Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension: A United Kingdom and Ireland Survey on Practice Variation

Abstract

Introduction Diversion of cerebrospinal fluid (CSF) in a traumatic brain injury (TBI) is an established means for achieving control of intracranial pressure (ICP), aimed at improving intracranial homeostasis. The literature and anecdotal reports suggest a variation in practice between neurosurgical centres internationally, with current guidelines advocating ventricular drainage over lumbar drainage. We sought to establish the current neurosurgical practice in the United Kingdom regarding the methods of ICP control in TBI. Methods A 20-point survey was distributed electronically to British and Irish neurosurgeons after ratification by the Society of British Neurological Surgeons. Questions were directed at the clinician’s opinion and experience of lumbar drain usage in patients with TBI: frequency, rationale, and experience of complications. Questions on lumbar drain usage in neurovascular patients were asked for practice comparison. Results Thirty-six responses from 21 neurosurgical centres were returned. Twenty-three per cent (23%) of responders reported using lumbar drains for refractory ICP in TBI patients: six units use lumbar drains and 15 do not. Three units showed partial usage, with mixed “yes/no” responses between consultants. Concerns of tonsillar herniation and familiarity with EVD were commonly given reasons against the usage of lumbar drains. Fifty-six per cent (56%) reported use in neurovascular patients. Conclusion This contemporary practice survey demonstrates mixed practice across the UK and within some centres. Responses and survey feedback demonstrate that the use of lumbar drains in TBI is a polarising topic. The variety of practice between and within neurosurgical units supports consideration of the prospective study of CSF diversion methods for control of refractory ICP in patients with TBI.

External Lumbar Drainage for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Systematic Review

“…Siting a ventriculostomy also permits measurement of intraventricular pressure by transduction of a closed drain, though in recent years, ICP monitoring has more commonly been achieved through intraparenchymal monitoring via a transcranial access device or "bolt" [5]. Practice varies from centre to centre [6], and between adults and paediatrics, with the usage of EVD monitoring and drainage being a more common practice in paediatric trauma centres [7] but less so in adults [8]. ELD originated in 1963 as a means for reducing cerebral tension intraoperatively [9] and has become an established method of CSF diversion in a variety of settings [10], including post-traumatic CSF leak [11,12], normal pressure hydrocephalus assessment [13], skull base surgery [14,15], and in thoracoabdominal aortic surgery to reduce spinal cord ischaemia [16].…”

“…Siting a ventriculostomy also permits measurement of intraventricular pressure by transduction of a closed drain, though in recent years, ICP monitoring has more commonly been achieved through intraparenchymal monitoring via a transcranial access device or “bolt” [ 5 ]. Practice varies from centre to centre [ 6 ], and between adults and paediatrics, with the usage of EVD monitoring and drainage being a more common practice in paediatric trauma centres [ 7 ] but less so in adults [ 8 ].…”