Efficacy and Predictors of Success of External Ventricular Drainage for The Management of Traumatic Intracranial Hypertension: A Retrospective Multicenter Cohort Study

Efficacy and Predictors of Success of External Ventricular Drainage for The Management of Traumatic Intracranial Hypertension: A Retrospective Multicenter Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy and Predictors of Success of External Ventricular Drainage for The Management of Traumatic Intracranial Hypertension: A Retrospective Multicenter Cohort Study Jean-Denis Moyer, Benjamin Cohen, Marie Werner, Vincent Legros, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7028290/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Oct, 2025 Read the published version in Neurocritical Care → Version 1 posted 5 You are reading this latest preprint version Abstract Background External ventricular drainage (EVD) is commonly used to manage elevated intracranial pressure (ICP) following traumatic brain injury (TBI). However, evidence supporting its effectiveness in this context remains limited. This study aimed to evaluate the effectiveness of EVD in controlling elevated ICP and to identify clinical and radiological factors associated with its success. Methods A multicenter retrospective cohort study was conducted between 1st January 2019 and 31 December 2022 across nine regional trauma centers in France participating in the Traumabase. All TBI patients with intracranial hypertension despite maximal medical therapy and treated with EVD were included. EVD success was defined as an efficient control of ICP avoiding the use of any third-tier therapy or avoiding a decision to withdraw life-sustaining treatment due to both refractory intracranial hypertension and severity of brain injury lesions. Results A cohort of 176 TBI patients with EVD was constituted. Among them, 88 patients (50%) had sustained control of intracranial pressure after EVD. In multivariate analysis, sedation with a combination of sedative drugs (OR 0.28; 95% CI 0.12–0.62, p = 0.002), obliterated cisternal basal on the brain CT scan prior to EVD placement (OR 0.07; 95% CI 0.00-0.39, p = 0.013) and severity of chest trauma (OR 0.79; 95% CI 0.64–0.99, p = 0.039) were factors associated with poor likelihood of EVD success. Conversely, EVD placement occurring more than 24 hours after admission was independently associated with success (OR 3.07; 95% CI 1.41–7.01, p = 0.006). Conclusion In this multicenter cohort of TBI patients with refractory ICH, EVD effectively controlled intracranial pressure in half of the cases. The effectiveness of EVD appears to depend on the severity and the rapidity of onset of traumatic intracranial hypertension. Traumatic brain injury intracranial hypertension external ventricular drain ventriculostomy cerebro-spinal fluid. Figures Figure 1 Figure 2 Figure 3 Introduction Traumatic brain injury (TBI) is a major public health concern affecting mostly young, victims of road traffic accidents, and elderly, victims of falls[ 1 ]. Among patients with severe TBI, intracranial hypertension (ICH) is a critical secondary complication, typically resulting from the combined mass effect of hematomas, cerebral contusions, and diffuse swelling[ 2 ]. The development of increased intracranial pressure (ICP) in patients with traumatic brain injury is associated with a higher risk of death and poor outcome[ 3 – 5 ]. If left untreated, rising ICP can lead to cerebral herniation, cerebral circulatory arrest and death. Management of elevated ICP in TBI is based on a tiered therapeutic framework, progressing from first-line interventions to more invasive measures such as barbiturate-induced coma, secondary decompressive craniectomy, or mild hypothermia[ 6 – 8 ]. Among available interventions, external