CSF withdrawal for the treatment of intracranial hypertension in acute head injuries

Analysis of Evolution of Hydrocephalus in Posterior Fossa Tumors and Validation Study of the Modified Canadian Preoperative Prediction Rule for Hydrocephalus in Children and Frankfurt Grading System for Prediction of Cerebrospinal Fluid Diversion in Adults with Posterior Fossa Tumors

OBJECTIVE

We sought to analyze the evolution of hydrocephalus and enumerate its predictive factors in posterior fossa tumors in children and adults. We also validated the modified Canadian Preoperative Prediction Rule for Hydrocephalus (mCPPRH) and Frankfurt grading systems as tools to predict cerebrospinal fluid (CSF) diversion in children and adults, respectively.

METHODS

A retrospective review of patients with posterior fossa tumors operated between 2012 and 2019 was performed. Clinical, radiologic, and operative data were obtained. Validation was performed for both scores via receiver operating characteristic (ROC) curves and evaluation of the area under the curve (AUC).

RESULTS

We included 116 children and 343 adults in the study. Of the adults, 141 patients had intraaxial tumors and 172 had extraaxial tumors. The insertion of external ventricular drain (EVD), its duration, papilledema was noted to have significant influence on the need for permanent CSF diversion (P < 0.05) in children. The ROC for mCPPRH score was 0.659 (0.501-0.816), Age- 0.496 (0.334-0.658) and Evans index- 0.788 (0.654-0.922). In adults- Intraaxial tumours Age, Frankfurt score, duration of EVD, Diagnosis, Extent of resection and periventricular capping significant predictors and ROC age AUC 0.300 (0.193-0.407), Evans index 0.939 (0.888-0.990), and Frankfurt score 0.908 (0.853-0.964) (P < 0.05), whereas in extraaxial tumors Frankfurt grading, sex, duration of EVD, presence of perilesional edema and extent of resection (P < 0.05) ROC age AUC 0.439 (0.344-0.534), Evans index 0.941 (0.906-0.977), and Frankfurt score 0.847 (0.782-0.912).

CONCLUSIONS

This is the first external validation study for the 2 predictive systems in use. mCPPRH demonstrated poor predictive accuracy, and Frankfurt grading system demonstrated good accuracy. EVD insertion and its duration was significantly predictive of the need for permanent CSF diversion.

A novel grading system for the prediction of the need for cerebrospinal fluid drainage following posterior fossa tumor surgery

OBJECTIVE

Prophylactic placement of an external ventricular drain (EVD) is often performed prior to resection of a posterior fossa tumor (PFT); however, there is no general consensus regarding the indications. The purpose of this study was to establish a novel grading system for the prediction of required CSF drainage due to symptomatic elevated intracranial pressure (ICP) after resection of a PFT to identify patients who require an EVD.

METHODS

The authors performed a retrospective analysis of data from a prospective database. All patients who had undergone resection of a PFT between 2012 and 2017 at the University Hospital, Goethe University Frankfurt, were identified and data from their cases were analyzed. PFTs were categorized as intraparenchymal (iPFT) or extraparenchymal (ePFT). Prior to resection, patients underwent EVD placement, prophylactic burr hole placement, or neither. The authors assessed the amount of CSF drainage (if applicable), rate of EVD placement at a later time point, and complication rate and screened for factors associated with CSF drainage. By applying those factors, they established a grading system to predict the necessity of CSF drainage for elevated ICP.

RESULTS

A total of 197 patients met the inclusion criteria. Of these 197, 70.6% received an EVD, 15.7% underwent prophylactic burr hole placement, and 29.4% required temporary CSF drainage. In the prophylactic burr hole group, 1 of 32 patients (3.1%) required EVD placement at a later time. Independent predictors for postoperative need for CSF drainage due to symptomatic intracranial hypertension in patients with iPFTs were preoperative hydrocephalus (OR 2.9) and periventricular CSF capping (OR 2.9), whereas semi-sitting surgical position (OR 0.2) and total resection (OR 0.3) were protective factors. For patients with ePFTs, petroclival/midline tumor location (OR 12.2/OR 5.7), perilesional edema (OR 10.0), and preoperative hydrocephalus (OR 4.0) were independent predictors of need for CSF drainage. According to our grading system, CSF drainage after resection of iPFT or ePFT, respectively, was required in 16.7% and 5.1% of patients with a score of 0, in 21.1% and 12.5% of patients with a score of 1, in 47.1% and 26.3% of patients with a score of 2, and in 100% and 76.5% of patients with a score ≥ 3 (p < 0.0001). The rate of relevant EVD complications was 4.3%, and 10.1% of patients were shunt-dependent at 3-month follow-up.

