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Grille P, Biestro A, Rekate HL. Intracranial Hypertension with Patent Basal Cisterns: Controlled Lumbar Drainage as a Therapeutic Option. Selected Case Series. Neurocrit Care 2024; 40:1070-1082. [PMID: 37936017 DOI: 10.1007/s12028-023-01878-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 10/06/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND There are pathological conditions in which intracranial hypertension and patent basal cisterns in computed tomography coexist. These situations are not well recognized, which could lead to diagnostic errors and improper management. METHODS We present a retrospective case series of patients with traumatic brain injury, subarachnoid hemorrhage, and cryptococcal meningitis who were treated at our intensive care unit. Criteria for deciding placement of an external lumbar drain were (1) intracranial hypertension refractory to osmotherapy, hyperventilation, neuromuscular blockade, intravenous anesthesia, and, in some cases, decompressive craniectomy and (2) a computed tomography scan that showed open basal cisterns and no mass lesion. RESULTS Eleven patients were studied. Six of the eleven patients treated with controlled lumbar drainage are discussed as illustrative cases. All patients developed intracranial hypertension refractory to maximum medical treatment, including decompressive craniectomy in Four of the eleven cases. Controlled external lumbar drainage led to immediate and sustained control of elevated intracranial pressure in all patients, with good neurological outcomes. No brain herniation, intracranial bleeding, or meningitis was detected during this procedure. CONCLUSIONS Our study provides preliminary evidence that in selected patients who develop refractory intracranial hypertension with patent basal cisterns and no focal mass effect on computed tomography, controlled lumbar drainage appears to be a therapeutic option. In our study there were no deaths or complications. Prospective and larger studies are needed to confirm our results.
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Affiliation(s)
- Pedro Grille
- Intensive Care Unit, Hospital Maciel, Administración de los Servicios de Salud del Estado (ASSE), 25 de Mayo 174, 11000, Montevideo, Uruguay.
| | - Alberto Biestro
- Intensive Care Unit, Facultad de Medicina, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Harold L Rekate
- Department of Neurosurgery, Hofstra University, Hempstead, NY, USA
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Stevens AR, Gilbody H, Greig J, Usuah J, Alagbe B, Preece A, Soon WC, Chowdhury YA, Toman E, Chelvarajah R, Veenith T, Belli A, Davies DJ. Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Single Center Experience. World Neurosurg 2023; 176:e265-e272. [PMID: 37207724 DOI: 10.1016/j.wneu.2023.05.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Diversion of cerebrospinal fluid (CSF) is a common neurosurgical procedure for control of intracranial pressure (ICP) in the acute phase after traumatic brain injury (TBI), where medical management is insufficient. CSF can be drained via an external ventricular drain (EVD) or, in selected patients, via a lumbar (external lumbar drain [ELD]) drainage catheter. Considerable variability exists in neurosurgical practice on their use. METHODS A retrospective service evaluation was completed for patients receiving CSF diversion for ICP control after TBI, from April 2015 to August 2021. Patients were included whom fulfilled local criteria deeming them suitable for either ELD/EVD. Data were extracted from patient notes, including ICP values pre/postdrain insertion and safety data including infection or clinically/radiologically diagnosed tonsillar herniation. RESULTS Forty-one patients were retrospectively identified (ELD = 30 and EVD = 11). All patients had parenchymal ICP monitoring. Both modalities affected statistically significant decreases in ICP, with relative reductions at 1, 6, and 24 hour pre/postdrainage (at 24-hour ELD P < 0.0001, EVD P < 0.01). Similar rates of ICP control failure, blockage and leak occurred in both groups. A greater proportion of patients with EVD were treated for CSF infection than with ELD. One event of clinical tonsillar herniation is reported, which may have been in part attributable to ELD overdrainage, but which did not result in adverse outcome. CONCLUSIONS The data presented demonstrate that EVD and ELD can be successful in ICP control after TBI, with ELD limited to carefully selected patients with strict drainage protocols. The findings support prospective study to formally determine the relative risk-benefit profiles of CSF drainage modalities in TBI.
