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External ventricular drainage for the management of traumatic intracranial hypertension : a multicenter retrospective cohort analysis
Position du problème et objectif(s) de l’étude
External ventricular drainage (EVD) is frequently used to control raised intracranial pressure (ICP) after traumatic brain injury (TBI)1. However, the available evidence about its effectiveness in this context remains limited2. The aim of this study was to evaluate the effectiveness of EVD to control ICP and to identify the clinical and radiological factors associated with its success.
Matériel et méthodes
A multicentre retrospective cohort study was conducted from January 2019 to December 2022 across nine regional trauma-center in France participating in the Traumabase®. All TBI patients with intracranial hypertension and treated with EVD during the 4-year period were included. External ventricular drainage success was defined as an efficient control of ICP avoiding the use of any third-tier therapy (mild hypothermia, secondary decompressive craniectomy and barbiturate coma) or avoiding a decision to withdraw life-sustaining treatment due to both refractory intracranial hypertension and severity of brain injury lesions. A univariate analysis was first performed between EVD success and EVD failure subgroup of patients, using a Fisher’s exact or a Pearson’s Chi-squared test as appropriate for the categorical variables and using a Mann-Whitney U test for the continuous variables. To identify independent predictors of EVD success, a multivariate logistic regression was afterward performed, including the variables with a p-value <0.20 in the univariate analysis as potential predictors. Using a backward stepwise selection, only significant variables (p <0.05) were retained in the final model. This study has been approved by the ethic committee of the French society of anesthesiology and intensive care (IRB: 00010254 ‐ 2024 – 114).
Résultats & Discussion
A cohort of 176 TBI patients was constituted. EVD success occurred in 88 patients (50%). Among the 88 patients with EVD failure, 29 (16%) patients required a decompressive craniectomy, 49 (56%) patients received mild hypothermia and in 35 cases (20%) refractory ICH led to a protocolized decision to withdraw life-sustaining treatment. In univariate analysis, the time between patient arrival and drain insertion was longer in the success group compared to the failure group (24 [6; 92] vs 13 [6; 31], p<0.001). Patients in the success group were less frequently treated with a combination of sedative drugs (41 (47%) vs. (58 (66%), p=0.01) before EVD than those in the failure group. Radiological pattern of raised ICP, including compressed basal cisterns (18 (20%) vs. 35 (40%), p<0.001) and compressed ventricles (34 (39%) vs. 45 (51%), p=0.015), were less frequently observed in the success group. In multivariate analysis, pupillary abnormality during prehospital management (OR 0.42; 95% CI 0.19-0.92, p=0.03), sedation with only one sedative drugs (OR 0.29; 95% CI 0.13-0.61, p=0.002) and the normal aspect of cisternal basal on the brain CT scan prior to EVD placement (OR 0.41; 95% CI 0.19-0.88, p=0.024) were factors associated with EVD success.
Conclusion
In this multicenter cohort of severe TBI patients, EVD effectively controlled intracranial hypertension in half of the cases. The effectiveness of EVD appears to depend on the severity and earliness of intracranial hypertension before EVD.
Auteurs
Thomas LEPERLIER (1) , Benjamin COHEN (2), Marie WERNER (3), Vincent LEGROS (4), Mathieu WILLIG (5), Caroline JEANTRELLE (6), Thomas CLAVIER (7), Clément GAKUBA (8), Benoit CHAMPIGNEULLE (9), Jean-Denis MOYER (1) - (1)Department Of Anesthesiology And Critical Care, Chu De Caen Normandie, Caen, France, (2)Department Of Anesthesiology And Intensive Care, Tours University Hospital, Tours, France, (3)Service Anesthésie-Réanimation Chirurgicale, Dmu 12 Anesthésie Réanimation Chirurgicale Médecine Péri-Opératoire Et Douleur Hôpital Bicêtre, Aphp, Université Pari Saclay, Le Kremlin Bicêtre, Paris, France, (4)Department Of Anesthesiology And Critical Care, Hôpital Maison Blanche, University Hospital, Reims, France, (5)Department Of Anesthesiology And Intensive Care, Dijon University Hospital, Dijon, France, (6)Department Of Neurosurgery, Chu Beaujon, Ap-Hp. Nord, Clichy, France, (7)Department Of Anesthesiology, Critical Care And Perioperative Medicine, Chu Rouen, Rouen, France, (8)Department Of Anesthesiology And Critical Care, Chu De Caen Normandie And Normandie Univ, Unicaen, Inserm, U1237, Physiopathology And Imaging Of Neurological Disorders, Institut Blood And Brain At Caen-Normandie, Cyceron, Caen, France, (9)Univ. Grenoble Alpes, Inserm, Chu Grenoble Alpes, Hp2, Department Of Anesthesiology And Intensive Care, Grenoble, France