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29.04.2019 | Original Work | Ausgabe 1/2019

Neurocritical Care 1/2019

Primary External Ventricular Drainage Catheter Versus Intraparenchymal ICP Monitoring: Outcome Analysis

Neurocritical Care > Ausgabe 1/2019
James William Bales, Robert H. Bonow, Robert T. Buckley, Jason Barber, Nancy Temkin, Randall M. Chesnut
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Intracranial pressure (ICP) monitoring is central to the care of severe traumatic brain injury (TBI). External ventricular drains (EVD) allow ICP control via cerebrospinal fluid drainage, whereas intraparenchymal monitors (IPM) for ICP do not, but it is unclear whether EVD placement improves outcomes. To evaluate whether there exists a difference in patient outcomes with the use of EVD versus IPM in severe TBI patients, we conducted a retrospective cohort study using data from the Citicoline Brain Injury Treatment trial.


Adults with Glasgow Coma Score < 9 who had either an EVD or IPM placed within 6 h of study center arrival were included. We compared patients with EVD placement to those without on Glasgow Outcome Scale-Extended (GOS-E) and neuropsychological performance at 180 days, mortality, and intensive care unit length of stay. We used regression models with propensity score weighting for probability of EVD placement to test for association between EVD use and outcomes. Of 224 patients included, 45% received an EVD.


EVD patients had lower GOS-E at 180 days [3.8 ± 2.2 vs 4.9 ± 2.2, p = 0.002; weighted difference − 0.97, 95% CI (− 1.58, − 0.37)], higher in-hospital mortality [23% vs 10%, p = 0.014; weighted OR 2.46, 95% CI (1.20, 5.05)], and did significantly worse on all 8 neuropsychological measures. Additional sensitivity analysis was performed to minimize confounding effects supported our initial results.


Our retrospective data analysis suggests that early placement of EVDs in severe TBI is associated with worse functional and neuropsychological outcomes and higher mortality than IPMs and future prospective trials are needed to determine whether these results represent an important consideration for clinicians.

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Supplemental figure 2. Alternate samples. This table shows analysis done to examine the effect of limiting our consideration for EVD placement to less than 3 hrs or considering all patients to have ever received an EVD. Here, we demonstrate that there is no difference in outcomes if we change our inclusion criteria for timing of EVD placement. (DOCX 19 kb)
Supplemental figure 3. As additional sensitivity analyses, we evaluated the effect of the instrumental variable percent of participants in the individual’s hospital who received and EVD on 6-month GOSE and got results comparable to that of the propensity weighted analysis. (DOCX 15 kb)
Supplemental figure 4. Demonstration of a stepwise regression rather than propensity weighting to adjust for measured potential confounders, with significantly better outcome in the No EVD group for all outcomes. (DOCX 21 kb)
Supplemental figures 5. Brief evaluation of average and high ICP values within the first five days after admission demonstrating no significant difference in ICP values. In addition whether CSF drainage was performed within the first day after admission has been examined. Data demonstrates that the majority of patients with an EVD placed had CSF drainage but it is unclear for what reason and if this drainage was continuous or intermittent. Further studies will need to delineate this information more completely. (DOCX 22 kb)
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