Improved outcome after severe head injury with a new therapy based on principles for brain volume regulation and preserved microcirculation

Crit Care Med. 1998 Nov;26(11):1881-6. doi: 10.1097/00003246-199811000-00033.


Objective: To assess the new "Lund therapy" of posttraumatic brain edema, based on principles for brain-volume regulation and improved microcirculation.

Design: A prospective, nonrandomized outcome study over a 5-yr period on severely head-injured patients with increased intracranial pressure, comparing the results with a historical control group with the same selection criteria for patients who were treated according to conventional principles.

Setting: General intensive care unit of a university hospital.

Patients: Fifty-three consecutive head-injured patients with a Glasgow Coma Score of <8, and with increased intracranial pressure (>25 mm Hg), despite conventional treatment.

Interventions: Interstitial fluid resorption was obtained by lowering intracapillary hydrostatic pressure, by preserving normal colloid osmotic pressure, and by maintaining a normovolemic (normal albumin/serum and hemoglobin/serum), not overtransfused patient. Intracapillary pressure was reduced by the combination of precapillary vasoconstriction (low-dose thiopental, dihydroergotamine) and reduction of mean arterial pressure, the latter attained with a beta1-antagonist (metoprolol 0.2 to 0.3 mg/kg/24 hrs iv) and an alpha2-agonist (clonidine 0.4 to 0.8 microg/kg x 4 to 6 iv). Clonidine, in combination with normovolemia, also improves microcirculation by reducing catecholamines in plasma. Intracranial blood volume was reduced by arterial (low-dose thiopental sodium and dihydroergotamine) and large-vein (dihydroergotamine) vasoconstriction. The start dose of dihydroergotamine (maximum 0.9 microg/kg/hr) was successively reduced toward discontinuation within 4 to 5 days.

Measurements and main results: There were 8% of patients who died and the neurologic conditions of 13% remained severely damaged, compared with 47% and 11%, respectively, for the control group.

Conclusions: The low mortality compared with previous outcome studies strongly indicates that this therapy improves outcome for severe head injuries. However, a randomized, controlled study is needed to reach general acceptance of this new therapy.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute Disease
  • Adult
  • Brain Edema / mortality
  • Brain Edema / physiopathology
  • Brain Edema / therapy*
  • Cerebrovascular Circulation* / drug effects
  • Chi-Square Distribution
  • Combined Modality Therapy
  • Craniocerebral Trauma / mortality
  • Craniocerebral Trauma / physiopathology
  • Craniocerebral Trauma / therapy*
  • Humans
  • Hydrostatic Pressure
  • Intracranial Hypertension / mortality
  • Intracranial Hypertension / physiopathology
  • Intracranial Hypertension / therapy
  • Microcirculation / drug effects
  • Microcirculation / physiopathology
  • Middle Aged
  • Prospective Studies
  • Treatment Outcome