A review of external lumbar drainage for the management of intracranial hypertension in traumatic brain injury

Object It has recently been suggested that the degree of intracranial pressure (ICP) above the treatment goal can be estimated by the area under the curve (AUC) of ICP versus time in patients with severe traumatic brain injury (TBI). The objective of this study was to determine whether the calculated “ICP dose”—the ICP AUC—is related to mortality rate, outcome, and Marshall CT classification. Methods Of 135 patients (age range 1–82 years) with severe TBI treated during a 5-year period at the authors' institution, 113 patients underwent ICP monitoring (84%). Ninety-three patients with a monitoring time > 24 hours were included for analysis of ICP AUC calculated using the trapezoidal method. Computed tomography scans were assessed according to the Marshall TBI classification. Patients with Glasgow Outcome Scale scores at 6 months and > 3 years were separated into 2 groups based on outcome. Results Sixty patients (65%) had ICP values > 20 mm Hg, and 12 (13%) developed severe intracranial hypertension and died secondary to herniation. A multiple regression analysis adjusting for Glasgow Coma Scale score, age, pupillary abnormalities and Injury Severity Scale score demonstrated that the ICP AUC was a significant predictor of poor outcome at 6 months (p = 0.034) and of death (p = 0.035). However, it did not predict long-term outcome (p = 0.157). The ICP AUC was significantly higher in patients with Marshall head injury Categories 3 and 4 (24 patients) than in those with Category 2 (23 patients, p = 0.025) and Category 5 (46 patients, p = 0.021) TBIs using the worst CT scan obtained. Conclusions The authors found a significant relationship between the dose of ICP, the worst Marshall CT score, and patient outcome, suggesting that the AUC method may be useful in refining and improving the treatment of ICP in patients with TBI.

Download Full-text

Experimental model of intracranial hypertension with continuous multiparametric monitoring in swine

Arquivos de Neuro-Psiquiatria ◽

10.1590/0004-282x20130126 ◽

2013 ◽

Vol 71 (10) ◽

pp. 802-806 ◽

Cited By ~ 4

Author(s):

Almir Ferreira de Andrade ◽

Matheus Schmidt Soares ◽

Gustavo Cartaxo Patriota ◽

Alessandro Rodrigo Belon ◽

Wellingson Silva Paiva ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Animal Model ◽

Brain Injury ◽

Intracranial Pressure ◽

Intracranial Hypertension ◽

Severe Traumatic Brain Injury ◽

Transcranial Doppler ◽

Porcine Model ◽

Cerebral Oximetry ◽

Suitable Animal Model

Objective Intracranial hypertension (IH) develops in approximately 50% of all patients with severe traumatic brain injury (TBI). Therefore, it is very important to identify a suitable animal model to study and understand the pathophysiology of refractory IH to develop effective treatments. Methods We describe a new experimental porcine model designed to simulate expansive brain hematoma causing IH. Under anesthesia, IH was simulated with a balloon insufflation. The IH variables were measured with intracranial pressure (ICP) parenchymal monitoring, epidural, cerebral oximetry, and transcranial Doppler (TCD). Results None of the animals died during the experiment. The ICP epidural showed a slower rise compared with parenchymal ICP. We found a correlation between ICP and cerebral oximetry. Conclusion The model described here seems useful to understand some of the pathophysiological characteristics of acute IH.

Download Full-text

Hypertonic saline infusion for treating intracranial hypertension after severe traumatic brain injury

Critical Care ◽

10.1186/s13054-018-1963-7 ◽

2018 ◽

Vol 22 (1) ◽

Cited By ~ 8

Author(s):

Halinder S. Mangat

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Hypertension ◽

Hypertonic Saline ◽

Severe Traumatic Brain Injury ◽

Saline Infusion ◽

Hypertonic Saline Infusion

Download Full-text

External Lumbar Drainage for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Systematic Review

10.21203/rs.3.rs-729880/v1 ◽

2021 ◽

Author(s):

Andrew Robert Stevens ◽

Wai Cheong Soon ◽

Yasir Arafat Chowdhury ◽

Emma Toman ◽

Antonio Belli ◽

...

