Role of Lumbar Puncture in Traumatic Brain Injury

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308 Indian Journal of Public Health Research & Development, April-June 2021, Vol. 12, No. 2 Role of Lumbar Puncture In Traumatic Brain Injury

Ranjeet Kumar Jha1, Rachna Gupta2

1Assistant Professor, Department of Neurosurgery, 2Professor, Department of Surgery, Shyam Shah Medical College, Rewa

Abstract Background: Cerebrospinal fluid (CSF) drainage via ventricular puncture is an established therapy of elevated intracranial pressure (ICP). In contrast, lumbar CSF removal is believed to be contraindicated with intracranial hypertension.

Method: We investigated the safety and efficacy of lumbar CSF drainage to decrease refractory elevated ICP in a small cohort of patients with traumatic brain injury (TBI). A score (0–8 points) was used to assess computed tomography (CT) images for signs of herniation and for patency of the basal cisterns. All patients received lumbar CSF drainage either as a continuous drainage or as a single lumbar puncture (LP). Type and method of CSF drainage, mean ICP 24 h prior and after CSF removal, and adverse events were documented. Outcome was assessed after 3 months (with dichotomized Glasgow outcome scale).

Results: Eight patients were evaluated retrospectively. n = 5 suffered a moderate, n = 2 a severe TBI (one Glasgow coma score not documented). The CT score was ≥5 in all patients prior to LP and decreased after puncture without clinical consequences in two patients. The amount of CSF removal did not correlate with score changes (P = 0.45). CSF drainage led to a significant reduction of mean ICP (from 22.3 to 13.9 mmHg, P = 0.002). Continuous drainage was more effective than a single LP. Three of eight patients reached a favorable outcome.

Conclusions: Lumbar CSF removal for the treatment of intracranial hypertension is effective and safe, provided the basal cisterns are discernible, equivalent to ≥5 points in the proposed new score. The score needs further validation.

Keywords: Intracranial hypertension, intracranial pressure, lumbar drainage, multimodality monitoring, score, traumatic brain injury.