CONCLUSIONS

This novel grading system for the prediction of need for CSF drainage following resection of PFT might be of help in deciding in favor of or against prophylactic EVD placement.

Management of Elevated Intracranial Pressure

Elevated intracranial pressure (ICP) is a primary cause of morbidity and mortality for many neurologic disorders. The relationship between ICP and brain volume is influenced by autoregulatory processes that can become dysfunctional. As a result, neurologic damage can occur by systemic and intracranial insults such as ischemia and excitatory amino acids. Therefore, survival is dependent on optimizing ICP and cerebral perfusion pressure. Treatment of intracranial hypertension requires intensive monitoring and aggressive therapy. Intracranial pressure monitoring techniques such as intraventricular catheters are useful for determining ICP elevations before changes in vital signs and neurologic status. Therapeutic modalities, generally aimed at reducing cerebral blood volume, brain tissue, and cerebrospinal fluid (CSF) volume, include nonpharmacologic (CSF removal, controlled hyperventilation, and elevating the patient’s head) and pharmacologic management. Mannitol and sedation are first-line agents used to lower ICP. Barbiturate coma may be beneficial in patients with elevated ICP refractory to conventional treatment. The use of prophylactic antiseizure therapy and optimal nutrition prevents significant complication. Currently, investigations are directed at discovering useful neuroprotective agents that prevent secondary neurologic injury.

Automated intracranial pressure-controlled cerebrospinal fluid external drainage with LiquoGuard

INTRODUCTION

LiquoGuard is a new device for intracranial pressure (ICP)-controlled drainage of cerebrospinal fluid (CSF). This present study evaluates the accuracy of ICP measurement via the LiquoGuard device in comparison with Spiegelberg. Thus, we compared data ascertained from simultaneous measurement of ICP using tip-transducer and tip-sensor devices.

MATERIAL AND METHODS

A total of 1,764 monitoring hours in 15 patients (range, 52-219 h) were analysed. All patients received an intraventricular Spiegelberg III probe with the drainage catheter connected to the LiquoGuard system. ICP reading of both devices was performed on an hourly basis. Statistical analysis was done by applying Pearson correlation and Wilcoxon-matched pair test (p < 0.05).

RESULTS

Mean ICP values were 11 ± 5 mmHg (Spiegelberg) and 10 ± 7 mmHg (LiquoGuard); the values measured with both devices correlated well (p = 0.001; Pearson correlation =0.349; n = 1,764). In two of the 15 patients with slit ventricles, episodes of significant differences in measured values could be observed. Both patients suffering from slit ventricles failed to produce reliable measurement with the external transducer of the LiquoGuard.

CONCLUSIONS

LiquoGuard is a valuable new device for ICP-controlled CSF drainage. However, LiquoGuard tends to provide misleading results in slit ventricles. Thus, before these drawbacks are further analysed, the authors recommend additional ICP measurement with internal tip-sensor devices to avoid dangerous erroneous interpretation of ICP data.

Continuous ventricular cerebrospinal fluid drainage with intracranial pressure monitoring for management of posttraumatic diffuse brain swelling

BACKGROUND: Ventricular drainage has played an important role in the management of traumatic brain-injured patients. The aim of the present study was describe outcomes in a series of 57 patients with diffuse brain swelling underwent to intracranial pressure (ICP) monitoring. METHOD: Fifty-eight patients with diffuse posttraumatic brain swelling, were evaluated prospectively. The Glasgow Coma Scale (GCS) scores of patients varied from 4 to 12. Patients groups divided according to GCS and age. Patient neurological assessment was classified as favorable, unfavorable, and death. RESULTS: Mechanisms of injury were vehicle accidents in 72.4% and falls in 15.6%. 54% of patients had GCS scores between 6 and 8. There were no statistical differences, regarding outcome, between groups separated by age. In the adults group (n=47), 44.7% evolved favorably. CONCLUSION: Our results indicate a poor prognosis in patients with brain swelling. We believe that continuous ventricular CSF drainage with ICP monitoring is a simple method as an adjunct in the management of these patients.

