Clinical Evaluation of the Safety and Efficacy of Lumbar Cerebrospinal Fluid Drainage for the Treatment of Refractory Increased Intracranial Pressure

Object: Several approaches have been established for the treatment of intracranial hypertension; however, a considerable number of patients remain unresponsive to even aggressive therapeutic strategies. Lumbar CSF drainage has been contraindicated in the setting of increased intracranial pressure (ICP) because of possible cerebral herniation. The authors of this study investigated the efficacy and safety of controlled lumbar CSF drainage in patients suffering from intracranial hypertension following severe traumatic brain injury (TBI) or aneurysmal subarachnoid hemorrhage (SAH).

Methods: The authors prospectively evaluated 100 patients-45 with TBI and 55 with SAH-having a mean age of 43.7 +/- 15.7 years (mean +/- SD) and suffering from refractory intracranial hypertension (ICP > 20 mm Hg). Intracranial pressure and cerebral perfusion pressure (CPP) before and after the initiation of lumbar CSF drainage as well as related complications were documented. Patient outcomes were assessed 6 months after injury.

Results: The application of lumbar CSF drainage led to a significant reduction in ICP from 32.7 +/- 10.9 to 13.4 +/- 5.9 mm Hg (p < 0.05) and an increase in CPP from 70.6 +/- 18.2 to 86.2 +/- 15.4 mm Hg (p < 0.05). Cerebral herniation with a lethal outcome occurred in 6% of patients. Thirty-six patients had a favorable outcome, 12 were severely disabled, 7 remained in a persistent vegetative state, and 45 died.

Conclusions: Lumbar drainage of CSF led to a significant and clinically relevant reduction in ICP. The risk of cerebral herniation can be minimized by performing lumbar drainage only in cases with discernible basal cisterns.