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Affiliation(s)
- Andrew R Stevens
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK; National Institute of Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre (SRMRC), University Hospitals Birmingham, Edgbaston, Birmingham, UK; Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK.
| | - Helen Gilbody
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Julian Greig
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - John Usuah
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Basit Alagbe
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Anne Preece
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Wai Cheong Soon
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Yasir A Chowdhury
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Emma Toman
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK; National Institute of Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre (SRMRC), University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Ramesh Chelvarajah
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK; College of Life and Environmental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Tonny Veenith
- Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK; Department of Anaesthesia and Critical Care, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Antonio Belli
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK; National Institute of Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre (SRMRC), University Hospitals Birmingham, Edgbaston, Birmingham, UK; Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK
| | - David J Davies
- Department of Neurosurgery, University Hospitals Birmingham, Edgbaston, Birmingham, UK; National Institute of Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre (SRMRC), University Hospitals Birmingham, Edgbaston, Birmingham, UK; Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK
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Wolf S, Mielke D, Barner C, Malinova V, Kerz T, Wostrack M, Czorlich P, Salih F, Engel DC, Ehlert A, Staykov D, Alturki AY, Sure U, Bardutzky J, Schroeder HWS, Schürer L, Beck J, Juratli TA, Fritsch M, Lemcke J, Pohrt A, Meyer B, Schwab S, Rohde V, Vajkoczy P. Effectiveness of Lumbar Cerebrospinal Fluid Drain Among Patients With Aneurysmal Subarachnoid Hemorrhage: A Randomized Clinical Trial. JAMA Neurol 2023; 80:833-842. [PMID: 37330974 PMCID: PMC10277935 DOI: 10.1001/jamaneurol.2023.1792] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/31/2023] [Indexed: 06/20/2023]
Abstract
Importance After aneurysmal subarachnoid hemorrhage, the use of lumbar drains has been suggested to decrease the incidence of delayed cerebral ischemia and improve long-term outcome. Objective To determine the effectiveness of early lumbar cerebrospinal fluid drainage added to standard of care in patients after aneurysmal subarachnoid hemorrhage. Design, Setting, and Participants The EARLYDRAIN trial was a pragmatic, multicenter, parallel-group, open-label randomized clinical trial with blinded end point evaluation conducted at 19 centers in Germany, Switzerland, and Canada. The first patient entered January 31, 2011, and the last on January 24, 2016, after 307 randomizations. Follow-up was completed July 2016. Query and retrieval of data on missing items in the case report forms was completed in September 2020. A total of 20 randomizations were invalid, the main reason being lack of informed consent. No participants meeting all inclusion and exclusion criteria were excluded from the intention-to-treat analysis. Exclusion of patients was only performed in per-protocol sensitivity analysis. A total of 287 adult patients with acute aneurysmal subarachnoid hemorrhage of all clinical grades were analyzable. Aneurysm treatment with clipping or coiling was performed within 48 hours. Intervention A total of 144 patients were randomized to receive an additional lumbar drain after aneurysm treatment and 143 patients to standard of care only. Early lumbar drainage with 5 mL per hour was started within 72 hours of the subarachnoid hemorrhage. Main Outcomes and Measures Primary outcome was the rate of unfavorable outcome, defined as modified Rankin Scale score of 3 to 6 (range, 0 to 6), obtained by masked assessors 6 months after hemorrhage. Results Of 287 included patients, 197 (68.6%) were female, and the median (IQR) age was 55 (48-63) years. Lumbar drainage started at a median (IQR) of day 2 (1-2) after aneurysmal subarachnoid hemorrhage. At 6 months, 47 patients (32.6%) in the lumbar drain group and 64 patients (44.8%) in the standard of care group had an unfavorable neurological outcome (risk ratio, 0.73; 95% CI, 0.52 to 0.98; absolute risk difference, -0.12; 95% CI, -0.23 to -0.01; P = .04). Patients treated with a lumbar drain had fewer secondary infarctions at discharge (41 patients [28.5%] vs 57 patients [39.9%]; risk ratio, 0.71; 95% CI, 0.49 to 0.99; absolute risk difference, -0.11; 95% CI, -0.22 to 0; P = .04). Conclusion and Relevance In this trial, prophylactic lumbar drainage after aneurysmal subarachnoid hemorrhage lessened the burden of secondary infarction and decreased the rate of unfavorable outcome at 6 months. These findings support the use of lumbar drains after aneurysmal subarachnoid hemorrhage. Trial Registration ClinicalTrials.gov Identifier: NCT01258257.
