Successful Treatment of Severe Traumatic Brain Injury by Prolonged TTM

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Successful Treatment of Severe Traumatic Brain Injury by Prolonged Targeted Temperature Management: A Comprehensive Case Analysis

Introduction

Traumatic brain injury (TBI) remains a leading cause of morbidity and mortality worldwide, particularly in severe cases (sTBI) complicated by cerebral edema, intracranial hypertension, and secondary neuronal damage. Conventional therapies often struggle to address the complex pathophysiological cascade triggered by sTBI. This article presents a detailed analysis of a case involving a 19-year-old female patient with sTBI and cerebral herniation who achieved remarkable neurological recovery following prolonged targeted temperature management (TTM). The case highlights innovative strategies in managing cerebral edema, modulating systemic inflammation, and optimizing neuroprotection through extended temperature control.

Case Presentation

Clinical History and Initial Presentation

The patient, a previously healthy 19-year-old female, sustained sTBI during a traffic accident on August 22, 2019. Immediate imaging revealed epidural and subdural hematomas with severe cerebral edema and midbrain herniation (Figure 1A). She underwent two emergency neurosurgical interventions: craniotomy for hematoma evacuation and decompressive craniectomy. Despite surgery, her Glasgow Coma Scale (GCS) score remained at 3 (deep coma) upon transfer to the intensive care unit (ICU) two days post-operation.

Admission Findings

  • Physical Examination: Pupils were fixed and dilated (3.5 mm), corneal reflexes absent, and decerebrate posturing observed. Vital signs included hypothermia (35.3°C), hypertension (151/128 mmHg), and mild tachycardia (90 beats/min).
  • Laboratory Results: Elevated inflammatory markers (procalcitonin [PCT]: 0.688 mg/L; high-sensitivity C-reactive protein [CRP]: 48.04 mg/L), leukocytosis (15.3 × 10⁹/L), anemia (hemoglobin: 92.3 g/L), and elevated creatine kinase (1259 U/L).
  • Imaging: Post-operative computed tomography (CT) demonstrated unresolved cerebral edema with effacement of sulci and gyri, lateral ventricle compression, and midline shift (Figure 1B).

Therapeutic Intervention

Targeted Temperature Management Protocol

TTM was initiated immediately upon ICU admission to mitigate secondary brain injury. The protocol included:

  1. Temperature Control:

    • Device: Arctic Sun® 5000 Temperature Management System with cooling blankets and nasal probe for real-time brain temperature monitoring.
    • Target Range: Mild hypothermia (35–36°C) maintained for 13 days, followed by normothermia (36–37°C) until day 22.
    • Adjuvant Measures: Arterial ice packs, alcohol baths, and antipyretics as needed.

  2. Sedation and Neuromuscular Blockade:

    • Continuous intravenous sedation (propofol 50 mg/h + dezocine 2.5 mg/h) to reduce cerebral metabolic demand.
    • Intermittent atracurium (1 mg/kg/min) to suppress shivering and ventilator asynchrony.

  3. Supportive Care:

    • Mechanical ventilation (FiO₂ 50%, SpO₂ 100%).
    • Osmotherapy (mannitol), prophylactic antibiotics, and neuro-nutrition.

Monitoring and Adjustments

  • Neurological Metrics: Bispectral index (BIS) monitoring showed progressive improvement from 0–10 (deep coma) to 60–90 (conscious state) by day 15.
  • Inflammatory Markers: PCT levels declined steadily without infection recurrence (Figure 1F).
  • Imaging Follow-Up: Serial CT scans demonstrated gradual resolution of cerebral edema:
    • Day 4: Reduced midline shift and partial sulcal re-emergence (Figure 1C).
    • Day 13: Near-complete resolution of edema (Figure 1D).
    • Day 22: Normal ventricular morphology and parenchymal architecture (Figure 1E).

Clinical Outcomes

Neurological Recovery

  • Day 9: Epidural drains removed; surgical site healed without infection.
  • Day 15: Regained consciousness (GCS 14), followed by tracheostomy decannulation on day 29.
  • Day 36: Independent ambulation and activities of daily living.
  • Day 50: Discharged with full neurological recovery.

Safety Profile

No TTM-related complications occurred:

  • Hemodynamic Stability: No arrhythmias, hypotension, or coagulation abnormalities.
  • Infection Control: Normalized CRP/PCT and intact wound healing.
  • Musculoskeletal Integrity: Absence of prolonged weakness or contractures.

Discussion

Reimagining TTM in sTBI

Traditional TTM protocols for TBI advocate strict hypothermia (32–34°C) for ≤72 hours, often insufficient to suppress peak edema (days 3–5 post-injury). This case challenges conventional paradigms by demonstrating the efficacy of prolonged mild hypothermia (35–36°C) tailored to dynamic cerebral edema metrics. Key advantages include:

  1. Extended Neuroprotection: 13-day hypothermia covered the edema resolution timeline, mitigating reperfusion injury and cytokine storms.
  2. Reduced Complication Risk: Avoiding deep hypothermia minimized risks of arrhythmias, coagulopathy, and immunosuppression.
  3. Synergistic Therapies: Sedation and neuromuscular blockade enhanced TTM effectiveness by suppressing metabolic demand and shivering.

Mechanistic Insights

TTM exerted multi-modal neuroprotection:

  • Cerebral Metabolic Suppression: Reduced oxygen consumption (CMRO₂) by 6–10% per 1°C cooling.
  • Blood-Brain Barrier Stabilization: Attenuated vasogenic edema via anti-inflammatory effects (IL-6 reduction from 31.62 pg/mL to normal range).
  • Oxidative Stress Mitigation: Lowered free radical production during reperfusion.

Patient-Specific Success Factors

  • Youth and Resilience: Absence of comorbidities enhanced recovery capacity.
  • Multidisciplinary Care: Integrated neurosurgical, critical care, and rehabilitation teams.
  • Precision Monitoring: BIS-guided sedation and CT-driven temperature adjustments.

Conclusion

This case establishes prolonged TTM as a viable strategy for sTBI, particularly in young patients with refractory cerebral edema. By individualizing temperature targets and duration to imaging biomarkers, clinicians can optimize neuroprotection while minimizing adverse effects. Future large-scale trials should validate this approach and refine protocols for broader applicability.

DOI: https://doi.org/10.1097/CM9.0000000000001282

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