ventricular drainage (EVD) offers a dual benefit: continuous cerebrospinal fluid (CSF) diversion and real-time ICP monitoring[ 9 , 10 ]. By draining intraventricular fluid, EVD reduces ICP and improves intracranial compliance, which may secondarily enhance cerebral perfusion by optimizing the balance between arterial inflow and intracranial resistance. Several studies have demonstrated reductions in ICP and improvements in cerebral perfusion pressure following EVD placement[ 11 – 14 ]. However, despite its widespread use, high-quality evidence on EVD’s role in reducing the need for therapeutic escalation remains scarce. Most available data are retrospective, from single-center studies, and with a limited external validity[ 15 , 16 ]. One such study reported a 40% success rate—defined as avoidance of progression to more aggressive therapies—with a low incidence of complications. Nevertheless, its retrospective, monocentric design and extended inclusion period limit the generalizability of the findings. Considering these limitations, a multicenter study is warranted to better characterize the real-world effectiveness and safety profile of EVD in the management of ICP after TBI. Such an approach may help identify clinical or radiological predictors of EVD success and refine therapeutic decision-making. This study aims to evaluate the effectiveness of EVD in controlling intracranial pressure and reducing the need for therapeutic escalation in a multicenter cohort, and to identify clinical and radiological factors associated with treatment success. Methods Study design This retrospective cohort study was conducted between 1st January 2019 and 31st December 2022 across nine level 1 trauma centers in France participating in the Traumabase ® registry (supplementary material 1). The Traumabase Ⓡ registry is a comprehensive database that compiles trauma cases from 31 hospitals nationwide[ 17 ]. Guidelines for reporting this retrospective study were from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement (supplementary material 2)[ 18 ]. Data source All patients aged 16 years or older with TBI (defined as bleeding on the initial brain CT scan) and ICP monitoring (using an intraparenchymal probe) admitted to intensive care unit were screened for inclusion. All patients who developed ICH during their ICU stay and required EVD for CSF drainage to control ICP were included. Patients that required EVD after primary decompressive craniectomy or for posttraumatic hydrocephalus were excluded. Data for all participating patients were extracted from the Traumabase ® registry and completed by review of the medical charts. Trauma brain injury management All participating centers reported adherence to a shared, stepwise, protocol-based approach for the management of TBI, grounded in national French recommendations and international guidelines, including those of the Seattle International Brain Injury Consensus Conference (SIBICC)[ 6 , 7 ]. While treatment decisions remained the responsibility of local teams, they were made within this common framework. Across all centers, EVD was used exclusively for the therapeutic management of ICH—not for ICP monitoring— when maximal medical therapies (tier-one therapies) failed to control ICP (ICP > 22 mmHg for at least 10 minutes) (supplementary material 3). Placement decisions were individualized through multidisciplinary discussions. EVD management In all participating centers, drain placement was performed by the neurosurgical team following each center’s local protocol. Across all participating sites, catheter insertion was guided by standard anatomical landmarks. When considered necessary, neuronavigation - assited surgery were used to ensure accurate placement. EVD management, including the choice of continuous or