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Therapy of malignant intracranial hypertension by lumbar cerebrospinal fluid drainage

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Objectives

The use of lumbar drainage in uncontrollable intracranial hypertension is considered to be contraindicated due to the possibility of inducing transtentorial or tonsillar herniation. The objective of this study was to investigate the effect of controlled lumbar CSF drainage on ICP and to evaluate the potential side effects of this new therapeutic modality in adult patients with therapy-refractory intracranial hypertension.

Methods

Twenty-three patients (age 36.09± 17.4 years) with severe traumatic brain injury (TBI) (n=12) or vasospasm after subarachnoid haemorrhage (SAH) (n=11) were included prospectively. Patients were considered for lumbar CSF drainage if they suffered persistent intracranial hypertension (>25 mmHg) for a period of more than 15 min and failed to respond to high intensity treatment. Lumbar CSF drainage was not performed in patients with tight basal cisterns. After institution of the lumbar drain, 5–20 ml CSF were initially aspirated and then continuous CSF drainage was maintained. ICP and CPP before and after bolus-aspiration were documented. The neurological outcome of the patients was scored according to the Glasgow Outcome Scale (GOS) 6 months after injury.

Results

Lumbar drainage was installed 4.8± 3 days after TBI/SAH and the average period of drainage was 6.6± 5.1 days. All patients showed an immediate and lasting decrease of ICP (-17.4± 11.4 mmHg; P<0.0001) and an increase of CPP (+14.3± 10.9 mmHg). Ten patients (44%) showed a favourable outcome (good recovery or moderate disability), 4 patients (17%) survived with a severe permanent neurological deficit, 1 patient (4%) remained in a persistent vegetative state and 8 patients (35%) died.

Conclusions

Controlled lumbar CSF 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.

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Münch, E., Vajkoczy, P., Bauhuf, C. et al. Therapy of malignant intracranial hypertension by lumbar cerebrospinal fluid drainage. Crit Care 4, P185 (2000). https://doi.org/10.1186/cc905

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Keywords

  • Traumatic Brain Injury
  • Intracranial Hypertension
  • Severe Traumatic Brain Injury
  • Glasgow Outcome Scale
  • Basal Cistern