The Journal of Neurotrauma is proud to publish a special issue dedicated to the new edition of the Guidelines for the Management of Severe Traumatic Brain Injury. Under the sponsorship of the Brain Trauma Foundation, these guidelines were first published in 1995, and the 2^nd revised edition was published in 2000. This 3^rd edition is substantially different, with six new topics added for a total of 15 chapters.

The Brain Trauma Foundation has drawn together 22 experts for the authorship of these guidelines, including 15 emerging experts in the field, each of whom were trained in evidence-based medicine methodology. The Foundation established the Center for Guidelines Management, which worked in partnership with methodologists from the Oregon Evidence-based Practice Center to develop the 3^rd Edition of these Guidelines. This group performed comprehensive electronic searches of all databases relevant to the neurotrauma literature, up to April 2006. They used criteria to assess the quality of the included literature that was based on the United States Preventive Services Taskforce, the National Health Services (UK) Centre for Reviews and Dissemination, and the Cochrane Collaboration.

Two independent members of the EPC staff reviewed each selected study and classified them as Class I, Class II, or Class III, with the aid of the neurotrauma expert panel. The literature lists and classifications were refined by consensus discussion, among the experts. The studies were limited to human studies in the adult age group (>17 years) in the English language, covering traumatic brain injury (TBI), and excluding editorials, expert opinion, and studies of fewer than 25 patients. The topics for review were selected based upon these criteria when there were sufficient published studies to formulate recommendations. Many more topics (such as decompressive craniotomy) were initially listed, but were eliminated, either because they were covered in other guideline documents, such as Guidelines for the Surgical Management of Traumatic Brain Injury or because of insufficient data.

For hypothermia, the conflicting findings in over 15 clinical trials in TBI led the EPC group to implement it's own independent meta-analysis to assess the clinical trials in question.

As with the previous guidelines for TBI, the reader must be aware of the limitations and restricted scope of the guidelines. The guidelines reflect only what is contained in the existing human-based literature. They do not reflect pathomechanistic information from animal studies, nor in vitro or mathematical modeling studies.

Since the first Guidelines for Management of Traumatic Brain Injury were published in 1995, there have been several studies clearly demonstrating that TBI management in accordance with the Guidelines can achieve substantially better outcomes in terms of metrics such as mortality rate, functional outcome scores, length of hospital stay, and costs. This has been shown in single Level I and II trauma centers in the United States, and in large population-based studies in Eastern Europe. Previous editions of the guidelines have been translated into over 15 different languages, and applied in most European countries, several countries in South America, and in parts of China. In the United States, surveys conducted in 1995, 2000, and 2006 have shown that increasing numbers of severe TBI patients are being managed in accordance with the Guidelines, with ICP monitoring, for example, rising from 32% in 1995 to 78% in 2005. The influence of these Guidelines upon patient care has thus already been enormous; and taken together with the Companion Guidelines for pediatric TBI, prehospital management of TBI, management of penetrating TBI, and surgical management of TBI,2 these documents offer the possibility for uniformity of TBI care, and conformity with the best standards of clinical practice. Only in this way can we provide the best milieu for the conduct of clinical trials to evaluate putative new therapies, which are being brought forth for clinical trials.

As in all areas of clinical medicine, the optimal plan of management for an individual patient may not fall exactly within the recommendations of these guidelines. This is because all patients, and in particular, neurotrauma patients, have heterogeneous injuries, and optimal management depends on a synthesis of the established knowledge based upon Guidelines, and then applied to the clinical findings in the individual patient, and refined by the clinical judgment of the treating physician.