Keyword(s):

Systematic Review ◽

Intracranial Hypertension ◽

Medical Therapy ◽

Data Extraction ◽

Lumbar Drainage ◽

Safety Reporting ◽

Sustained Effect ◽

Cerebral Herniation ◽

Adverse Patient Outcome ◽

External Lumbar Drainage

Abstract BackgroundExternal lumbar drainage remains a controversial therapy for medically refractory intracranial hypertension in patients with acute TBI. This systematic review sought to compile the available evidence for the efficacy and safety of the use of lumbar drains for ICP control. MethodsA systematic review of the literature was performed with the search and data extraction performed by two reviewers independently in duplicate.ResultsNine independent studies were identified enrolling 230 patients, 159 with TBI. Efficacy for ICP control was observed across all studies, with immediate and sustained effect, reducing medical therapy requirements. Lumbar drainage with medical therapy appears effective when used alone and as an adjunct to ventricular drainage. Safety reporting varied in quality. Cerebral herniation (with unclear relationship to lumbar drainage) was observed in 14/230 patients resulting in one incident of morbidity without adverse patient outcome. ConclusionsThe available data is generally poor in quality and volume, but supportive of efficacy of lumbar drainage for ICP control. Few reports of adverse outcome are suggestive of, but are insufficient to confirm, safety of use in the appropriate patient and clinical setting. Further large prospective observational studies are required to generate sufficient support of an acceptable safety profile.

Download Full-text

External lumbar drainage in progressive pediatric idiopathic intracranial hypertension

Journal of Neurosurgery Pediatrics ◽

10.3171/2021.2.peds2143 ◽

2021 ◽

pp. 1-7

Author(s):

Gad Dotan ◽

Natalie Hadar Cohen ◽

Hanya M. Qureshi ◽

Mika Shapira Rootman ◽

Yoram Nevo ◽

...

Keyword(s):

Intracranial Hypertension ◽

Idiopathic Intracranial Hypertension ◽

Vision Loss ◽

Symptom Relief ◽

Visual Outcome ◽

Fiber Layer ◽

Lumbar Drainage ◽

Lumbar Drain ◽

Rnfl Thickness ◽

External Lumbar Drainage

OBJECTIVE Pediatric idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure despite normal cerebrospinal fluid and neuroimaging findings. Initial management is typically medical; however, nearly 10% of children will eventually require surgery for persistent headache and/or vision loss. External lumbar drainage, which is a considerably safer treatment option, has not been adequately analyzed in children with medically refractory IIH. METHODS The authors conducted a single-institution retrospective analysis of children with medically refractory IIH who had undergone external lumbar drain (ELD) placement because of worsening papilledema, reflected as increased retinal nerve fiber layer (RNFL) thickness on optical coherence tomography (OCT) testing. The main outcome measures were effects of external lumbar drainage on papilledema resolution, symptoms, and vision. RESULTS The authors analyzed the medical records of 13 children with IIH (11 girls, mean age 15.0 ± 2.3 years) whose mean CSF opening pressure was 45.5 ± 6.8 cm H2O. In all children, the average global RNFL thickness in both eyes significantly increased at ELD placement (right eye 371.8 ± 150.2 μm, left eye 400.3 ± 96.9 μm) compared with presentation thickness (right eye 301.6 ± 110.40 μm, left eye 350.2 ± 107.7 μm) despite acetazolamide medical therapy (20–30 mg/kg/day), leading to ELD placement after 9.5 ± 6.9 days (range 3–29 days). After ELD insertion, there was headache resolution, gradual and continuous improvement in optic disc thickness, and preservation of good vision. CONCLUSIONS ELD placement in children with medically refractory IIH who demonstrated worsening papilledema with increased RNFL thickening on OCT testing typically results in symptom relief and disc edema resolution with good visual outcome, often preventing the need for additional definitive surgeries that carry greater failure and morbidity risks.

Download Full-text

Abstract 3942: Mild Controlled Hypothermia Induction is Safe and Feasible for the Treatment of Intracranial Hypertension in Patients with Aneurysmal Subarachnoid Hemorrhage.

