title: Therapy of malignant intracranial hypertension by controlled lumbar cerebrospinal fluid drainage.
abstract: OBJECTIVE
  To evaluate the effect of controlled lumbar cerebrospinal fluid drainage in adult patients with refractory intracranial hypertension.
  
  
  METHODS
  Prospective, pre- vs. postintervention study.
  
  
  METHODS
  Surgical intensive care unit of a university hospital.
  
  
  METHODS
  Twenty-three patients with severe traumatic brain injury or delayed ischemia after subarachnoid hemorrhage with intracranial hypertension refractory to aggressive treatment, including repeated applications of tromethamine, hypertonic saline solution, barbiturate coma, and decompressive craniectomy. Patients were considered for controlled lumbar cerebrospinal fluid drainage if basal cisterns on computerized tomography scan were discernible.
  
  
  METHODS
  After institution of a lumbar drain, cerebrospinal fluid was gradually aspirated, and then, continuous cerebrospinal fluid drainage was maintained under control of intracranial pressure (ICP) and pupillary status.
  
  
  RESULTS
  ICP and cerebral perfusion pressure before and after initiation of lumbar cerebrospinal fluid drainage and related complications were documented. The neurologic outcome of the patients was assessed according to the Glasgow Outcome Scale 6 months after injury. As a result of lumbar cerebrospinal fluid drainage, all patients demonstrated an immediate and lasting decrease of ICP and a concomitant increase of cerebral perfusion pressure. Two patients temporarily showed a unilateral fixed and dilated pupil 6 and 8 hrs after onset of lumbar cerebrospinal fluid drainage, respectively. Ten patients showed a favorable outcome, four patients survived with a severe permanent neurologic deficit, one patient remained in a persistent vegetative state, and eight patients died.
  
  
  CONCLUSIONS
  Controlled lumbar cerebrospinal fluid drainage significantly reduces refractory intracranial hypertension. The danger of transtentorial or tonsillar herniation is minimized by considering lumbar drainage in the presence of discernible basilar cisterns only.
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, the Faculty of Clinical Medicine Mannheim, University of Heidelberg, Germany.
authors.forename: E C
authors.initials: EC
authors.lastname: Münch
authors.forename: C
authors.initials: C
authors.lastname: Bauhuf
authors.forename: P
authors.initials: P
authors.lastname: Horn
authors.forename: H R
authors.initials: HR
authors.lastname: Roth
authors.forename: P
authors.initials: P
authors.lastname: Schmiedek
authors.forename: P
authors.initials: P
authors.lastname: Vajkoczy
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001930:Brain Injuries / Q000150:complications*; D002555:Cerebrospinal Fluid; D004322:Drainage / Q000379:methods*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D006974:Hypertension, Malignant / Q000209:etiology / Q000628:therapy*; D007362:Intensive Care Units; D007427:Intracranial Pressure; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013129:Spinal Puncture; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome