Improved Outcome from Traumatic Coma Using Ventricular CSF Drainage

Summary

The use of intracranial pressure (ICP) monitoring and the treatment of intracranial hypertension (IH) in severe head injury remain controversial. Hyperventilation, osmotic diuretics, barbiturates and steroids may contribute to secondary cerebral hypoperfusion in the traumatized brain. Ventricular cerebrospinal fluid (CSF) drainage, in contrast, is thought not to contribute to ischemia and may improve cerebral blood flow. This treatment, however, has never been evaluated as the sole therapeutic modality for IH.

Forty-nine patients with severe head injuries (Glasgow Coma Scale score ≤7) were entered into a prospective randomized study to assess the efficacy of ICP monitoring and CSF drainage for the treatment of IH. One group received ICP monitoring by ventriculostomy and CSF drainage for ICP greater than 15 mm Hg, while the control group received neither ICP monitoring nor specific treatment of IH. The mortality rate in the treated group was 12% compared to 53% in the control (p< 0.0001). Morever, 59% of patients returned to functional independence, based on their Glasgow Outcome Score (GOS), in the treated group compared to 2:% of the untreated patients (p< 0.0001). The percentages of vegetative and severely disabled patients did not differ significantly between groups. Outcomes for the treated group compared favorably with those of sevei al previous studies of severe head injury.

This study demonstrates that ICP monitoring and treatment of IH in posttraumatic comatose patients significantly reduces mortality and increases the percentage of patients living independently. A graded approach to the management of IH, with CSF drainage as the principal treatment, is advocated.