Department of Anaesthesiology and Intensive Care, Dr. Manninger Jenő Traumatology Centre, Fiumei út 17., Budapest 1081, Hungary.
Department of Radiology, Szent György University Hospital, Székesfehérvár, Hungary.
Injury. 2024 Sep;55 Suppl 3:111337. doi: 10.1016/j.injury.2024.111337. Epub 2024 Sep 17.
Early treatment of elevated intracranial pressure (ICP) is a cornerstone of the therapy in severe traumatic brain injury (TBI) patients. Treatment of refractory high ICP however, remain challenging as only limited and risky third-tier therapeutic interventions are available. Controlled lumbar cerebrospinal fluid (CSF) drainage has been known as an efficient method of ICP reduction after TBI for decades, but it is not recommended in international guidelines because of low evidence background and safety issues. Our centre has a long-standing experience using this intervention for more than 15 years. Here we present our data about the safety and efficacy of controlled lumbar drainage to avoid further second- and third tier ICP lowering therapies and beneficially influence functional outcome.
Observational (retrospective and prospective) analysis was performed using demographic, clinical and outcome data of severe TBI patients admitted to our centre. Analysis was retrospective between 2008 and 2013 and prospective from 2014 to 2019. Only severe TBI patients (GCS<9) with ICP monitoring were enrolled. Lumbar drainage (LD) was used as a second-tier therapy to control intracranial hypertension in salvageable patients with normal haemostasis and discernible basal cisterns on pre-interventional CT scan.
Data of 45 patients were analysed. Patients were young, comatose and with severe injuries (median age: 29, GMS: 4, ISS: 25). Lumbar drain was inserted mainly on the first week and maintained for further 5 days. Episodes of intracranial hypertension (ICP>20 Hgmm) within one day (10 vs 2) were reduced. The need of additional second- and third-line therapies (deep sedation, hyperventilation, barbiturate administration, decompressive craniectomy) also significantly decreased (60 vs 25 interventions, p<0.001). The in-hospital mortality and 6-month functional outcome were more favourable than the whole TBI population and as predicted by prognostic calculations (mortality: 16% vs. 48 %; GOSE 1-4: 49% vs. 65% vs CRASH: 87% vs. IMPACT: 51 %) in this period.
Our results support the view that controlled lumbar drainage is a highly efficient method to manage intracranial hypertension and significantly decreases the need of further harmful ICP lowering therapies without altering functional outcome of severe TBI patients.
早期治疗颅内压升高（ICP）是严重创伤性脑损伤（TBI）患者治疗的基石。然而，治疗难治性高 ICP 仍然具有挑战性，因为只有有限的、风险较大的三级治疗干预措施可用。控制腰椎脑脊液（CSF）引流作为 TBI 后降低 ICP 的有效方法已有数十年的历史，但由于证据基础薄弱和安全性问题，国际指南不推荐使用该方法。我们中心使用这种干预措施已有 15 年多的历史。在这里，我们介绍了控制腰椎引流的安全性和有效性数据，以避免进一步的第二级和第三级 ICP 降低治疗，并对功能结果产生有益影响。
使用我们中心收治的严重 TBI 患者的人口统计学、临床和结局数据进行观察性（回顾性和前瞻性）分析。分析在 2008 年至 2013 年期间为回顾性，在 2014 年至 2019 年期间为前瞻性。仅纳入接受 ICP 监测的严重 TBI 患者（GCS<9）。腰椎引流（LD）被用作二线治疗，以控制有正常止血功能和预干预 CT 扫描可识别的基底池的可挽救患者的颅内高压。
共分析了 45 例患者的数据。患者年轻、昏迷且受伤严重（中位年龄：29 岁，GMS：4，ISS：25）。腰椎引流主要在第一周插入，并维持 5 天。一天内（10 次 vs 2 次）颅内压升高（ICP>20 Hgmm）发作减少。还显著减少了额外的第二级和第三级治疗（深度镇静、过度通气、巴比妥类药物给药、减压性颅骨切除术）的需要（60 次干预 vs 25 次干预，p<0.001）。住院死亡率和 6 个月功能结局均优于整个 TBI 人群，并且与该时期的预后计算（死亡率：16% vs. 48%；GOSE 1-4：49% vs. 65% vs. CRASH：87% vs. IMPACT：51%）相符。
我们的结果支持这样一种观点，即控制腰椎引流是一种管理颅内高压的高效方法，可显著减少进一步有害的 ICP 降低治疗的需求，而不会改变严重 TBI 患者的功能结局。
