CSF Lumbar Drainage: A Safe Surgical Option in Refractory Intracranial Hypertension Associated with Acute Posttraumatic External Hydrocephalus

  • R. Manet
  • E. A. Schmidt
  • F. Vassal
  • D. Charier
  • L. Gergelé
Part of the Acta Neurochirurgica Supplement book series (NEUROCHIRURGICA, volume 122)


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.


Traumatic brain injury Head trauma Traumatic subarachnoid hemorrhage Intracranial pressure Intracranial hypertension Second-tier therapy External lumbar drainage External hydrocephalus Posttraumatic hydrocephalus 


  1. 1.
    Hirsch W, Beck R, Behrmann C, Schobess A, Spielmann RP (2000) Reliability of cranial CT versus intracerebral pressure measurement for the evaluation of generalised cerebral oedema in children. Pediatr Radiol 30(7):439–443CrossRefPubMedGoogle Scholar
  2. 2.
    Eide PK (2003) The relationship between intracranial pressure and size of cerebral ventricles assessed by computed tomography. Acta Neurochir 145(3):171–179; discussion 179CrossRefPubMedGoogle Scholar
  3. 3.
    Kouvarellis AJ, Rohlwink UK, Sood V, Van Breda D, Gowen MJ, Figaji AA (2011) The relationship between basal cisterns on CT and time-linked intracranial pressure in pediatric head injury. Childs Nerv Syst 27(7):1139–1144CrossRefPubMedGoogle Scholar
  4. 4.
    Cushing H (1909) Some aspects of the pathological physiology of intracranial tumors. Boston Med Surg J 141:71–80CrossRefGoogle Scholar
  5. 5.
    Hepburn H (1938) The risk of spinal puncture. Can Med Assoc J 39:449–450PubMedPubMedCentralGoogle Scholar
  6. 6.
    Levinson A, Greengard J, Lifvendahl R (1926) Cerebrospinal fluid in the new-born. Am J Dis Child 32(2):208–218Google Scholar
  7. 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
  8. 8.
    Abulhasan YB, Al-Jehani H, Valiquette M-A, McManus A, Dolan-Cake M, Ayoub O et al (2013) Lumbar drainage for the treatment of severe bacterial meningitis. Neurocrit Care 19(2):199–205CrossRefPubMedGoogle Scholar
  9. 9.
    Javouhey E, Richard N, Stamm D, Floret D (2008) Lumbar drainage as treatment of refractory intracranial hypertension in bacterial meningitis. Intensive Care Med 34(6):1166–1167CrossRefPubMedGoogle Scholar
  10. 10.
    Manosuthi W, Sungkanuparph S, Chottanapund S, Tansuphaswadikul S, Chimsuntorn S, Limpanadusadee P (2008) Temporary external lumbar drainage for reducing elevated intracranial pressure in HIV-infected patients with cryptococcal meningitis. Int J STD AIDS 19(4):268–271CrossRefPubMedGoogle Scholar
  11. 11.
    Münch EC, Bauhuf C, Horn P, Roth HR, Schmiedek P, Vajkoczy P (2001) Therapy of malignant intracranial hypertension by controlled lumbar cerebrospinal fluid drainage. Crit Care Med 29(5):976–981CrossRefPubMedGoogle Scholar
  12. 12.
    Murad A, Ghostine S, Colohan ART (2008) Controlled lumbar drainage in medically refractory increased intracranial pressure. A safe and effective treatment. Acta Neurochir Suppl 102:89–91CrossRefPubMedGoogle Scholar
  13. 13.
    Murad A, Ghostine S, Colohan ART (2011) Role of controlled lumbar CSF drainage for ICP control in aneurysmal SAH. Acta Neurochir Suppl 110(Pt 2):183–187PubMedGoogle Scholar
  14. 14.
    Murad A, Ghostine S, Colohan ART (2012) A case for further investigating the use of controlled lumbar cerebrospinal fluid drainage for the control of intracranial pressure. World Neurosurg 77(1):160–165CrossRefPubMedGoogle Scholar
  15. 15.
    Tuettenberg J, Czabanka M, Horn P, Woitzik J, Barth M, Thomé C et al (2009) Clinical evaluation of the safety and efficacy of lumbar cerebrospinal fluid drainage for the treatment of refractory increased intracranial pressure. J Neurosurg 110(6):1200–1208CrossRefPubMedGoogle Scholar
  16. 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. 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. 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
  19. 19.