Stroke ◽

10.1161/str.43.suppl_1.a3942 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Mohammad Ibrahim ◽

Mohammad Moussavi ◽

Elzbieta Wirkowski ◽

Adel Hanna ◽

Cecilia Carlowicz ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Subarachnoid Hemorrhage ◽

Brain Injury ◽

Intracranial Pressure ◽

Intracranial Hypertension ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Electrolyte Imbalance ◽

Surface Cooling ◽

Conventional Methods ◽

Rebound Increase

Introduction Hypothermia has been increasingly used for cerebral resuscitation in comatose survivors of cardiac arrest. A large number of studies have been undertaken in patients with traumatic brain injury to asses the efficacy of hypothermia for reduction of intracranial hypertension. Hypothermia has also been shown to reduce mortality and increase functional outcome if used for longer duration in patients with severe traumatic brain injury. Due to the risk of rebound cerebral edema during re-warming, medical complications and other factors, hypothermia has not been widely utilized for other neurologic catastrophes. To determine the safety and feasibility of hypothermia to treat intracranial hypertension in patients with aneurysmal subarachnoid hemorrhage (SAH), we performed this study. Methods Retrospective analysis was performed on 11 consecutive patients with poor grade (Hunt and Hess IV and V) SAH who had high intracranial pressure that was either non responsive or poorly responsive to conventional methods (head of bed at 30 degrees, sedation, CSF drainage and osmotherapy). All patients had intracranial pressure (ICP) monitoring via an external ventriculostomy drain (EVD) catheter. Hypothermia was induced non-invasively via surface cooling pads (Artic Sun Temperature Management System). Intravenous sedation and paralysis was used via intravenous infusion to control shivering. Hypothermia (target temperature of 32 to 34 degree C) was maintained until ICP normalized. Results Duration of hypothermia ranged from 79 hours to 190 hours. One patient required re-induction due to rebound increase in ICP during re-warming. Modified rankin scale was recorded at 3 month after the ictus. Eight patients (72%) survived with good recovery, one patient (9%) survived with severe disability and two patients (18%) died. The most common side effect was electrolyte imbalance seen in seven patients (63%), thrombocytopenia in three patients (27%), and pneumonia in four patients(36%). All complications were successfully treated and major consequences of complications (bleeding diathesis, septic shock syndrome and death) were not observed in any of these patients. Two patients had decompressive hemicraniectomy prior to hypothermia induction. Out of nine patients who did not undergo hemi-craniectomy, two died and seven did not require surgical intervention after induction of hypothermia. Conclusions Mild hypothermia induction for 72 hours or more for the treatment of intracranial hypertension refractory to other conventional methods in patients with SAH appears safe and feasible. Hypothermia may potentially be an earlier treatment option than currently recommended. This study serves as a template for future efficacy trials.

Download Full-text

Abnormalities on Perfusion CT and Intervention for Intracranial Hypertension in Severe Traumatic Brain Injury

Journal of Clinical Medicine ◽

10.3390/jcm9062000 ◽

2020 ◽

Vol 9 (6) ◽

pp. 2000

Author(s):

Shannon Cooper ◽

Cino Bendinelli ◽

Andrew Bivard ◽

Mark Parsons ◽

Zsolt J. Balogh

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Hypertension ◽

Severe Traumatic Brain Injury ◽

Injury Severity ◽

Intervention Group ◽

Small Sample ◽

Perfusion Computed Tomography ◽

Group I ◽

Second Tier

The role of invasive intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (STBI) remain unclear. Perfusion computed tomography (CTP) provides crucial information about the cerebral perfusion status in these patients. We hypothesised that CTP abnormalities would be associated with the severity of intracranial hypertension (ICH). To investigate this hypothesis, twenty-eight patients with STBI and ICP monitors were investigated with CTP within 48 h from admission. Treating teams were blind to these results. Patients were divided into five groups based on increasing intervention required to control ICH and were compared. Group I required no intervention above routine sedation, group II required a single first tier intervention, group III required multiple different first-tier interventions, group IV required second-tier medical therapy and group V required second-tier surgical therapy. Analysis of the results showed demographics and injury severity did not differ among groups. In group I no patients showed CTP abnormality, while patients in all other groups had abnormal CTP (p = 0.003). Severe ischaemia observed on CTP was associated with increasing intervention for ICH. This study, although limited by small sample size, suggests that CTP abnormalities are associated with the need to intervene for ICH. Larger scale assessment of our results is warranted to potentially avoid unnecessary invasive procedures in head injury patients.

Download Full-text