Peer-Review Reports
External Ventricular Drains versus Intraparenchymal Intracranial Pressure Monitors in Traumatic Brain Injury: A Prospective Observational Study Hua Liu1, Wenming Wang1, Feng Cheng1, Qiang Yuan2, Jian Yang1, Jin Hu2, Guanghui Ren1
Key words Intracranial pressure monitoring type - Neurological outcome - Traumatic brain injury -
Abbreviations and Acronyms CSF: Cerebrospinal fluid CT: Computed tomography EVD: External ventricular drain GCS: Glasgow Coma Scale GOS: Glasgow Outcome Score ICP: Intracranial pressure ICU: Intensive care unit IPM: Intraparenchymal fiberoptic monitor RICH: Refractory intracranial hypertension TBI: Traumatic brain injury From the 1Department of Neurosurgery, the First People’s Hospital of Kunshan, Jiangsu University, Suzhou; and 2 Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China To whom correspondence should be addressed: Hua Liu, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2015). http://dx.doi.org/10.1016/j.wneu.2014.12.040 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
- BACKGROUND:
Intracranial pressure (ICP) monitoring is the standard of care for patients with traumatic brain injury (TBI) and is used frequently. However, the efficacy of treatment based on the type of ICP monitor used for improving patient outcome has not been assessed prospectively. This study explores whether the type of ICP monitoring device used affects the neurologic outcomes of patients with TBI.
- METHODS:
A prospective, observational study was conducted in 122 patients with TBI ‡13 years old with indications for monitoring who were being treated in neurosurgical intensive care units between January 2009 and December 2012. All enrolled patients required monitoring randomly using an external ventricular drain (EVD) or intraparenchymal fiberoptic monitor (IPM). Patients were placed into 2 groups depending on the type of monitoring device. Clinically relevant outcomes, refractory intracranial hypertension, survival rates, and devicerelated complications were compared between the 2 groups.
- RESULTS:
There was a significant between-group difference in the Glasgow Outcome Scale score 6 months after injury, which was the primary outcome. Refractory intracranial hypertension was diagnosed in 44 of 122 patients, and patients monitored using IPM had a higher percentage of refractory intracranial hypertension (51.7% vs. 21.0%, P < 0.001). The 1-month survival rate was 90.3% in the EVD group and 76.7% in the IPM group (log-rank test, P [ 0.04), and patients managed with EVDs had a significantly higher 6-month postinjury survival rate compared with patients treated with IPMs (88.7% vs. 68.3%, log-rank test, P [ 0.006). There was no statistically significant difference between the groups in device-related complications (P [ 0.448).
INTRODUCTION
- CONCLUSIONS:
Traumatic brain injury (TBI) is the leading cause of death and disability worldwide (9). Over the last decade, severe brain injury outcomes have improved concurrent with the application of guidelines and standardized protocols and the implementation of intracranial pressure (ICP) monitoring as the standard procedure in most large trauma centers (2, 13). Despite the lack of strong scientific evidence that routine continuous ICP monitoring in patients with brain trauma improves outcome (5, 7, 14, 19-21), ICP monitoring remains the cornerstone of acute neurologic treatment after TBI, with the aim of reducing ICP elevation and maintaining adequate cerebral blood flow and oxygenation (4). At the present time, 2 major methods of continuous ICP monitoring are used, intraparenchymal
fiberoptic monitors (IPMs) and external ventricular drains (EVDs); each method has its own merits and drawbacks (1). Device selection continues to depend largely on personal preference, experience, the requirement for cerebrospinal fluid (CSF) or blood drainage, and institutional practices. Although EVDs are believed to be the most accurate and reliable method and are considered by the Brain Trauma Foundation Guidelines to be the gold standard for ICP measurement, no prospective studies have been conducted to
Device selection for ICP monitoring provides prognostic discrimination, and use of EVDs may have a bigger advantage in controlling refractory intracranial hypertension. Based on our findings, we recommend routine placement of an EVD in patients with TBI, unless only parenchymal-type monitoring is available.
WORLD NEUROSURGERY - [-]: ---, MONTH 2015
compare the prognosis of patients with TBI using different ICP monitors.
MATERIALS AND METHODS Design This prospective, observational study comprised 122 patients with TBI (21 female and 101 male patients) 13 years old who were admitted to the Kunshan Hospital neurosurgical intensive care unit (ICU) and required ICP monitoring between January
www.WORLDNEUROSURGERY.org
1
PEER-REVIEW REPORTS HUA LIU ET AL.
