Head injury (moderate to severe): reducing cerebral oedema

INTRODUCTION: Head injury in young adults is often associated with motor vehicle accidents, violence, and sports injuries. In older adults, it is often associated with falls. Severe head injury can lead to secondary brain damage from cerebral ischaemia resulting from hypotension, hypercapnia, and raised intracranial pressure. Severity of brain injury is assessed using the Glasgow Coma Scale (GCS). While about one quarter of people with severe brain injury (GCS score less than 8) will make a good recovery, about one third will die, and one fifth will have severe disability or be in a vegetative state. METHODS AND OUTCOMES: We conducted a systematic overview and aimed to answer the following clinical question: What are the effects of interventions to reduce cerebral oedema in people with moderate to severe head injury as defined by GCS? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2014 (BMJ Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS: At this update, searching of electronic databases retrieved 306 studies. After deduplication and removal of conference abstracts, 209 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 161 studies and the further review of 48 full publications. Of the 48 full articles evaluated, two systematic reviews and four RCTs were added at this update. We performed a GRADE evaluation for six PICO combinations. CONCLUSIONS: In this systematic overview, we categorised the efficacy for three interventions, based on information relating to the effectiveness and safety of decompressive craniectomy, hypertonic saline compared with mannitol, and hypertonic saline compared with placebo (normal saline).