Comparative Effectiveness of Diversion of Cerebrospinal Fluid for Children With Severe Traumatic Brain Injury

Abstract

Key Points Question Is cerebrospinal fluid (CSF) diversion associated with improved outcomes or intracranial pressure in children with severe traumatic brain injury (TBI)? Findings In this comparative effectiveness study of 1000 children with severe TBI, there was no association between CSF diversion and Glasgow Outcome Score–Extended for Pediatrics at 6 months after injury in propensity-matched participants. However, CSF diversion was associated with decreased intracranial pressure in the propensity-matched participants. Meaning These findings suggest that the current evidenced-based guidelines that support CSF diversion as a first-line therapy for TBI in children should be reconsidered.

The Role of Ventriculostomy in Severe Traumatic Brain Injury in Children—to Drain or Not to Drain?

“…They found that there was no significant difference in GOS-EP between groups at 6 months but that the patients who received EVD had lower ICP during their acute care. 1 Bell et al 1 conclude that use of ventriculostomy drainage as a front-line treatment should be reconsidered. This is the largest study, to our knowledge, to look closely and specifically at the efficacy of EVD in children with severe TBI, from a multisite, international network that has shown admirable success in collecting large amounts of data in children with TBI who undergo ICP monitoring.…”

“…Choice of parenchymal monitor vs ventriculostomy was not randomized in the study by Bell et al, 1 and the authors acknowledge at the outset that significant variability exists with respect to practice. The inclusion of centers spanning 8 countries and 5 continents ensures heterogeneity with respect to patient population, local resources, and individual practitioner approach.…”

“…Despite their epidemiologic and functional importance, there is a dearth of clear data to determine the most effective strategies for managing severe traumatic brain injury (TBI) in children. The study by Bell et al attempts to fill some of the data gaps with an observational comparative effectiveness study to assess the associations of use of external ventricular drainage (EVD) vs parenchymal intracranial pressure (ICP) monitors with Glasgow Outcome Score–Extended Pediatric version (GOS-EP) score at 6 months postinjury, and with ICP during the acute care stage. From an overall pool of 1000 children, Bell et al used propensity matching to compare 98 pairs of children with and without ventriculostomies in a nonrandomized, intention-to-treat design.…”

Errors in Abstract and Main Text Results

“…In the Original Investigation titled “Comparative Effectiveness of Diversion of Cerebrospinal Fluid for Children With Severe Traumatic Brain Injury,” published July 8, 2022, there were errors in the Results sections of the Abstract and the main text. In the Abstract, the median (IQR) Glasgow Outcome Score–Extended for Pediatrics should have been 0 (−2 to 3) ( P = .40) and the mean (SD) difference in intracranial pressure should have been 3.98 (0.14) mm HG.…”

“…In the main text, the P value for the propensity-matched analysis of odds ratio of death at 28 days should have been P = .62. This article has been corrected …”