gms | German Medical Science

Objective: Controlled continuous lumbar drainage of cerebrospinal fluid (CSF) has been used in neurosurgery for a variety of reasons. The use of lumbar drainage in uncontrollable intracranial hypertension was considered to be contraindicated because of the possibility of inducing transtentorial or tonsillar herniation. The objective of this study was to investigate the effect of continuous external lumbar CSF drainage on ICP and to evaluate the potential side effects of this new therapeutic modality in adult patients suffering sustained therapy-resistant intracranial hypertension.

Methods: Prospective evaluation of 96 patients (age 43.67±15.73 yrs) suffering from severe traumatic brain injury (TBI) (n=43) or vasospasm after subarachnoid haemorrhage (SAH) (n=53) was carried out. Patients were considered for external CSF drainage if they suffered persistent intracranial hypertension and failed to respond to high intensity treatment. External lumbar drainage was not performed in patients with tight basal cisterns. After institution of the lumbar drain (silicon-catheter, Tuohy type needle) aspiration of 5 to 20 ml CSF was performed and continuous CSF-drainage was maintained. ICP and CPP before and after bolus-aspiration were documented. Complications in placement of the lumbar catheter and in continuous drainage were documented. CCT scans taken before and after institution of the lumbar drainage were analyzed to determine the visibility of the lateral ventricles and the mesencephalic cisterns. The neurological outcome of the patients was scored according to the Glasgow Outcome Scale (GOS) 6 months after injury.

Results: All patients showed a significantly abrupt and lasting decrease of ICP from 32.7±11 to 13.4±6 mmHg and an increase of CPP from 70.6±18 to 86.2±15 mmHg. There were 7 cases of infection that could be related to the lumbar catheter. 32 patients (34%) showed a favourable outcome (good recovery or moderate disability), 10 patients (10%) survived with a severe permanent neurological deficit, 10 patients (10%) remained in a persistent vegetative state and 44 patients (46%) died.

Conclusions: Controlled external lumbar drainage reduces therapy-resistant intracranial hypertension significantly. The hazard of transtentorial or tonsillar herniation might be limited by considering lumbar drainage only in the presence of discernible basilar cisterns.