CSF diversion did not improve outcome in kids after TBI

Cerebrospinal fluid diversion was not associated with improved outcome for children following a traumatic brain injury. However, a decrease in intracranial pressure was observed, researchers reported in JAMA Network Open.

Michael J. Bell, MD, the chief of the division of critical care medicine at Children’s National Hospital in Washington, D.C., and colleagues aimed to determine whether cerebrospinal fluid (CSF) diversion is associated with improved Glasgow Outcome Score-Extended for Pediatrics scores and decreased rates of intracranial pressure in children with severe traumatic brain injuries (TBIs).

Bell and colleagues performed an observational comparative effectiveness study at 51 clinical centers caring for children with TBI in eight countries, with follow-up at 6 months after injury. Children were included if they had a Glasgow Coma Score of 8 or lower, had an intracranial pressure monitor placed on-site and were younger than aged 18 years.

A total of 1,000 children with TBI enrolled, with 314 who received CSF diversion (mean age 7.18 years; 66.2% male), and 686 who did not (7.79 years; 63.7% male). The propensity match analysis included 98 pairs.

When assessing the matched pairs, there was no difference between the groups in Glasgow Outcome Score-Extended for Pediatrics scores (difference, 0; interquartile range, –3 to 1). However, there was a decrease in overall intracranial pressure in the group who received CSF diversion (difference, 3.97 mm Hg).

“Further studies will be necessary to determine if there are subsets of children who might benefit,” Bell and colleagues wrote. “However, in light of our findings, recommendations for CSF diversion may need to be reconsidered.”

In a related editorial from Ann-Christine Duhaime, MD, a pediatric neurosurgeon at Massachusetts General Hospital, and Patricia B. Raksin, MD, a neurosurgery specialist at Cook County Health in Illinois, the two state that Bell and colleagues’ propensity-matched analysis of 98 pairs may have been too small to observe “subtle neurocognitive or behavioral differences.”

“It might be reasonable to deemphasize the negative conclusion with regard to [Glasgow Coma Scale-Extended for Pediatrics]–determined outcomes, as CSF drainage is but a single variable with the potential to impact outcome,” Duhaime and Raksin wrote. “That is why the overall approach to treatment of patients with severe TBI involves multifaceted, interwoven interventions that most often are tailored to the specific patient at hand.”

References:

• Bell MJ, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.20969.
• Duhaime AC, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.20978.