External Lumbar Drainage for Refractory Intracranial Hypertension in Acute Brain Injury: A Narrative Review and Case Series.

Refractory intracranial hypertension in the setting of acute brain injury (ABI) is defined as sustained intracranial pressure (ICP) elevation above 22 mmHg despite escalating medical management. When unresponsive to these therapies, mortality reaches 84%-100%. External lumbar drainage (ELD) has emerged as a minimally invasive adjunct for cerebrospinal fluid (CSF) diversion, either as complementary to or alternative to external ventricular drainage (EVD), potentially avoiding the need for barbiturate coma or decompressive craniectomy. The objective of this paper is to review current evidence on the use of ELD in refractory intracranial hypertension following ABI and to present a single-center case series illustrating its clinical application, efficacy, and safety. We conducted a narrative review of the literature and retrospectively analyzed five consecutive patients admitted to a neurointensive care unit between August 2025 and April 2026 who were treated with ELD for refractory intracranial hypertension. Patient demographics, clinical severity scores (Glasgow Coma Scale (GCS), Simplified Acute Physiology Score 3 (SAPS 3), Sequential Organ Failure Assessment (SOFA)), ICP values, timing of ELD placement, treatment escalation, length of stay, mechanical ventilation days, destination at discharge, and 28-day Glasgow Outcome Scale (GOS) were recorded. Five patients (four male; mean age 38.4 years) were treated with ELD: three with traumatic brain injury (TBI), one with hypertensive intracerebral hemorrhage, and one with aneurysmal subarachnoid hemorrhage (aSAH). The median time to ELD placement was three days (range 2-8). In two patients, ELD was implemented as a tier 2 measure following sedation and analgesia, osmotherapy, and head-of-bed elevation. In the remaining patients, ELD was used as a tier 3 intervention, combined with decompressive craniectomy (n = 2) and/or barbiturate coma (n = 2). CSF drainage was guided by ICP elevation, performed only when it exceeded 20 mmHg; however, three of the five patients required continuous rate-based drainage (5 mL/h in Cases 1 and 5 and 10 mL/h in Case 4) because of sustained intracranial hypertension. Sustained ICP reduction with a favorable neurological outcome (GOS 4) was observed in one patient treated with early ELD (second day). Three patients died (one of whom died following transfer to another institution), and one patient developed two episodes of over-drainage due to accidental system disconnection, requiring ELD removal after one day. No infectious complications were recorded. Our conclusion is that ELD is a feasible, minimally invasive therapeutic option for refractory intracranial hypertension in ABI. Early placement, appropriate patient selection based on neuroimaging (patent basal cisterns, absence of significant mass effect), and continuous neuromonitoring are critical for safety and efficacy. Prospective randomized trials are needed to define optimal timing, patient phenotype, and drainage protocols.