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Affiliation(s)
- Stefan Wolf
- Department of Neurosurgery, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Christoph Barner
- Department of Anesthesiology, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Vesna Malinova
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Thomas Kerz
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Technical University Munich, Munich, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, Hamburg University Medical Center, Hamburg, Germany
| | - Farid Salih
- Department of Neurology, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Doortje C. Engel
- Department of Neurosurgery, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Angelika Ehlert
- Department of Neurosurgery, Asklepios Hospital St Georg, Hamburg, Germany
| | - Dimitre Staykov
- Department of Neurology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, Hospital of the Brothers of St John, Eisenstadt, Austria
| | - Abdulrahman Y. Alturki
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
- Neurovascular Surgery Section, Adult Neurosurgery Department, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany
| | - Jürgen Bardutzky
- Department of Neurology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, University of Freiburg, Freiburg, Germany
| | | | - Ludwig Schürer
- Department of Neurosurgery, Klinikum Bogenhausen, Technical University Munich, Munich, Germany
| | - Jürgen Beck
- Department of Neurosurgery, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Inselspital, University of Bern, Switzerland
| | - Tareq A. Juratli
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Michael Fritsch
- Department of Neurosurgery, Dietrich Bonhoeffer Klinikum, Neubrandenburg, Germany
| | - Johannes Lemcke
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Anne Pohrt
- Department of Medical Biometrics, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University Munich, Munich, Germany
| | - Stefan Schwab
- Department of Neurology, University Medical Center Erlangen-Nuremberg, Erlangen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Zheng M, Tian Q, Wang X, Liu L, Deng X, Qu Y, Cai Q. Analysis of risk factors and treatment strategies for lumbar cistern blockage after craniocerebral surgery. Front Neurosci 2023; 17:1124395. [PMID: 36925741 PMCID: PMC10012248 DOI: 10.3389/fnins.2023.1124395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/18/2023] [Indexed: 03/08/2023] Open
Abstract
Objective Lumbar cistern blockage is a common complication of continuous lumbar cistern drainage. This paper analyzes the risk factors for lumbar cistern blockage drainage due to various causes and proposes a series of prevention and intervention measures to reduce blockage or improve recanalization after blockage. Methods The clinical data of 637 patients with various lesions who underwent lumbar cistern drainage in our hospital were retrospectively collected and analyzed. Perioperative clinical and imaging data were assessed. Variates were analyzed using univariate and multivariate logistic regression analyses. Results A total of 13.7% (87/637) of patients had lumbar cistern blockage. Multivariate analysis revealed that drainage time (≥7 days), CSF volume <200 (mL/d), CSF leakage, and abnormal CSF properties were predictors of lumbar cistern blockage. Reducing the probability of lumbar cistern blockage can be achieved by repeatedly flushing, increasing the drainage flow and shortening the drainage time. The recanalization rate after blockage was 67.8% (59/87). After the drainage tube was removed, no complications related to the drainage tube occurred during the 1-week follow-up. Conclusion Lumbar cistern blockage is the main reason for poor drainage. Prevention or early intervention can effectively reduce the probability of blockage and achieve the purpose of drainage of cerebrospinal fluid.
