This document summarizes guidelines from the Brain Trauma Foundation (BTF) for the management of traumatic brain injury (TBI). It provides indications and recommendations for surgery on various brain injuries like epidural hematomas, subdural hematomas, and depressed skull fractures based on factors like volume and Glasgow Coma Scale. It also outlines Level I-III evidence for treatments, monitoring thresholds, and recommendations regarding intracranial pressure, cerebral perfusion pressure, seizures and other topics.

1. BTF Guidelines
Dr Dikpal

2. History : BTF
• 1986
• Dr Jam Ghajar
• HQ : Campbell, California
• Guidelines and Research fellowships in TBI
• Current is 4th Edition : 2016
• Living Guideline Model

3. Methods
• Systemic review
Class 1: Good quality RCT
Class 2: Mod RCT , Good Cohort / CCS
Class 3: low RCT, mod – low Cohort / CCS
• Synthesis of evidence
• Derivation of recommendation

4. Level of Evidence
LEVEL I (Standard)
• Prospective, Randomized, Controlled Trials
LEVEL II (Guideline)
• A: obtained from well-designed controlled trials without
randomization
• B: obtained from well-designed cohort or case-control
analytic studies, preferably from more than one center or
research group
LEVEL III (Optional)
• Case Series
• Case Reports
• Expert Opinion

5. Overview
• Indications for Surgery
• Treatment recommendation
• Monitoring recommendation
• Threshold recommendation

6. Epidural Hematoma
Indications
• Volume greater than 30cc should be evacuated
regardless of GCS
• Volume less than 30cc/less than 15mm
thickness/less than 5mm midline shift/GCS
greater than 8 may be managed non-operatively
Timing
• Any patient with acute EDH/GCS<9/anisocoria
should undergo operation “as soon as possible”

7. Current perspective in EDH
• CAN EDH > 30 cc be conserved ?

9. Subdural Hematoma
Indications
• SDH with thickness > 10mm/midline shift > 5mm should be
evacuated regardless of GCS
• Patients with acute SDH and GCS < 9 should have ICP
monitoring
• SDH with thickness < 10mm or < 5mm midline shift should
be evacuated if GCS drops 2 or more points from injury to
admission, pupillary function is abnormal, or ICP> 20 mm
Hg
Methods
• Craniotomy with or without bone flap removal/duroplasty

11. Traumatic Parenchymal Lesions
Indications
• Parenchymal mass lesion with referable neurologic
deterioration, medically refractory intracranial hypertension
or signs of mass effect on CT should be evacuated
• Patients with GCS 6-8, with frontal or temporal lesion volume
> 20cc with midline shift >5mm or cisternal compression, or
any lesion volume > 50cc should be evacuated
• Parenchymal mass lesions without clinical neurologic
compromise, with no signs of mass effect and with controlled
ICP can be treated non-operatively

12. Posterior Fossa Mass Lesions
Indications
• Patients with mass effect on CT or neurologic
dysfunction or deterioration referable to a lesion
should undergo evacuation; “mass effect” is defined as
distortion of the 4th ventricle, effacement of basilar
cisterns or obstructive hydrocephalus
• Patients without mass effect of neurologic dysfunction
may be treated non-operatively
Methods
• Suboccipital craniectomy is the predominant method
reported and is therefore recommended

13. Depressed Cranial Fractures
Indications
• Open fractures with depression greater than the
thickness of the skull should be treated surgically to
prevent infection
• Open depressed skull fractures may be treated
non-operatively provided there is no evidence of
dural penetration, intraparenchymal hematoma,
depression > 1 cm, frontal sinus involvement, gross
cosmetic deformity, wound infection,
pneumocephalus, or gross wound contamination
• Closed depressed skull fractures may be treated
non-operatively

14. Methods
• Elevation and debridement is recommended
• Primary bone fragment replacement is an
option in the absence of wound infection at
the time of surgery
• All management options for open depressed
fractures should include antibiotics

15. Treatment guidelines
• 1. Decompressive Craniectomy
• 2. Prophylactic Hypothermia
• 3. Hyperosmolar Therapy
• 4. Cerebrospinal Fluid Drainage
• 5. Ventilation Therapies
• 6. Anesthetics, Analgesics, and Sedatives
• 7. Steroids
• 8. Nutrition
• 9. Infection Prophylaxis
• 10. Deep Vein Thrombosis Prophylaxis
• 11. Seizure Prophylaxis

16. DECOMPRESSIVE CRANIECTOMY
• There was insufficient evidence to support a
Level I recommendation for this topic.
• Level IIA
-Bifrontal DC is not recommended to improve
outcomes
-A large frontotemporoparietal DC (12 x 15 cm or
15 cm diameter) is recommended over a small
frontotemporoparietal DC
• RESCUEicp trial

20. PROPHYLACTIC HYPOTHERMIA
• No Level I / II A
• LEVEL II B: Early (within 2.5 hours), short-term
(48 hours post-injury) prophylactic
hypothermia is not recommended to improve
outcomes in patients with diffuse injury.

21. HYPEROSMOLAR THERAPY
• LEVEL I, II, AND III: Although hyperosmolar
therapy may lower intracranial pressure, there
was insufficient evidence about effects on
clinical outcomes to support a specific
recommendation, or to support use of any
specific hyperosmolar agent, for patients with
severe traumatic brain injury.

23. CEREBROSPINAL FLUID DRAINAGE
• There was insufficient evidence to support a Level I
or II recommendation for this topic.
LEVEL III
• An EVD system zeroed at the midbrain with
continuous drainage of CSF may be considered to
lower ICP burden more effectively than
intermittent use.
• Use of CSF drainage to lower ICP in patients with an
initial Glasgow Coma Scale (GCS) <6 during the first
12 hours after injury may be considered

24. VENTILATION THERAPIES
• There was insufficient evidence to support a
Level I or II A recommendation for this topic
LEVEL II B
• Prolonged prophylactic hyperventilation with
partial pressure of carbon dioxide in arterial
blood (PaCO2) of 25 mm Hg or less is not
recommended.