intermittent drainage and the selected drainage height, was left to the discretion of each participating center. Data collection The collected data included demographic characteristics (age, sex, height, weight, and mechanism of injury), as well as prehospital clinical parameters. These included the initial Glasgow Coma Scale (GCS) score, the presence of pupillary abnormalities (unilateral or bilateral mydriasis), hemodynamic and respiratory status at the time of prehospital assessment and administered therapeutics (orotracheal intubation and mechanical ventilation, norepinephrine and osmotherapy). Upon hospital admission, the presence of hemorrhagic shock—defined as the transfusion of six or more units of packed red blood cells within 24 hours—and initial laboratory findings (platelets, prothrombin time and fibrinogen levels) were recorded. Injury severity was assessed on initial whole-body CT using the Abbreviated Injury Scale (AIS), with the maximum AIS recorded for each body region (head, face, chest, abdomen, and lower extremities). The initial brain CT-scan was also used to determine the Marshall classification score[ 19 ]. In the intensive care unit, the number of sedative drugs (one sedative drugs: midazolam or propofol; combination: propofol and midazolam), the use of osmotherapy (20% mannitol or hypertonic saline) or barbiturate before and after EVD placement were documented. Intracranial pressure measurements were collected from the day prior to EVD placement up to day 4 post-procedure. The volume of daily cerebrospinal fluid collected through EVD was recorded over the same period. Brain imaging data on the last CT scan before drain insertion, including ventricular size and visibility of the basal cisterns, were jointly assessed by a senior radiologist and the attending intensivist at each participating center. Complications related to EVD were noted, including catheter obstruction requiring replacement, and accidental catheter removal. Potential hemorrhagic complications induced by EVD placement were described on the first post-EVD brain CT scan. Healthcare associated ventriculitis was defined according to the 2017 Infectious Diseases Society of America's Clinical Practice Guidelines[ 20 ]. A CSF culture was mandatory to establish the diagnosis of ventriculitis. Clinical outcomes included length of stay in the intensive care unit, in-hospital mortality and the Glasgow Outcome Scale–Extended (GOS-E) at ICU discharge. Outcomes EVD success was defined as the ability of EVD to avoid a rebound of ICP requiring the use of the third-tier therapies (mild hypothermia, secondary decompressive craniectomy, barbiturate coma) or a decision to withdraw life-sustaining treatment (WLST) due to both refractory ICH and severity of brain injury lesions. Conversely, EVD failure was defined as a lack of ICP control requiring third-tier therapies or a decision to WLST after the implementation of the EVD. A good outcome at ICU discharge was defined as GOS-E ≥ 4. Statistical analysis Categorical variables were expressed as absolute counts and percentages (%). As their distributions were mostly skewed, continuous variables were expressed as median [25th ,75th percentiles]. Factors associated with EVD success a univariate analysis was first performed between EVD success and EVD failure subgroup of patients, using a Fisher’s exact or a Pearson’s Chi-squared test as appropriate for the categorical variables and using a Mann-Whitney U test for the continuous variables. No imputation was performed for missing values. To identify independent predictors of EVD success, a multivariate logistic regression was afterward performed using a backward stepwise selection and initially including the variables with a p-value < 0.20 in the univariate analysis as potential