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Figure 1. Study flow diagram.
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Figure 1

Figure 1. Study flow diagram.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies. Seven studies are included in this review.
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies. Seven studies are included in this review.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 1 Unfavourable outcome at end of treatment period to one month.
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Analysis 1.1

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 1 Unfavourable outcome at end of treatment period to one month.

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 2 Unfavourable outcome at six months.
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Analysis 1.2

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 2 Unfavourable outcome at six months.

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 3 Unfavourable outcome at 12 months.
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Analysis 1.3

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 3 Unfavourable outcome at 12 months.

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 4 Best case scenario (12 months).
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Analysis 1.4

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 4 Best case scenario (12 months).

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 5 Worst case scenario (12 months).
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Analysis 1.5

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 5 Worst case scenario (12 months).

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 6 Unfavourable outcome at final follow‐up.
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Analysis 1.6

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 6 Unfavourable outcome at final follow‐up.

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 7 Best case scenario (final follow‐up).
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Analysis 1.7

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 7 Best case scenario (final follow‐up).

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 8 Worst case scenario (final follow‐up).
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Analysis 1.8

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 8 Worst case scenario (final follow‐up).

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 9 Unfavourable outcome ‐ subgroup by treatment pressure.
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Analysis 1.9

Comparison 1 Unfavourable functional outcome (for example GOS 1, 2, or 3), Outcome 9 Unfavourable outcome ‐ subgroup by treatment pressure.

Comparison 2 Death at final follow‐up, Outcome 1 Death at final follow‐up.
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Analysis 2.1

Comparison 2 Death at final follow‐up, Outcome 1 Death at final follow‐up.

Comparison 2 Death at final follow‐up, Outcome 2 Best case death.
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Analysis 2.2

Comparison 2 Death at final follow‐up, Outcome 2 Best case death.

Comparison 2 Death at final follow‐up, Outcome 3 Worst case death.
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Analysis 2.3

Comparison 2 Death at final follow‐up, Outcome 3 Worst case death.

Comparison 3 Intracranial pressure, Outcome 1 Mean peak ICP at any time (subgroup by myringotomy).
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Analysis 3.1

Comparison 3 Intracranial pressure, Outcome 1 Mean peak ICP at any time (subgroup by myringotomy).

Comparison 4 Progress in Glasgow Coma Scale, Outcome 1 Final Glasgow Coma Score after therapy.
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Analysis 4.1

Comparison 4 Progress in Glasgow Coma Scale, Outcome 1 Final Glasgow Coma Score after therapy.

Comparison 5 Adverse effects of treatment, Outcome 1 Pulmonary.
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Analysis 5.1

Comparison 5 Adverse effects of treatment, Outcome 1 Pulmonary.

Comparison 5 Adverse effects of treatment, Outcome 2 Neurological toxicity.
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Analysis 5.2

Comparison 5 Adverse effects of treatment, Outcome 2 Neurological toxicity.

Comparison 5 Adverse effects of treatment, Outcome 3 Ear barotrauma.
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Analysis 5.3

Comparison 5 Adverse effects of treatment, Outcome 3 Ear barotrauma.

Summary of findings for the main comparison. Hyperbaric oxygen therapy for acute traumatic brain injury

Hyperbaric oxygen therapy for acute traumatic brain injury

Patient or population: Patients with acute traumatic brain injury
Settings: Patients admitted to acute neurosurgical intensive care
Intervention: Hyperbaric oxygen therapy

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Hyperbaric Oxygen Therapy

Death at any time in trial period
case mortality count
Follow‐up: 2 to 52 weeks

Study population

RR 0.69
(0.54 to 0.88)

385
(4 studies)

⊕⊕⊕⊝
moderate1

414 per 1000

286 per 1000
(224 to 364)

Low risk population

160 per 1000

110 per 1000
(86 to 141)

High risk population

500 per 1000

345 per 1000
(270 to 440)

Favourable outcome
GOS <9 or similar
Follow‐up: 1 to 12 months

Study population

RR 1.94
(0.92 to 4.08)2

380
(4 studies)

337 per 1000

654 per 1000
(310 to 1000)

Low risk population

100 per 1000

194 per 1000
(92 to 408)

High risk population

500 per 1000

970 per 1000
(460 to 1000)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Two of the contributing trials are more than 20 years old and assessed as at high risk of bias in some dimensions
2 Note that this is the RR for a favourable outcome with HBOT. In the main text this has been presented as the RR of an unfavourable outcome in order to maintain consistency in the graphical direction of effects through all outcomes.

Figuras y tablas -
Summary of findings for the main comparison. Hyperbaric oxygen therapy for acute traumatic brain injury
Comparison 1. Unfavourable functional outcome (for example GOS 1, 2, or 3)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Unfavourable outcome at end of treatment period to one month Show forest plot

2

159

Risk Ratio (M‐H, Random, 95% CI)

0.74 [0.61, 0.88]

2 Unfavourable outcome at six months Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3 Unfavourable outcome at 12 months Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4 Best case scenario (12 months) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

5 Worst case scenario (12 months) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

6 Unfavourable outcome at final follow‐up Show forest plot

4

380

Risk Ratio (M‐H, Random, 95% CI)

0.71 [0.50, 1.01]

7 Best case scenario (final follow‐up) Show forest plot

4

382

Risk Ratio (M‐H, Random, 95% CI)

0.71 [0.49, 1.02]

8 Worst case scenario (final follow‐up) Show forest plot

4

382

Risk Ratio (M‐H, Random, 95% CI)

0.71 [0.50, 1.00]

9 Unfavourable outcome ‐ subgroup by treatment pressure Show forest plot

4

380

Risk Ratio (M‐H, Random, 95% CI)

0.71 [0.50, 1.01]

9.1 High pressure (2.5ATA)

2

115

Risk Ratio (M‐H, Random, 95% CI)

0.46 [0.14, 1.58]

9.2 Low pressure (1.5ATA)

2

265

Risk Ratio (M‐H, Random, 95% CI)

0.84 [0.57, 1.24]

Figuras y tablas -
Comparison 1. Unfavourable functional outcome (for example GOS 1, 2, or 3)
Comparison 2. Death at final follow‐up

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Death at final follow‐up Show forest plot

4

385

Risk Ratio (M‐H, Fixed, 95% CI)

0.69 [0.54, 0.88]

2 Best case death Show forest plot

3

327

Risk Ratio (M‐H, Fixed, 95% CI)

0.69 [0.54, 0.89]

3 Worst case death Show forest plot

3

327

Risk Ratio (M‐H, Fixed, 95% CI)

0.67 [0.53, 0.87]

Figuras y tablas -
Comparison 2. Death at final follow‐up
Comparison 3. Intracranial pressure

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Mean peak ICP at any time (subgroup by myringotomy) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.1 HBOT with myringotomy versus control

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.2 HBOT no myringotomy versus control

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

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Comparison 3. Intracranial pressure
Comparison 4. Progress in Glasgow Coma Scale

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Final Glasgow Coma Score after therapy Show forest plot

2

120

Mean Difference (IV, Fixed, 95% CI)

‐2.68 [‐3.52, ‐1.84]

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Comparison 4. Progress in Glasgow Coma Scale
Comparison 5. Adverse effects of treatment

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pulmonary Show forest plot

2

228

Risk Ratio (M‐H, Fixed, 95% CI)

15.57 [2.11, 114.72]

2 Neurological toxicity Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3 Ear barotrauma Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Figuras y tablas -
Comparison 5. Adverse effects of treatment