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Affiliation(s)
- Min Zheng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Qilong Tian
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Xuejiao Wang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Liqin Liu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Xiurui Deng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Qing Cai
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
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Zhang G, Wang D, Liu S. Commentary: External Lumbar Drainage Following Traumatic Intracranial Hypertension: A Systematic Review and Meta-Analysis. Neurosurgery 2022; 91:e111-e112. [PMID: 35861806 DOI: 10.1227/neu.0000000000002084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/18/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Guanzhong Zhang
- Department of Neurosurgery, Zaozhuang Municipal Hospital, Zaozhuang, China
| | - Dejun Wang
- Medical School, Zaozhuang Vocational College, Zaozhuang, China
| | - Siguan Liu
- Department of Emergency, Zaozhuang Municipal Hospital, Zaozhuang, China
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Chowdhury YA, Stevens AR, Soon WC, Toman E, Veenith T, Chelvarajah R, Belli A, Davies D. Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension: A United Kingdom and Ireland Survey on Practice Variation. Cureus 2022; 14:e25877. [PMID: 35836457 PMCID: PMC9275783 DOI: 10.7759/cureus.25877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Diversion of cerebrospinal fluid (CSF) in a traumatic brain injury (TBI) is an established means for achieving control of intracranial pressure (ICP), aimed at improving intracranial homeostasis. The literature and anecdotal reports suggest a variation in practice between neurosurgical centres internationally, with current guidelines advocating ventricular drainage over lumbar drainage. We sought to establish the current neurosurgical practice in the United Kingdom regarding the methods of ICP control in TBI. Methods A 20-point survey was distributed electronically to British and Irish neurosurgeons after ratification by the Society of British Neurological Surgeons. Questions were directed at the clinician’s opinion and experience of lumbar drain usage in patients with TBI: frequency, rationale, and experience of complications. Questions on lumbar drain usage in neurovascular patients were asked for practice comparison. Results Thirty-six responses from 21 neurosurgical centres were returned. Twenty-three per cent (23%) of responders reported using lumbar drains for refractory ICP in TBI patients: six units use lumbar drains and 15 do not. Three units showed partial usage, with mixed “yes/no” responses between consultants. Concerns of tonsillar herniation and familiarity with EVD were commonly given reasons against the usage of lumbar drains. Fifty-six per cent (56%) reported use in neurovascular patients. Conclusion This contemporary practice survey demonstrates mixed practice across the UK and within some centres. Responses and survey feedback demonstrate that the use of lumbar drains in TBI is a polarising topic. The variety of practice between and within neurosurgical units supports consideration of the prospective study of CSF diversion methods for control of refractory ICP in patients with TBI.
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Abstract
PURPOSE OF REVIEW The aim of this study was to provide an overview on advances in intracranial pressure (ICP) protocols for care, moving from traditional to more recent concepts. RECENT FINDINGS Deep understanding of mechanics and dynamics of fluids and solids have been introduced for intracranial physiology. The amplitude or the harmonics of the cerebral-spinal fluid and the cerebral blood waves shows more information about ICP than just a numeric threshold. When the ICP overcome the compensatory mechanisms that maintain the compliance within the skull, an intracranial compartment syndrome (ICCS) is defined. Autoregulation monitoring emerge as critical tool to recognize CPP management. Measurement of brain tissue oxygen will be a critical intervention for diagnosing an ICCS. Surgical procedures focused on increasing the physiological compliance and increasing the volume of the compartments of the skull. SUMMARY ICP management is a complex task, moving far than numeric thresholds for activation of interventions. The interactions of intracranial elements requires new interpretations moving beyond classical theories. Most of the traditional clinical studies supporting ICP management are not generating high class evidence. Recommendations for ICP management requires better designed clinical studies using new concepts to generate interventions according to the new era of personalized medicine.
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