Use of Ventriculostomy for Severe Traumatic Brain Injury Significantly Reduces Mortality Compared to Intraparenchymal Monitor Use

INTRODUCTION: There is a lack of data on whether intracranial pressure (ICP)-guided therapy with an intraparenchymal fiberoptic monitor (IPM) or an external ventricular drain (EVD) leads to superior outcomes. Given the lack of consensus on whether an EVD or an IPM monitor should be preferentially used if both are feasible options, there is a pressing need to determine which modality leads to more effective ICP-guided therapy while also minimizing the procedure-related complications. METHODS: Retrospective analysis of severe TBI that required IPM or EVD placement for ICP-guided therapy from 1/1/2010-12/31/2020. The data was obtained from the Pennsylvania Trauma Systems Foundation (PTSF) registry. RESULTS: A total of 2,305 patients met the inclusion criteria with 1,048 (45.5%) IPM and 1,257 (54.5%) EVD placed. A craniectomy was performed in 47.0% of the patients in the IPM cohort and 66.0% of the EVD cohort (p < 0.001). Multivariable logistic regression analysis showed that older age (OR 1.03, p < 0.001), decreasing GCS score (OR 1.16, p < 0.001), requiring craniectomy (OR 1.22, p = 0.049), and an IPM (OR 1.40, p = 0.001) were significant predictors of mortality. Among those treated medically only, inpatient mortality occurred in 171 (30.8%) of those with an IPM and in 100 (23.4%) of those with an EVD (p = 0.010); the EVD conferred significant mortality benefit (30% decrease, p = 0.005) when controlling for age and admission GCS. CONCLUSIONS: The lack of consensus on whether IPM monitor or EVD is more effective leads to ambiguity in the treatment of patients with severe TBI. Our study demonstrates a significant improvement in mortality was associated with the use of EVD in comparison to IPM. This mortality benefit was seen in patients who underwent decompressive hemicraniectomy as well as those who did not.