25. ANESTHETICS, ANALGESICS, AND
SEDATIVES
LEVEL II B
• Administration of barbiturates to induce burst suppression
measured by EEG as prophylaxis against the development
of intracranial hypertension is not recommended.
• High-dose barbiturate administration is recommended to
control elevated ICP refractory to maximum standard
medical and surgical treatment. Hemodynamic stability is
essential before and during barbiturate therapy.
• Although propofol is recommended for the control of ICP, it
is not recommended for improvement in mortality or 6-
month outcomes

26. STEROIDS
• LEVEL I: The use of steroids is not
recommended for improving outcome or
reducing ICP. In patients with severe TBI, high-
dose methylprednisolone was associated with
increased mortality and is contraindicated.

29. NUTRITION
• LEVEL II A: Feeding patients to attain basal
caloric replacement at least by the 5th day and
at most by the 7th day post-injury is
recommended to decrease mortality.
• LEVEL II B: Transgastric jejunal feeding is
recommended to reduce the incidence of
ventilator-associated pneumonia.

30. INFECTION PROPHYLAXIS
• LEVEL II A: Early tracheostomy is recommended
to reduce mechanical ventilation days when the
overall benefit is felt to outweigh the
complications associated with such a
procedure. However, there is no evidence that
early tracheostomy reduces mortality or the
rate of nosocomial pneumonia.
• The use of povidone-iodine (PI) oral care is not
recommended
• LEVEL III: Antimicrobial-impregnated catheters
may be considered to prevent catheter-related
infections during external ventricular drainage.

31. DEEP VEIN THROMBOSIS
PROPHYLAXIS
• LEVEL III: Low molecular weight heparin (LMWH) or
low-dose unfractioned heparin may be used in
combination with mechanical prophylaxis. However,
there is an increased risk for expansion of intracranial
hemorrhage.
• In addition to compression stockings, pharmacologic
prophylaxis may be considered if the brain injury is
stable and the benefit is considered to outweigh the
risk of increased intracranial hemorrhage. There is
insufficient evidence to support recommendations
regarding the preferred agent, dose, or timing of
pharmacologic prophylaxis for deep vein thrombosis.

32. SEIZURE PROPHYLAXIS
• LEVEL II A: Prophylactic use of phenytoin or valproate
is not recommended for preventing late post traumatic
seizures (PTS).
• Phenytoin is recommended to decrease the incidence
of early PTS (within 7 days of injury), when the overall
benefit is felt to outweigh the complications associated
with such treatment. However, early PTS have not been
associated with worse outcomes.
• At the present time there is insufficient evidence to
recommend levetiracetam over phenytoin regarding
efficacy in preventing early post-traumatic seizures and
toxicity.

33. • The risk factors for early PTS include:
Glasgow Coma Scale (GCS) score of ≤10;
immediate seizures; post-traumatic amnesia
lasting longer than 30 minutes; linear or
depressed skull fracture; penetrating head
injury; subdural, epidural, or intracerebral
hematoma; cortical contusion; age ≤65
years; or chronic alcoholism.

34. Monitoring recommendation
• Intracranial Pressure Monitoring
• Cerebral Perfusion Pressure
Monitoring
• Advanced Cerebral Monitoring

35. INTRACRANIAL PRESSURE
MONITORING
• LEVEL II B: Management of severe TBI patients
using information from ICP monitoring is
recommended to reduce in-hospital and 2-
week post-injury mortality.

36. CEREBRAL PERFUSION PRESSURE
MONITORING
• LEVEL II B: Management of severe TBI patients
using guidelines-based recommendations for
CPP monitoring is recommended to decrease
2-week mortality.
•

37. ADVANCED CEREBRAL MONITORING
• LEVEL III: Jugular bulb monitoring of
arteriovenous oxygen content difference
(AVDO2), as a source of information for
management decisions, may be considered to
reduce mortality and improve outcomes at 3
and 6 months post-injury.

38. Threshold guidelines
• Blood Pressure Thresholds
• Intracranial Pressure Thresholds
• Cerebral Perfusion Pressure
Thresholds
• Advanced Cerebral Monitoring
Threshold

39. Blood Pressure Thresholds
• LEVEL III: Maintaining SBP at ≥100 mm Hg for
patients 50 to 69 years old or at ≥110 mm Hg
or above for patients 15 to 49 or over 70 years
old may be considered to decrease mortality
and improve outcomes.

40. INTRACRANIAL PRESSURE
THRESHOLDS
• LEVEL II B: Treating ICP above 22 mm Hg is
recommended because values above this level
are associated with increased mortality.
• LEVEL III: A combination of ICP values and
clinical and brain CT findings may be used to
make management decisions.

41. CEREBRAL PERFUSION PRESSURE
THRESHOLDS
• LEVEL II B: The recommended target cerebral
perfusion pressure (CPP) value for survival and
favorable outcomes is between 60 and 70 mm
Hg. Whether 60 or 70 mm Hg is the minimum
optimal CPP threshold is unclear and may depend
upon the patient’s autoregulatory status.
• LEVEL III: Avoiding aggressive attempts to
maintain CPP above 70 mm Hg with fluids and
pressors may be considered because of the risk of
adult respiratory failure.

42. ADVANCED CEREBRAL MONITORING
THRESHOLDS
• LEVEL III: Jugular venous saturation of <50%
may be a threshold to avoid in order to reduce
mortality and improve outcomes.