Prevention of secondary ischemic insults after severe head injury

Crit Care Med. 1999 Oct;27(10):2086-95. doi: 10.1097/00003246-199910000-00002.


Objective: The purpose of this study was to compare the effects of two acute-care management strategies on the frequency of jugular venous desaturation and refractory intracranial hypertension and on long-term neurologic outcome in patients with severe head injury.

Design: Randomized clinical trial.

Setting: Level I trauma hospital.

Patients: One hundred eighty-nine adults admitted in coma because of severe head injury.

Interventions: Patients were assigned to either cerebral blood flow (CBF)-targeted or intracranial pressure (ICP)-targeted management protocols during randomly assigned time blocks. In the CBF-targeted protocol, cerebral perfusion pressure was kept at >70 mm Hg and PaCO2 was kept at approximately 35 torr (4.67 kPa). In the ICP-targeted protocol, cerebral perfusion pressure was kept at >50 mm Hg and hyperventilation to a PaCO2 of 25-30 torr (3.33-4.00 kPa) was used to treat intracranial hypertension.

Measurements and main results: The CBF-targeted protocol reduced the frequency of jugular desaturation from 50.6% to 30% (p = .006). Even when the frequency of jugular desaturation was adjusted for all confounding factors that were significant, the risk of cerebral ischemia was 2.4-fold greater with the ICP-targeted protocol. Despite the reduction in secondary ischemic insults, there was no difference in neurologic outcome. Failure to alter long-term neurologic outcome was probably attributable to two major factors. A low jugular venous oxygen saturation was treated in both groups, minimizing the injury that occurred in the ICP-targeted group. The beneficial effects of the CBF-targeted protocol may have been offset by a five-fold increase in the frequency of adult respiratory distress syndrome.

Conclusions: Secondary ischemic insults caused by systemic factors after severe head injury can be prevented with a targeted management protocol. However, potential adverse effects of this management strategy may offset these beneficial effects.

Publication types

  • Clinical Trial
  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Analgesics, Opioid / therapeutic use
  • Brain Injuries / complications*
  • Brain Injuries / diagnosis
  • Brain Injuries / drug therapy
  • Brain Ischemia / diagnosis
  • Brain Ischemia / etiology
  • Brain Ischemia / prevention & control*
  • Catheterization, Central Venous
  • Cerebrovascular Circulation
  • Critical Care / methods*
  • Diuretics, Osmotic / therapeutic use
  • Drainage
  • Drug Therapy, Combination
  • Female
  • Follow-Up Studies
  • Humans
  • Hypnotics and Sedatives / therapeutic use
  • Intracranial Hypertension / diagnosis
  • Intracranial Hypertension / etiology
  • Intracranial Hypertension / prevention & control*
  • Intracranial Pressure
  • Jugular Veins / metabolism
  • Male
  • Oxygen / blood
  • Tomography, X-Ray Computed
  • Trauma Centers
  • Trauma Severity Indices
  • Treatment Outcome


  • Analgesics, Opioid
  • Diuretics, Osmotic
  • Hypnotics and Sedatives
  • Oxygen