2009 and December 2012. The Jiangsu University Hospital Medical Ethics Board approved the research protocol. Because the patients may have been in a coma, consent for patients >20 years old was discussed with the family, and consent for patients 13e20 years old was discussed with the parent or legal guardian. Written consent was obtained in Chinese. Care was taken to include in this discussion not only the purpose of the study but also other relevant information about the study, including the procedures to which the participants would be exposed and the benefits or risks to participants and the right to decide whether or not to participate in the research study. Whenever the patient regained consciousness, the consent process was repeated to obtain consent (or the child’s assent for patients 13e20 years old) to continue. Indications for ICP monitoring included a Glasgow Coma Scale (GCS) score 8 with an abnormal head computed tomography (CT) scan; a GCS score 12 with an abnormal CT scan and the need for sedation; or evidence of severe TBI with a normal CT and 2 of the following: age >40 years, motor posturing, or systolic blood pressure 40 years old) and the GCS score (3e8 vs. 9e12). Randomization was routinely implemented using a passwordprotected application on a laptop computer. Inclusion criteria were as follows: admission to study hospital within 24 hours of injury, closed head trauma, eligibility and indications for monitoring at admission or within 48 hours after injury, no foreign object in the brain parenchyma, and >12 years old. Exclusion criteria were as follows: GCS score of 3 with bilateral fixed and dilated pupils or decision not to pursue active treatment before enrollment into study, no beds available in the ICU, pregnancy, prisoner, no consent given, nonsurvivable injury, other (e.g., life expectancy 20 mm Hg to remove the smallest volume of fluid necessary to control ICP as rapidly as possible. Drainage continued for 5 minutes; then the ventricular catheter was capped, and the ICP was rechecked. Mild hyperventilation (partial pressure of carbon dioxide 30e33 mm Hg) was used as necessary. Refractory intracranial hypertension (RICH) was defined as ICP increases to >30 mm Hg or a reduction in cerebral perfusion pressure to 15 minutes, along with failure to respond to the above-mentioned maximum medical treatment. If RICH occurred, decompressive craniotomy was performed as soon as possible. Insertion Technique We commonly employed Kocher’s point for ICP monitors (18). The location for the twist drill hole and point of insertion of the ventricular catheter was the junction of 1 cm anterior to the coronal suture and a parasagittal plane passing through the pupil of the ipsilateral eye. From this site, the ventricular catheter insertion was directed toward the medial canthus of the ipsilateral eye and maintained in the coronal plane that passes through the external auditory meatus. The catheter was advanced with a stylet until CSF was obtained (should be
External Ventricular Drains versus Intraparenchymal Intracranial Pressure Monitors in Traumatic Brain Injury: A Prospective Observational Study Hua Liu1, Wenming Wang1, Feng Cheng1, Qiang Yuan2, Jian Yang1, Jin Hu2, Guanghui Ren1
Key words Intracranial pressure monitoring type - Neurological outcome - Traumatic brain injury -
Abbreviations and Acronyms CSF: Cerebrospinal fluid CT: Computed tomography EVD: External ventricular drain GCS: Glasgow Coma Scale GOS: Glasgow Outcome Score ICP: Intracranial pressure ICU: Intensive care unit IPM: Intraparenchymal fiberoptic monitor RICH: Refractory intracranial hypertension TBI: Traumatic brain injury From the 1Department of Neurosurgery, the First People’s Hospital of Kunshan, Jiangsu University, Suzhou; and 2 Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China To whom correspondence should be addressed: Hua Liu, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2015). http://dx.doi.org/10.1016/j.wneu.2014.12.040 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
- BACKGROUND:
Intracranial pressure (ICP) monitoring is the standard of care for patients with traumatic brain injury (TBI) and is used frequently. However, the efficacy of treatment based on the type of ICP monitor used for improving patient outcome has not been assessed prospectively. This study explores whether the type of ICP monitoring device used affects the neurologic outcomes of patients with TBI.
- METHODS:
A prospective, observational study was conducted in 122 patients with TBI ‡13 years old with indications for monitoring who were being treated in neurosurgical intensive care units between January 2009 and December 2012. All enrolled patients required monitoring randomly using an external ventricular drain (EVD) or intraparenchymal fiberoptic monitor (IPM). Patients were placed into 2 groups depending on the type of monitoring device. Clinically relevant outcomes, refractory intracranial hypertension, survival rates, and devicerelated complications were compared between the 2 groups.
- RESULTS:
There was a significant between-group difference in the Glasgow Outcome Scale score 6 months after injury, which was the primary outcome. Refractory intracranial hypertension was diagnosed in 44 of 122 patients, and patients monitored using IPM had a higher percentage of refractory intracranial hypertension (51.7% vs. 21.0%, P < 0.001). The 1-month survival rate was 90.3% in the EVD group and 76.7% in the IPM group (log-rank test, P [ 0.04), and patients managed with EVDs had a significantly higher 6-month postinjury survival rate compared with patients treated with IPMs (88.7% vs. 68.3%, log-rank test, P [ 0.006). There was no statistically significant difference between the groups in device-related complications (P [ 0.448).