predictors. Multicollinearity among predictors was ruled out using variance inflation factors computation. Good-of-fitness of the final model was assessed by the Hosmer–Lemeshow test. Changes in therapeutic after EVD insertion an alluvial plot was generated to visualize the transition in term of hypnotic sedative regimen or third tier therapy requirement, following EVD placement in accordance with the EVD success or failure. Changes in ICP trends and cerebrospinal fluid drainage volume The trend in maximal ICP value recorded by day (24 hours before EVD insertion, then until 4 days after) and as well as the cerebrospinal fluid volume drained by day following EVD placement were compared among the EVD failure and the EVD success subgroups of patients. As the data did not fulfill the required assumptions for a linear mixed-effect model, a non-parametric approach for repeated measures was used using the nparLD R package to test the two-way interaction of EVD success × time. In case of significant interaction, between-group post-hoc comparisons tests were performed at each time point using Mann-Whitney U test with Bonferroni corrections[ 21 ]. All tests were two sided, and a p -value of < 0.05 was considered significant. All statistical analyses were performed using the R software (v.4.4.1, The R Foundation for Statistical Computing, Vienna, Austria) and GraphPad Prism (v.9.5.0, GraphPad Software, Boston, MA, USA). Results Study population Among 912 patients admitted for TBI and who underwent ICP monitoring across the nine participating centers during the study period, 176 patients treated with EVD were included (Fig. 1 ). Table 1 summarizes the key characteristics of the study cohort. Patients were mostly young males and presented with a median initial GCS of 7 [IQR 4; 11]. The median ISS was 25 [19; 33] with a head AIS of 4 [4; 5]. The EVD insertion occurred after a median time of 17 [6; 49] hours after admission and the median length of CSF drainage was 9 [5; 14] days. Continuous EVD drainage was used in almost all patients (99%) (Supplementary materials 4). Glasgow outcome scale at hospital discharge was 2 [1; 4] (Table 1 ). Table 1 Characteristics of the overall population according to the success or failure of extra ventricular drain. Missing values Total (n = 176) EVD failure (n = 88) EVD success (n = 88) p-value Clinical characteristics Age (years) 0 41 [26, 57] 38 [27, 55] 45 [26, 59] 0.5 Male, n (%) 0 150 (85) 74 (84) 76 (86) 0.7 Height (cm) 31 175 [170, 180] 176 [170, 180] 175 [170, 180] 0.4 Weight (kg) 17 78 [70, 86] 81 [71, 86] 75 [65, 85] 0.11 Prehospital Cause of injury, n (%) 0 0.5 • Road traffic accident 84 (48) 44 (50) 40 (45) • Fall 74 (42) 33 (38) 41 (47) • Other 16 (10) 11 (12) 7 (8) Initial Glasgow Coma Scale score 3 7 [ 4 , 11 ] 6 [4, 10] 7 [4, 11] 0.4 Initial motor Glasgow coma score 13 4 [1, 5] 4 [1, 5] 4 [1, 5] 0.4 Pupillary abnormalities, n (%) 4 49 (28) 31 (36) 18 (21) 0.028 Initial arterial blood pressure • Systolic blood pressure (mmHg) 22 140 [120–160] 144 [127–164] 132 [120–160] 0.11 • Diastolic blood pressure (mmHg) 22 82 [70–93] 85 [71–98] 82 [70–90] 0.2 Initial Heart rate (beat/min) 22 87 [72–103] 84 [72–107] 88 [72–100] 0.9 Episode of hypotension (SBP < 110 mmHg), n (%) 39 37 (27) 16 (23) 21 (31) 0.3 Episode of hypoxemia (SpO2 < 92%), n (%) 31 23 (16) 14 (19) 9 (13) 0.3 Osmotherapy (Mannitol or HSS), n (%) 93 45 (54) 27 (57) 18 (50) 0.5 Orotracheal Intubation, n (%) 5 136 (80) 69 (81) 67 (78) 0.6 Hospital admission Hemorrhagic shock, n (%) 0 23 (13) 11 (13) 12 (14) 0.8 Hemoglobin (g/dL) 3 13.0 [11.4, 14.1] 13.2 [11.6, 14.3] 13.0 [11.4, 14.0] 0.6 Platelets (G/L) 3 214 [169, 264] 210 [165, 268] 223 [172, 257] 0.8 PT ratio 56 1.06 [1.00, 1.20] 1.12 [100, 1.21] 1.05 [100, 1.20] 0.4 Fibrinogen (g/L) 10 2.40 [2.00, 2.90] 