Introduction helpless result after TBI.[10,16] Throughout the most recent many years, a normalized, evidence‑based flight of stairs Horrible mind injury (TBI) is a significant reason for way to deal with treat expanded ICP was developed.[2,18] grimness and mortality and a main source of death with Whereas outside ventricular seepage of cerebrospinal an expected yearly rate of 262 cases for each 100,000 liquid (CSF) through frontal burr‑hole craniostomy is one populace in Europe.[15] An expansion in intracranial set up strategy to diminish intracranialhypertension,[13,19] pressure (ICP) is one of the key pathogenic instruments a couple of studies have assessed the wellbeing and for the advancement of optional mind harm and for handiness of lumbar CSF expulsion in the setting of raised intracranial hypertension.[1,8,12,19] Supratentorial or potentially infratentorial herniation stays a significant Corresponding Author: worry under these circumstances.[4,6] The point of this Dr. Ranjeet Kumar Jha pilot study was to dissect imaging changes found in Assistant Professor, Department of Neurosurgery, patients going through lumbar CSF expulsion to treat Shyam Shah Medical College, REWA posttraumatic intracranial hypertension, and to build up e-mail: ranjeetjha20 @gmail.com a score that would allow to assess the danger of cerebral Mobile No.: 9005949482 herniation related with lumbar CSF waste. Indian Journal of Public Health Research & Development, April-June 2021, Vol. 12, No. 2 309 Materials and Method storage, the width of the quadrigeminal storage, and assess indications of uncal and additionally foraminal The choice to put a lumbar seepage (LD) was based on herniation. Uncal herniation was characterized as an interdisciplinary agreement of clinicians with aptitude either present or then again missing if there should in neurosurgery and neurointensive consideration. be an occurrence of prolapse of the uncus temporalis The patients had a place with two gatherings: (1) they beneath the linea of the upper tentorial edge. Foraminal either had effectively limited ventricles, with the goal herniation was characterized as the cerebellar tonsil(s) at that ventricular cut was accepted to be troublesome or beneath the degree of the occipital foramen. A point or potentially just of short‑term viability, or (2) they esteem was appointed to adjustments related with every exhibited an inconsistency between ICP estimated with thing in view of observational grounds . A base score of intraparenchymal gadgets andThe choice to put a lumbar 5 or higher was accepted to be important to guarantee a waste (LD) was based morphological discoveries on CT safe evacuation of lumbar CSF. examines accepted to cause raised ICP, for example, diffuse mind growing. Results and Observation Method Clinical data of eight patients is summarized . The average age was 54.1 years (range 27–70 years). Six All patients going through lumbar CSF expulsion patients were males (75%). The initial Glasgow coma for the treatment of stubborn ICP after moderate or score (GCS) ranged from 3 to 15. The patients had either serious TBI between November 2017 and July 2020 suffered severe (n = 2) or moderate (n = 5) TBI. In one were included. All patients had an intraparenchymal patient the initial GCS was not documented. Five patients ICP checking gadget set up. Suggested rules for the underwent prior evacuation of an intracranial hematoma consideration of patients with TBI were continued either by osteoplastic (n = 2) or by osteoclastic (n = 3) altogether patients. Stubborn ICP was characterized as craniotomy. ICP >25 mmHg in the wake of having gotten normalized and raising nonsurgical treatment, as per standard CSF removal via the lumbar route was accomplished working methodology (e.g., developing of sedation, by either single puncture/intermittently open drainage hyperosmolar treatment, and mellow hyperventilation) (LP, n = 4) or by continuous drainage (LD, n = 5). and following the rules of the Brain Trauma Foundation. One patient underwent a single puncture initially and a [2] Once clinical treatment had fizzled, lumbar CSF continuous drainage thereafter. expulsion was thought about to keep away from an excessive prolongation of sedation[5,14] or as a middle The amount of CSF removed by either LP or LD was advance before continue with decompressive craniotomy 23.5 ml/24 h (mean, SD 16.41, range 0–40 ml) following or barbiturate unconsciousness. Lumbar CSF seepage lumbar access. The CT score ranged between a minimum was started either by single lumbar cut (LP) with the of 5 and a maximum of 8 before starting CSF drainage patient in the sidelong prostrate position, or by putting and between 3 and 8 after CSF drainage . In four patients a discontinuously open LD (both alluded to as LP), or the score showed no alteration. The score decreased by putting a consistently open LD. In all patients with (indicating a reduction of the cisternal space) after CSF a nonstop seepage, CSF was depleted at the degree of drainage in two patients, and increased in two patients. the foramen of Monroe. LP wasperformed between The decrease was without clinical consequences. days 1 and 13 after injury. ICP esteems furthermore, Narrowing was observed in the prepontine cistern and unfavorable functions were recorded. For information the quadrigeminal cistern. One patient showed an uncal understanding the hourly ICP estimations of the 24 h herniation on both sides after lumbar CSF withdrawal going before and the 24 h following the lumbar CSF without mydriasis or other clinical signs of cerebral access were found the middle value of. Clinical result herniation . Regarding the amount of CSF removed was resolved following 3 months utilizing the Glasgow within the first 24 h, there was no statistically significant result score (GOS), dichotomized into positive (GOS difference between the patients with a worsening of 4 and 5) and horrible (GOS 1–3). All patients went the imaging score (31.5 ml, SD 10.6) and those with a through CT checking inside 8 h earlier furthermore, after stable or improved imaging score (19.5 ml, SD 18.64, LP or LD. Spatial intracranial connections were assessed P = 0.45). Lumbar CSF removal led to a reduction of efficiently by investigating the width of the prepontine ICP in all patients . Mean ICP was 22.3 mmHg (SD 3.0) 310 Indian Journal of Public Health Research & Development, April-June 2021, Vol. 12, No. 2 before CSF drainage and was 13.9 mmHg (SD 4.7) after increased risk of CSF infection.[3] However, Schade drainage (P = 0.002). A constantly open lumbar CSF and Schinkel[17] reported that the risk of infection drainage was significantly more effective than a single with continuous lumbar CSF drainage and the LP [Figure 1]. The ICP decreased by 13.2 mmHg (mean, infection‑associated death remains low. SD 3.0) with constant drainage and by 2.7 mmHg (mean, SD 1.3) with intermittent open or single LP (P = 0.0003). This study has limitations. The sample size is small and data analysis is retrospective. We therefore limited No severe adverse events were registered in our analysis to the immediate effects of lumbar CSF association with the procedure in this cohort, especially removal on the ICP course. Whether this influenced the no clinically evident case of herniation or infection clinical outcome remains highly speculative. associated with lumbar CSF removal. However, in one patient we observed radiological signs of uncal Conclusion herniation on one CT scan. Lumbar CSF drainage represents an efficient and A favorable outcome after 3 months was observed in safe treatment to reduce intracranial hypertension, three patients (37.5%). Four patients attained a GOS of3, provided the images prior to LP are carefully analyzed, whereas one patient remained in a persistent vegetative the right conclusions are drawn, and nursing expertise state (GOS 2). in handling of the drainage is guaranteed. The newly introduced “Innsbruck Intracranial Reserve Score”, an Discussion image‑based score to predict the safety of lumbar CSF drainage, needs further validation in a larger prospective The main findings of this study are, first, that it is trial before its use can be recommended on a more safe to perform lumbar CSF removal in the setting of an general basis. increased ICP provided the basal cisterns are discernible and bilateral uncal herniation is absent. Second, the use Ethical Clearance: Taken from ethical committee of a score provides a structured approach to prepuncture of institution. image analysis and may add to the safety of the procedure. Third, continuous removal of CSF might be Source of Funding: Self more effective than intermittent drainage. Conflict of Interest: Nil TBI‑related intracranial hypertension is associated with poor outcome.[1] Drainage of CSF in patients with References intracranial hypertension is known to be an effective way 1. Abadal‑Centellas JM, Llompart‑Pou JA, to decrease ICP.[12,19] However, lumbar CSF removal Homar‑Ramirez J, Perez‑Barcena J, Rossello‑Ferrer under these circumstances remains a controversial A, Ibanez‑Juve J. Neurologic outcome of procedure due to the perceived risk of cerebral posttraumatic refractory intracranial hypertension herniation and the risk of infection.[4,9] As a matter treated with external lumbar drainage. 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