INTRODUCTION
- CONCLUSIONS:
Traumatic brain injury (TBI) is the leading cause of death and disability worldwide (9). Over the last decade, severe brain injury outcomes have improved concurrent with the application of guidelines and standardized protocols and the implementation of intracranial pressure (ICP) monitoring as the standard procedure in most large trauma centers (2, 13). Despite the lack of strong scientific evidence that routine continuous ICP monitoring in patients with brain trauma improves outcome (5, 7, 14, 19-21), ICP monitoring remains the cornerstone of acute neurologic treatment after TBI, with the aim of reducing ICP elevation and maintaining adequate cerebral blood flow and oxygenation (4). At the present time, 2 major methods of continuous ICP monitoring are used, intraparenchymal
fiberoptic monitors (IPMs) and external ventricular drains (EVDs); each method has its own merits and drawbacks (1). Device selection continues to depend largely on personal preference, experience, the requirement for cerebrospinal fluid (CSF) or blood drainage, and institutional practices. Although EVDs are believed to be the most accurate and reliable method and are considered by the Brain Trauma Foundation Guidelines to be the gold standard for ICP measurement, no prospective studies have been conducted to
Device selection for ICP monitoring provides prognostic discrimination, and use of EVDs may have a bigger advantage in controlling refractory intracranial hypertension. Based on our findings, we recommend routine placement of an EVD in patients with TBI, unless only parenchymal-type monitoring is available.
WORLD NEUROSURGERY - [-]: ---, MONTH 2015
compare the prognosis of patients with TBI using different ICP monitors.
MATERIALS AND METHODS Design This prospective, observational study comprised 122 patients with TBI (21 female and 101 male patients) 13 years old who were admitted to the Kunshan Hospital neurosurgical intensive care unit (ICU) and required ICP monitoring between January
www.WORLDNEUROSURGERY.org
1
PEER-REVIEW REPORTS HUA LIU ET AL.
2009 and December 2012. The Jiangsu University Hospital Medical Ethics Board approved the research protocol. Because the patients may have been in a coma, consent for patients >20 years old was discussed with the family, and consent for patients 13e20 years old was discussed with the parent or legal guardian. Written consent was obtained in Chinese. Care was taken to include in this discussion not only the purpose of the study but also other relevant information about the study, including the procedures to which the participants would be exposed and the benefits or risks to participants and the right to decide whether or not to participate in the research study. Whenever the patient regained consciousness, the consent process was repeated to obtain consent (or the child’s assent for patients 13e20 years old) to continue. Indications for ICP monitoring included a Glasgow Coma Scale (GCS) score 8 with an abnormal head computed tomography (CT) scan; a GCS score 12 with an abnormal CT scan and the need for sedation; or evidence of severe TBI with a normal CT and 2 of the following: age >40 years, motor posturing, or systolic blood pressure 40 years old) and the GCS score (3e8 vs. 9e12). Randomization was routinely implemented using a passwordprotected application on a laptop computer. Inclusion criteria were as follows: admission to study hospital within 24 hours of injury, closed head trauma, eligibility and indications for monitoring at admission or within 48 hours after injury, no foreign object in the brain parenchyma, and >12 years old. Exclusion criteria were as follows: GCS score of 3 with bilateral fixed and dilated pupils or decision not to pursue active treatment before enrollment into study, no beds available in the ICU, pregnancy, prisoner, no consent given, nonsurvivable injury, other (e.g., life expectancy 20 mm Hg to remove the smallest volume of fluid necessary to control ICP as rapidly as possible. Drainage continued for 5 minutes; then the ventricular catheter was capped, and the ICP was rechecked. Mild hyperventilation (partial pressure of carbon dioxide 30e33 mm Hg) was used as necessary. Refractory intracranial hypertension (RICH) was defined as ICP increases to >30 mm Hg or a reduction in cerebral perfusion pressure to 15 minutes, along with failure to respond to the above-mentioned maximum medical treatment. If RICH occurred, decompressive craniotomy was performed as soon as possible. Insertion Technique We commonly employed Kocher’s point for ICP monitors (18). The location for the twist drill hole and point of insertion of the ventricular catheter was the junction of 1 cm anterior to the coronal suture and a parasagittal plane passing through the pupil of the ipsilateral eye. From this site, the ventricular catheter insertion was directed toward the medial canthus of the ipsilateral eye and maintained in the coronal plane that passes through the external auditory meatus. The catheter was advanced with a stylet until CSF was obtained (should be