2.30 [1.85, 2.85] 2.40 [2.05, 2.90] 0.2 Marshall score, n (%) 0 0.005 • Diffuse Injury II 60 (34) 23 (26) 37 (42) • Diffuse injury III 31 (18) 19 (22) 12 (14) • Diffuse Injury IV 18 (10) 8 (9) 10 (11) • Evacuated Mass lesion 28 (16) 10 (11) 18 (20) • Non evacuated Mass lesion 39 (22) 28 (32) 11 (13) ISS score 0 25 [ 19 , 33 ] 25 [ 20 , 33 ] 25 [ 17 , 29 ] 0.10 • AIS head 4 [ 4 , 5 ] 4 [ 4 , 5 ] 4 [ 4 , 5 ] 0.6 • AIS face 0 [0, 1] 0 [0, 1] 0 [0, 1] 0.3 • AIS Thorax 0 [0, 3] 2 [0, 3] 0 [0, 2] 0.012 • AIS abdomen 0 [0, 0] 0 [0, 0] 0 [0, 0] 0.2 • AIS extremities 0 [0, 0] 0 [0, 0] 0 [0, 0] 0.8 SAPS II score 47 [38, 57] 50 [39, 58] 47 [38, 56] 0.4 Before extra ventricular drainage Neurosurgical procedure (first 24h) 0 73 (41) 34 (39) 39 (44) 0.9 ICP monitoring, n (%) 0 176 (100) 176 (100) 176 (100) 1 Sedative drugs, n (%) 0 0.01 • One sedative (propofol or midazolam) 77 (44) 30 (34) 47 (53) • Combination (propofol and midazolam) 99 (56) 58 (66) 41 (47) Bolus of osmotherapy, n (%) 0 115 (65) 63 (72) 52 (59) 0.08 Bolus of barbiturate, n (%) 0 35 (20) 22 (25) 13 (15) 0.09 Norepinephrine to maintain CPP at 60–70 mmHg n (%) 0 176 (100) 88 (100) 88 (100) 1 Transcranial Doppler upon admission • Pulsatility index 57 1.3 [1.0, 1.7] 1.3 [1.0, 1.7] 1.2 [1.0, 1.7] 0.6 • Diastolic velocity (cm/s) 102 27 [17, 33] 21[15, 30] 30 [25, 37] 0.002 Cisternal basal, n (%) 0 < 0.001 • Normal 112 (64) 43 (49) 69 (78) • Compressed 53 (30) 35 (40) 18 (20) • Obliterated 11 (6) 10 (11) 1 (1) Lateral Ventricles, n (%) 0 0.015 • Normal 80 (45) 31 (35) 49 (56) • Compressed 79 (45) 45 (51) 34 (39) • Obliterated 17 (10) 12 (14) 5 (5) Time from admission to EVD placement (hours) 0 17 [6 ; 49] 13 [6; 31] 24 [6; 92] 0.02 After extra ventricular drainage Tier-three therapies a • Barbiturate coma, n (%) 0 30 (17) 30 (34) - • Hypothermia (32–35°C), n (%) 0 49 (28) 49 (56) - • Decompressive craniectomy, n (%) 0 29 (16) 29 (33) - Refractory ICP leading to early WSTL, n (%) 0 23 (13) 23 (26) - Sedative drugs within 24h after EVD, n (%) 0 < 0.001 • No sedative drug 38 (22) 0 38 (43) • One sedative (propofol or midazolam) 53 (30) 12 (14) 41 (47) • Combination (propofol and midazolam) 85 (48) 76 (86) 9 (10) EVD duration (days) 9 [5, 14] 6 [2, 12] 11 [9, 15] < 0.001 Complications of extra ventricular drainage Hematoma on EVD path, n (%) 0 • < 1cm 12 (7) 7 (8) 5 (6) 0.5 • ≥ 1cm 6 (3) 4 (4) 2 (2) 0.7 Ventriculitis, n (%) 0 7 (4) 2 (2) 5 (6) 0.4 Obstruction requiring drain replacement 21 (12) 11 (13) 10 (11) 0.7 Unintended ablation, n (%) 0 6 (3) 2 (2) 4 (5) 0.7 Outcomes ICU mortality n (%) 0 81 (46) 60 (68) 21 (24) < 0.001 ICU length of stay (days) 4 24 [10, 39] 11 [ 6 , 30 ] 29 [20, 43] < 0.001 GOS-E at ICU discharge 4 2 [1; 4] 1 [1; 3] 4 [2; 5] < 0.001 EVD: external ventricular drainage; SBP: systolic blood pressure; SpO2 ISS: Injury Severity Score; HSS: hypertonic saline solution; ICP: intracranial pressure; AIS: Abbreviated Injury Scale; PTr: Prothrombin Time ratio; GOS-E: Glasgow outcome scale extended; SAPS II: Simplified acute physiology score II, ICU: intensive care unit; CT: computer tomography. Data were expressed as median (interquartile range [IQR]) for quantitative variables and count (percentage) for qualitative variables. a Thier-three therapies were combinate in some patients. Rate and factors associated with success EVD success occurred in 88 patients (50%). The clinical course following EVD insertion and ICU discharge outcome is illustrated in Fig. 2 . Among the 88 patients with EVD failure, 29 (16%) patients required a decompressive craniectomy (isolated or associated with another thier-three therapy), 49 (56%) patients received mild hypothermia (isolated or associated with another thier-three therapy) and in 23 cases (26%) refractory ICH led to an early decision to WLST (i.e., their-three therapy deemed futile). In univariate analysis, the time from admission to drain insertion was longer in the success group compared to the failure group (24 [6; 92] vs 13 [6; 31], p = 0.02). TBI and trauma severity respectively assessed by the initial GCS (7 [5; 11] vs . 