CSF Lumbar Drainage: A Safe Surgical Option in Refractory Intracranial Hypertension Associated with Acute Posttraumatic External Hydrocephalus
Introduction: External lumbar drainage (ELD) of cerebrospinal fluid (CSF) in posttraumatic refractory intracranial hypertension (ICHT) is controversial. We report our experience of ELD in ICHT associated with acute disturbance of CSF flow within subarachnoid spaces (SASs). Materials and Methods: Four adult patients admitted to the neurointensive care unit for severe TBI who presented with secondary ICHT are retrospectively reported. When refractory to second-tier therapy, if external ventricular drainage were not possible or failed, and in the absence of an indication for craniotomy to treat a mass lesion or decompressive craniectomy, we assessed the evolution of CSF volume within cranial SAS and checked the presence of basal cisterns and the absence of tonsillar herniation to evaluate interest in and the safety of ELD. Results: As second-tier therapy failed to lower intracranial pressure (ICP; mean ICP 37 ± 5 mmHg), and computed tomography (CT) showed abnormally enlarged cranial SAS following traumatic subarachnoid hemorrhage, patients received ELD. ICP decreased, with immediate and long-term effect (mean ICP 5 mmHg ± 2 mmHg). There were no complications to report. Discussion: Acute traumatic external hydrocephalus may explain some of the specific situations of secondary increased ICP, with a “normal” CT scan, that is refractory to medical treatment. In these situations, lumbar drainage should be considered to be a safe, minimally invasive, and effective surgical option.
KeywordsTraumatic brain injury Head trauma Traumatic subarachnoid hemorrhage Intracranial pressure Intracranial hypertension Second-tier therapy External lumbar drainage External hydrocephalus Posttraumatic hydrocephalus
- 6.Levinson A, Greengard J, Lifvendahl R (1926) Cerebrospinal fluid in the new-born. Am J Dis Child 32(2):208–218Google Scholar
- 7.Baldwin HZ, Rekate HL (1991–1992). Preliminary experience with controlled external lumbar drainage in diffuse pediatric head injury. Pediatr Neurosurg 17(3):115–120Google Scholar
- 16.Brain Trauma Foundation and American Association of Neurological Surgeons. Guidelines for the management of severe traumatic brain injury, 3rd edn. [BTF Web site]. Available at: https://www.braintrauma.org/pdf/protected/Guidelines_Management_2007w_bookmarks.pdf. Accessed 6 February 2014
- 17.Taylor A, Butt W, Rosenfeld J, Shann F, Ditchfield M, Lewis E, Klug G, Wallace D, Henning R, Tibballs J (2001) A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension. Childs Nerv Syst 17(3):154–162CrossRefPubMedGoogle Scholar
- 18.Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D'Urso P, Kossmann T, Ponsford J, Seppelt I, Reilly P, Wolfe R, DECRA Trial Investigators, Australian and New Zealand Intensive Care Society Clinical Trials Group (2011) Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 364(16):1493–1502CrossRefPubMedGoogle Scholar