134472.Google Scholar
44.Beca, T. Pilot study of early and prolonged hypothermia in severe traumatic brain injury in children. ClinicalTrials.gov ID: NCT00282269.Google Scholar
45.Hutchison, JS, Ward, RE, Lacroix, J, et al.Hypothermia therapy after traumatic brain injury in children. N Engl J Med 2008;358:2447–56.Google Scholar