    Sahuquillo J, Martínez-Ricarte F, Poca MA (2013) Decompressive craniectomy in traumatic brain injury after the DECRA trial. Where do we stand? Curr Opin Crit Care 19(2):101–106CrossRefPubMedGoogle Scholar
  20. 20.
    Walcott BP, Kahle KT, Simard JM (2013) The DECRA trial and decompressive craniectomy in diffuse traumatic brain injury: is decompression really ineffective? World Neurosurg 79(1):80–81CrossRefPubMedGoogle Scholar
  21. 21.
    Honeybul S, Ho KM, Lind CR (2013) What can be learned from the DECRA study. World Neurosurg 79(1):159–161CrossRefPubMedGoogle Scholar
  22. 22.
    Grady MS (2009) Lumbar drainage for increased intracranial pressure. J Neurosurg 110:1198–1199CrossRefPubMedGoogle Scholar
  23. 23.
    Abadal-Centellas JM, Llompart-Pou JA, Homar-Ramírez J, Pérez-Bárcena J, Rosselló-Ferrer A, Ibáñez-Juvé J (2007) Neurologic outcome of posttraumatic refractory intracranial hypertension treated with external lumbar drainage. J Trauma 62(2):282–286; discussion 286CrossRefPubMedGoogle Scholar
  24. 24.
    Llompart-Pou JA, Abadal JM, Pérez-Bárcena J, Molina M, Brell M, Ibáñez J (2011) Long-term follow-up of patients with post-traumatic refractory high intracranial pressure treated with lumbar drainage. Anaesth Intensive Care 39(1):79–83PubMedGoogle Scholar
  25. 25.
    Bruce DA, Alavi A, Bilaniuk L, Dolinskas C, Obrist W, Uzzel B (1981) Diffuse cerebral swelling following head injuries in children: the syndrome of malignant brain edema. J Neurosurg 54:170–178CrossRefPubMedGoogle Scholar
  26. 26.
    Stocchetti N, Colombo A, Ortolano F, Videtta W, Marchesi R, Longhi L (2007) Time course of intracranial hypertension after traumatic brain injury. J Neurotrauma 24(8):1339–1346CrossRefPubMedGoogle Scholar
  27. 27.
    Unterberg A, Kiening K, Schmiedek P, Lanksch W (1993) Long-term observations of intracranial pressure after severe head injury. The phenomenon of secondary rise of intracranial pressure. Neurosurgery 32(1):17–23; discussion 23–24CrossRefPubMedGoogle Scholar
  28. 28.
    Dandy WE, Blackfan KD (1914) Internal hydrocephalus: an experimental, clinical, and pathological study. Am J Dis Child 8:406CrossRefGoogle Scholar
  29. 29.
    Cardoso ER, Galbraith S (1985) Posttraumatic hydrocephalus – a retrospective review. Surg Neurol 23:261–264CrossRefPubMedGoogle Scholar
  30. 30.
    Groswasser Z, Cohen M, Reider-Groswasser I, Stern MJ (1988) Incidence, CT findings and rehabilitation outcome of patients with communicative hydrocephalus following severe head injury. Brain Inj 2(4):267–272CrossRefPubMedGoogle Scholar
  31. 31.
    Kammersgaard LP, Linnemann M, Tibæk M (2013) Hydrocephalus following severe traumatic brain injury in adults. Incidence, timing, and clinical predictors during rehabilitation. Neurorehabilitation 33(3):473–480PubMedGoogle Scholar
  32. 32.
    Katz RT, Brander V, Sahgal V (1989) Updates on the diagnosis and management of posttraumatic hydrocephalus. Am J Phys Med Rehabil 68(2):91–96CrossRefPubMedGoogle Scholar
  33. 33.
    Tian H-L, Xu T, Hu J, Cui Y, Chen H, Zhou L-F (2008) Risk factors related to hydrocephalus after traumatic subarachnoid hemorrhage. Surg Neurol 69(3):241–246CrossRefPubMedGoogle Scholar
  34. 34.
    Mazzini L, Campini R, Angelino E, Rognone F, Pastore I, Oliveri G (2003) Posttraumatic hydrocephalus: a clinical, neuroradiologic, and neuropsychologic assessment of long-term outcome. Arch Phys Med Rehabil 84:1637–1641CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  • R. Manet
    • 1
    • 2
  • E. A. Schmidt
    • 3
  • F. Vassal
    • 1
  • D. Charier
    • 4
  • L. Gergelé
    • 4
  1. 1.Department of NeurosurgeryUniversity Hospital of Saint-EtienneSaint-ÉtienneFrance
  2. 2.Service de neurochirurgieCHU de Saint-Etienne, Hôpital NordSaint-Priest-en-JarezFrance
  3. 3.Department of NeurosurgeryUniversity Hospital of ToulouseToulouseFrance
  4. 4.Department of Anesthesiology and Intensive CareUniversity Hospital of Saint EtienneSaint-ÉtienneFrance

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