Related Experiment Video
Updated: Sep 5, 2025
A Bedside, Single Burr Hole Approach to Multimodality Monitoring in Severe Brain Injury
Published on: March 26, 2019
Comparative Effectiveness of Diversion of Cerebrospinal Fluid for Children With Severe Traumatic Brain Injury
Michael J Bell1, Bedda L Rosario2, Patrick M Kochanek3
1Division of Critical Care Medicine, Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia.
Insights
Cerebrospinal fluid (CSF) diversion in children with severe traumatic brain injury (TBI) did not improve outcomes but did decrease intracranial pressure (ICP). Current guidelines recommending CSF diversion for TBI may need reconsideration based on this evidence.
Area of Science:
- Pediatric neurosurgery
- Trauma care
- Critical care medicine
Background:
- Cerebrospinal fluid (CSF) diversion is a long-standing treatment for severe pediatric traumatic brain injury (TBI).
- Current evidence-based guidelines recommend CSF diversion, but these are based on limited studies.
Purpose of the Study:
- To determine if CSF diversion improves the Glasgow Outcome Score-Extended for Pediatrics (GOS-EP) in children with severe TBI.
- To assess if CSF diversion decreases intracranial pressure (ICP) in this patient population.
Main Methods:
- An observational comparative effectiveness study involving 1000 children with severe TBI across 51 centers in 8 countries.
- Propensity matching was used to compare children who underwent CSF diversion with those who did not.
- Outcomes, including GOS-EP and ICP, were assessed at 6 months post-injury.
Main Results:
- In propensity-matched analyses (98 pairs), CSF diversion was not associated with a significant difference in GOS-EP at 6 months (P=.08).
- A statistically significant decrease in overall intracranial pressure (ICP) was observed in the CSF diversion group (mean difference, 3.97 mm Hg; P<.001).
Conclusions:
- CSF diversion in children with severe TBI is not associated with improved functional outcomes at 6 months.
- The study observed a reduction in ICP with CSF diversion, suggesting a potential physiological effect.
- Given the higher quality evidence from this study, existing guidelines on CSF diversion for pediatric TBI should be re-evaluated.
Importance:
Diversion of cerebrospinal fluid (CSF) has been used for decades as a treatment for children with severe traumatic brain injury (TBI) and is recommended by evidenced-based guidelines. However, these recommendations are based on limited studies.
Objective:
To determine whether CSF diversion is associated with improved Glasgow Outcome Score-Extended for Pediatrics (GOS-EP) and decreased intracranial pressure (ICP) in children with severe TBI.
Design, Setting, And Participants:
This observational comparative effectiveness study was performed at 51 clinical centers that routinely care for children with severe TBI in 8 countries (US, United Kingdom, Spain, the Netherlands, Australia, New Zealand, South Africa, and India) from February 2014 to September 2017, with follow-up at 6 months after injury (final follow-up, October 22, 2021). Children with severe TBI were included if they had Glasgow Coma Scale (GCS) scores of 8 or lower, had intracranial pressure (ICP) monitor placed on-site, and were aged younger than 18 years. Children were excluded if they were pregnant or an ICP monitor was not placed at the study site. Consecutive children were screened and enrolled, data regarding treatments were collected, and at discharge, consent was obtained for outcomes testing. Propensity matching for pretreatment characteristics was performed to develop matched pairs for primary analysis. Data analyses were completed on April 18, 2022.
Exposures:
Clinical care followed local standards, including the use of CSF diversion (or not), with patients stratified at the time of ICP monitor placement (CSF group vs no CSF group).
Main Outcomes And Measures:
The primary outcome was GOS-EP at 6 months, while ICP was considered as a secondary outcome. CSF vs no CSF was treated as an intention-to-treat analysis, and a sensitivity analysis was performed for children who received delayed CSF diversion.
Results:
A total of 1000 children with TBI were enrolled, including 314 who received CSF diversion (mean [SD] age, 7.18 [5.45] years; 208 [66.2%] boys) and 686 who did not (mean [SD] age, 7.79 [5.33] years; 437 [63.7%] boys). The propensity-matched analysis included 98 pairs. In propensity score-matched analyses, there was no difference between groups in GOS-EP (median [IQR] difference, 0 [-3 to 1]; P = .08), but there was a decrease in overall ICP in the CSF group (mean [SD] difference, 3.97 [0.12] mm Hg; P < .001).
Conclusions And Relevance:
In this comparative effectiveness study, CSF diversion was not associated with improved outcome at 6 months after TBI, but a decrease in ICP was observed. Given the higher quality of evidence generated by this study, current evidence-based guidelines related to CSF diversion should be reconsidered.
