Departments of1Pediatric Neurosurgery.
2Université Paris Cité, Paris; and.
J Neurosurg Pediatr. 2024 Sep 20;34(6):566-573. doi: 10.3171/2024.7.PEDS24156. Print 2024 Dec 1.
Guidelines for the management of pediatric severe traumatic brain injury (TBI) recommend external ventricular drainage for CSF drainage as a first-tier treatment in the intracranial pressure (ICP) pathway. However, ventriculostomy in children can sometimes be challenging because of the small size of the lateral ventricles. External lumbar drainage (ELD) may be a useful alternative; therefore, the authors analyzed the outcome of a cohort of pediatric patients who underwent ELD to manage intracranial hypertension (ICH).
This study retrospectively enrolled pediatric patients with ICH following severe TBI who underwent ELD. Radiological and clinical severity scores (Marshall classification, Rotterdam score, Injury Severity Score, and Pediatric Trauma Score) were noted. ICP and cerebral perfusion pressure (CPP) curves were analyzed 12 hours before and after the procedure. Any change in medical therapy was recorded, as well as the total volume and duration of drainage. Cerebellar tonsillar position according to the McRae line was noted before and after ELD. Glasgow Outcome Scale-Extended score at follow-up was also noted.
Thirty patients were included, with a mean age of 8 ± 4.4 years, and a median admission Glasgow Coma Scale score of 7 ± 4 (range 3-13). ELD was performed after a median delay of 1 day (range 0-7 days), mean drainage volume/day was 296 ± 129 ml, and median duration of drainage was 7 ± 5 (range 2-12) days. Forty-three percent of the patients underwent ELD as a part of the first-tier therapy. ICP decreased after ELD (mean difference 13.4 ± 6.2 mm Hg, p < 0.001), whereas CPP increased (mean difference 10.6 ± 6.4 mm Hg, p < 0.001). Fifty-three percent of the cohort did not need any further second-tier therapy after ELD. The study found 1 case of drain revision and 3 cases of cerebellar tonsil herniation.
These preliminary data suggest ELD is a valuable option to treat ICH in severely head-injured children, limiting the use of second-tier treatments. This pilot study should lay the foundation for a multicenter prospective trial.
儿科严重创伤性脑损伤（TBI）管理指南建议将脑室外引流作为颅内压（ICP）通路的一线治疗方法，用于 CSF 引流。然而，由于侧脑室较小，儿童脑室造口术有时可能具有挑战性。腰椎外引流（ELD）可能是一种有用的替代方法；因此，作者分析了一组接受 ELD 以治疗颅内高压（ICH）的儿科患者的结果。
本研究回顾性纳入了因严重 TBI 后发生 ICH 而接受 ELD 的儿科患者。记录了放射学和临床严重程度评分（Marshall 分类、鹿特丹评分、损伤严重程度评分和儿科创伤评分）。分析了 ELD 前后 12 小时的 ICP 和脑灌注压（CPP）曲线。记录了任何药物治疗的变化，以及引流的总容量和持续时间。ELD 前后，根据 McRae 线记录小脑扁桃体的位置。还记录了随访时的格拉斯哥预后量表扩展评分。
共纳入 30 例患者，平均年龄 8 ± 4.4 岁，入院时格拉斯哥昏迷评分中位数为 7 ± 4（范围 3-13）。ELD 在中位数 1 天后（范围 0-7 天）进行，平均日引流量为 296 ± 129 ml，中位引流时间为 7 ± 5（范围 2-12）天。43%的患者将 ELD 作为一线治疗的一部分。ELD 后 ICP 降低（平均差值 13.4 ± 6.2 mmHg，p < 0.001），CPP 升高（平均差值 10.6 ± 6.4 mmHg，p < 0.001）。ELD 后 53%的患者无需任何进一步的二线治疗。研究发现 1 例引流管修正和 3 例小脑扁桃体疝。
这些初步数据表明，ELD 是治疗严重颅脑损伤儿童 ICH 的一种有价值的选择，可以限制二线治疗的使用。这项初步研究应为多中心前瞻性试验奠定基础。
