External Lumbar Drainage in Uncontrollable Intracranial Pressure in Adults with Severe Head Injury: A Report of 7 Cases

Abstract

SummaryThe retrospective results of external lumbar drainage in 7 adult patients with severe closed head injury and intracranial pressure (ICP) refractory to aggressive management strategies are presented. All patients had Glasgow Coma Scale (GCS) scores of 8 or less within 24 hours after admission and were treated by a staircase protocol including sedation, ventricular drainage, hyperventilation and mannitol. In three cases barbiturate drugs and an artificially induced hypothermia were used. Four patients required surgical evacuation of mass lesions. Three patients made a good functional recovery, 2 were severely disabled and 2 patients died. In none of the patients clinical signs of cerebral herniation occurred. We recommend additional external lumbar drainage in adults with severe head injury unresponsive to agressive ICP control with open basilar cisterns and absent focal mass lesions on computerized-tomography scan before drainage.

Clinical evaluation of the safety and efficacy of lumbar cerebrospinal fluid drainage for the treatment of refractory increased intracranial pressure

“…Cerebral herniation did not occur in any of the treated children in response to lumbar CSF drainage. 10,21,39 Considering that refractory intracranial hypertension remains a major problem in severely braininjured patients, we decided to reevaluate the efficacy and safety of lumbar CSF drainage by using improved and refined medical and technical standards.…”

“…According to the recommendations of Levy et al 21 and Willemse and Egeler-Peerdeman, 39 lumbar CSF drainage should be undertaken only in patients demonstrating open and well-defined basal cisterns on cranial CT to minimize the danger of cerebral herniation. These recommendations were based on retrospective data in 16 children with open basal cisterns before the application of lumbar CSF drainage.…”

“…Clinical studies in a small number of patients demonstrated a significant reduction of increased ICP in response to controlled lumbar CSF drainage without any signs of cerebral herniation. 1,10,19,21,39 In researching this issue, we have demonstrated a significant reduction in ICP by using controlled lumbar CSF drainage according to defined indications in 23 patients with either TBI or SAH. 28 Signs of herniation were observed temporarily in 2 patients in that series.…”

Applying circular posterior‐hinged craniotomy to malignant cerebral edemas

“…Temporal trepanation is the standard surgical procedure with its concomitant risks of severe brain damage because of herniation at the edges of the trepanation holes. Other favored methods to lower an increased ICP, as reported by Caruselli et al (1992) and Willemse and Egeler-Peerdeman (1998), are continuous or intermittent ventricular drainage with or without lumbar drainage. In cerebral edema, however, the ventricles are compressed by the increasing pressure and at levels higher than 25 mm Hg, penetration of the ventricles can be extremely difficult.…”

Emergent, Controlled Lumbar Drainage for Intracranial Pressure Monitoring During Orthotopic Liver Transplantation

“…The technique for placing LDs has nicely been described elsewhere [5] and reported in the neurocritical care literature for measuring ICP and drainage of CSF, with or without other ICP intracranial monitors. Controlled CSF drainage and ICP monitoring has been reported in patients with intracranial hypertension from various causes including acute hydrocephalus in subarachnoid hemorrhage [5] and refractory intracranial hypertension in traumatic brain injury [6,[8][9][10][11][12]. The concomitant use of EVD and LD in the setting of communicating hydrocephalus with ICH has also been described in the literature [13].…”