What is the role of targeted temperature management (TTM) in patients with traumatic brain injury?

Updated: Jul 26, 2019
  • Author: Alex Koyfman, MD; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Answer

TTM has been shown to be effective in traumatic brain injury (TBI) with high intracranial pressure (ICP) in adults. [54, 55] No benefit exists for patients with TBI with normal ICP. [27] Moderate therapeutic hypothermia adds no benefit and may increase incidence of hypothermia-related complications. [56, 57] Compared with short-term hypothermia (2-3 d), long-term hypothermia (5 d) significantly improves the outcome of patients with severe TBI with cerebral contusion and elevated ICP without causing significant complications.

Some research suggests that all patients with TBI may benefit from hypothermia (not just patients with elevated ICP) and that the level of prehospital hypothermia predicts efficacy. However, results from the National Acute Brain Injury Study: Hypothermia II (NABIS:H II), comprising data from 232 patients, showed that early induction of hypothermia was not effective as a primary neuroprotective strategy in adults aged 18-45 years with severe TBI. [58]

A 2008 literature review by Saxena et al found no evidence that modest hypothermia (35ºC-37.5ºC) in the first week after TBI resulted in improved outcomes, citing a lack of randomized controlled trials of post-TBI modest cooling therapies. [59] A more recent review by the same investigators in 2014 reiterated the lack of, and need for, randomized trials designed to evaluate patient outcomes with these interventions. [60]

Hypothermia in children can be considered an optional therapy for refractory intracranial hypertension but, to date, should not be regarded as standard of care. Studies have shown that hypothermia is safe and may be effective in selected pediatric patients with TBI; however, pediatric expert consensus requires more prospective clinical trials to be conducted. Mild therapeutic hypothermia may lower the seizure threshold and cause pulmonary hypertension in approximately 30% of pediatric patients treated with hypothermia. Complications can be predicted and safely treated in the intensive care unit (ICU) environment. [61, 62, 63]

In a 2018 post hoc analysis of a prospective multicenter trial (Brain Hypothermia [B-HYPO Study]), investigators found that after severe TBI, a mild decrease in heart rate during the early phase of TTM after tachycardia on admission is associated with unfavorable neurologic outcomes. [64]


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