Elsevier

World Neurosurgery

Volume 83, Issue 5, May 2015, Pages 794-800
World Neurosurgery

Peer-Review Report
External Ventricular Drains versus Intraparenchymal Intracranial Pressure Monitors in Traumatic Brain Injury: A Prospective Observational Study

https://doi.org/10.1016/j.wneu.2014.12.040Get rights and content

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 device-related 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).

Conclusions

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.

Introduction

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, 20, 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 compare the prognosis of patients with TBI using different ICP monitors.

Section snippets

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 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 13–20

Results

All patients were placed into 2 groups randomly depending on the type of monitoring device they received. Group 1 comprised 62 patients who were monitored with an EVD, and group 2 comprised 60 patients who were monitored with an IPM. The demographic and clinical characteristics of the patients are summarized in Table 1. The most common causes of TBI were accidents involving electric bicycles, traffic collisions, falls, and injuries from assaults. The initial ICP values of all 122 patients

Discussion

The aim of this study was to determine whether the type of ICP monitoring device used was associated with neurologic outcomes in patients with TBI. The results indicated that patients managed with EVDs had a lower rate of RICH and, as expected, underwent fewer craniotomies. Our primary outcome, GOS score at 6 months after injury, was also significantly better in the EVD group. Management with an EVD was associated with higher survival rates at 1 and 6 months after injury. Additionally, initial

Conclusions

Device selection for ICP monitoring provides good prognostic discrimination, and use of EVDs may have a bigger advantage in controlling RICH. Based on our findings, we recommend routine placement of an EVD in patients with TBI, unless only parenchymal-type monitoring is available.

Acknowledgments

The authors thank Qiang Yuan for his diligent record keeping. Wenming Wang and Feng Cheng did all data sorting and statistical analyses. Because Hua Liu, Wenming Wang, and Feng Cheng contributed equally to this work, they are considered as co–first authors.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

    H.L., W.W., and F.C. are co–first authors.

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