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

Abstract

Considerable variation exists in the clinical practice of cerebrospinal fluid diversion for medically refractory intracranial hypertension in patients with acute traumatic brain injury (TBI), which is achievable via lumbar or ventricular drainage. This systematic review sought to compile the available evidence for the efficacy and safety of the use of lumbar drains for intracranial pressure (ICP) control.A systematic review of the literature was performed with the search and data extraction performed by two reviewers independently in duplicate. Nine independent studies were identified, enrolling 230 patients, 159 with TBI. Efficacy for ICP control was observed across all studies, with immediate and sustained effect, reducing medical therapy requirements. Lumbar drainage with medical therapy appears effective when used alone and as an adjunct to ventricular drainage. Safety reporting varied in quality. Clinical or radiological incidents of cerebral herniation (with an unclear relationship to lumbar drainage) were observed in 14/230 patients resulting in one incident of morbidity without adverse patient outcome.The available data is generally poor in quality and volume, but supportive of the efficacy of lumbar drainage for ICP control. Few reports of adverse outcomes are suggestive of, but are insufficient to confirm, the safety of use in the appropriate patient and clinical setting. Further large prospective observational studies are required to generate sufficient support of an acceptable safety profile.

Increased Intracranial Pressure in Pediatric Myelin Oligodendrocyte Glycoprotein Antibody–Associated Disease

“… 27 The use of lumbar drainage to treat ICP can be effective, but it usually requires a functional EVD, is case-specific, and is contraindicated if imaging shows an intracranial mass lesion, herniation, or complete cisternal effacement. 28 Ultimately, if ICP is refractory to medical management or if lateralizing signs due to brainstem compression or mass effect are present, decompressive craniectomy is an option; there have been case reports describing good outcomes for ADEM. 29 - 37 None of the previously published cases, however, were tested for or reported to be positive for anti-MOG-IgG.…”

The Effect of Subcutaneous Tunneling on External Lumbar Drainage Complications

“…Continuous lumbar drainage systems are employed in the treatment of cerebrospinal fluid leaks [7]. These techniques also diagnose patients with hydrocephalus at standard pressure and benign intracranial hypertension [8,9]. After inserting a needle into the lumbar area, typically at the L3-4 or L4-5 level, a catheter is advanced into the subarachnoid space.…”

Neurotrauma—From Injury to Repair: Clinical Perspectives, Cellular Mechanisms and Promoting Regeneration of the Injured Brain and Spinal Cord

“…Whilst this paradigm has been the subject of some historical debate, ICP remains at the centre of clinical guidelines [ 26 ]. Therapeutic interventions to reduce ICP use are as follows: (1) patient head positioning, (2) therapeutic hypocapnia, (3) sedation and paralysis, (4) osmotic therapy, (5) diversion of cerebrospinal fluid (CSF), (6) barbiturate-induced coma and (7) decompressive craniectomy [ 26 , 27 , 28 , 29 , 30 , 31 ]…”

“…(1) patient head positioning, (2) therapeutic hypocapnia, (3) sedation and paralysis, (4) osmotic therapy, (5) diversion of cerebrospinal fluid (CSF), (6) barbiturate-induced coma and (7) decompressive craniectomy [26][27][28][29][30][31] Since the establishment of ICP monitoring as a standard of care in TBI, additional monitoring capabilities have been integrated with an ICP probe into cranial access to increase the scope of the "bolt" paradigm (Figure 1). This has seen the greatest success with the introduction of partial pressure of brain tissue oxygen (PbtO 2 ) monitoring and, to a lesser extent, with microdialysis probes [32][33][34].…”