The effect of cerebrospinal fluid drainage on cerebral perfusion in traumatic brain injured adults

Cerebrospinal fluid drainage is a first line treatment used to manage severely elevated intracranial pressure (> or = 20 mm Hg) and improve outcomes in patients with acute head injury. There is no consensus regarding the optimal method of cerebrospinal fluid removal. The purpose of this investigation was to determine whether cerebrospinal fluid drainage decreases intracranial pressure and improves cerebral perfusion and to identify factors that impact treatment effectiveness. This study involved 31 severely head injured patients. Intracranial pressure and other indices of cerebral perfusion (cerebral perfusion pressure, cerebral blood flow velocity, and regional cerebral oximetry) were measured before, during, and after cerebrospinal fluid drainage. Arterial and jugular venous oxygen content was measured before and after cerebrospinal fluid drainage. Patients underwent three randomly ordered cerebrospinal fluid drainage protocols that varied in the volume of cerebrospinal fluid removed (1 mL, 2 mL, and 3 mL) for a total of 6 mL of cerebrospinal fluid removed. There was a significant change in the intracranial pressure from a mean at baseline of 26.1 mm Hg (SD = 4.4) to 22.1 mm Hg immediately after drainage. One third of patients experienced a decrease in the intracranial pressure below 20 mm Hg; in two patients the intracranial pressure dropped less than 1 mm Hg. The following factors predicted 61.5% of the variance in the responsiveness of intracranial pressure to drainage: vecuronium hypothermia, baseline cerebral perfusion pressure and acuity of illness. Cerebrospinal fluid drainage provides a transient decrease in intracranial pressure without a measurable improvement in other indices of cerebral perfusion.

Resolution of brain edema in severe brain injury at controlled high and low intracranial pressures

A series of 87 patients with severe brain injury were studied. Intracranial pressure (ICP) monitoring and external ventricular drainage were used to control ICP at high and low levels. Clearance of ytterbium-169-labeled diethylenetriaminepentaacetic acid (169Yb-DTPA), Evans blue dye, and ventricular cerebrospinal fluid protein was measured at the two ICP levels over consecutive periods of 4 hours to confirm clearance of brain edema. The results support the hypothesis that brain edema is in part absorbed in the cerebrospinal fluid via transventricular flow.

Pharmacologic management of acute intracranial hypertension

Acute intracranial hypertension requires aggressive treatment with physiologic and pharmacologic measures guided by intracranial pressure monitoring devices. Therapy involves the use of diuretics, corticosteroids, and barbiturates in combination with hyperventilation, ventricular drainage, and general supportive measures. This review focuses on the pathophysiology of increased intracranial pressure and the pharmacologic agents used in its management.

Mass lesions of the frontal lobes in acute head injuries. A comparison with temporal lesions

Contusions and lacerations of the frontal lobes are very frequent; 43.4% in the whole series of traumatic brain mass lesions. Clinical ICP, CT scan data and neuropathological findings in patients with such lesions are analysed and correlated. Moreover, the clinical features and the outcome of frontal masses undergoing surgery are also compared with similar lesions located in the temporal lobes. Frontal lesions cannot be differentiated on purely clinical grounds and the factors governing the outcome in both lactations are the same. On the whole, surgical indications nowadays seem to be rather rare; only lesions behaving truly as expanding lesions with obvious intracranial hypertension benefiting from surgery. Brain contusion-laceration syndromes in general can no longer be considered separate entities. Neither should they be included in the miscellaneous group of "traumatic intracranial mass lesions", since the pathophysiological significance of purely extracerebral effusions is entirely different. Traumatic contusions and lacerations and/or intracerebral haematomas, whether frontal or located elsewhere, should instead, be considered in the context of head injuries of a different degree of gravity, as having collateral features which, on occasion, may call for surgical management.