6 [3; 9], p = 0.31) and the ISS (25 [17; 29] vs . 25 [20; 33], p = 0.10) did not differ between groups while thoracic injury severity, reflected by AIS thorax scores, (0 [0; 2] vs . 2 [0; 3], p = 0.012) was lower in the success group. Biological parameters at admission did not differ between the two groups (Table 1 ). Before EVD, the maximal ICP was lower in the success group (Fig. 3 A). A combination of sedative drugs and bolus of osmotherapy were administrated less frequently in the EVD success group (41 (47%) vs. 58 (66%) p = 0.01). On the last brain CT-scan prior to EVD insertion, basal cisterns (69 (78%) vs. 43 (49%), p < 0.001) and ventricular size (31 (35%) vs . 49 (56%), p = 0.015) were more frequently described as normal in the EVD success group (Table 1 ). Following EVD, the maximal ICP decrease was significantly greater in the success group vs. the failure group (Fig. 3 A) whereas there was no statistical difference in daily CSF drainage between both group (Fig. 3 B). In the success group, 38 patients (43%) were not receiving any sedative drugs 24 hours after drain insertion, whereas 76 patients (86%) in the failure group were receiving a combination of sedative drugs (Table 1 and Fig. 2 ). In multivariate analysis, several factors were independently associated with a lower likelihood of EVD success, including the severity of chest trauma (OR 0.79; 95% CI 0.64–0.99, p = 0.039), the use of combined sedative drugs (OR 0.28; 95% CI 0.12–0.62, p = 0.002), and the presence of obliterated basal cisterns on brain CT prior to EVD placement (OR 0.07; 95% CI 0.00–0.39, p = 0.013). Conversely, EVD placement occurring more than 24 hours after admission was independently associated with success (OR 3.07; 95% CI 1.41–7.01, p = 0.006) (Table 2 ). Table 2 Factors associated with external ventricular success in multivariate analysis Variable Odds ratio (95% confidence interval) p-value AIS Thorax 0.79 (0.64–0.99) 0.039 Pre-EVD sedative drugs • One sedative drug • Combination of sedative drugs Ref. 0.28 (0.12–0.62) 0.002 Pre-EVD bolus of barbiturate 0.49 (0.20–1.16) 0.11 Pre-EVD bolus of osmotherapy 0.50 (0.23–1.03) 0.065 Cisternal basal on CT-scan before EVD placement • Normal Ref. • Compressed 0.42 (0.19–0.88) 0.023 • Obliterated 0.07 (0.00–0.39) 0.013 Time from admission to EVD placement ≥ 24h 3.07 (1.41–7.01) 0.006 Good-of-fitness Hosmer-Lemeshow p-value was 0.605. AIS: Abbreviated Injury Scale; EVD: external ventricular drainage, CT: computer tomography. Complications of EVD In 7 cases (4%) an EVD associated bacterial ventriculitis was documented. Four of them were related to gram-positive bacteria ( Staphylococcus epidermidis ) and three of them were relative to gram-negative bacteria (Pseudomonas aeruginosa, Enterobacter cloacae, Citrobacter koseri) . In 18 patients (10%), an EVD associated intracranial hemorrhage was diagnosed on the first CT-scan after drain insertion; twelve patients (7%) had a hematoma < 1cm and 6 (3%) ≥ 1cm along the drain. None required surgical management. Discussion In this multicenter cohort study, EVD used in a tiered approach allowed an effective control of refractory elevated intracranial pressure after TBI in approximately 50% of cases without major complications. Clinical and radiological markers of severe ICH such as the absence of basal cistern compression, and post-EVD parameters, including a more significant reduction in ICP, were associated with EVD efficiency. These findings may help refine patient selection in the future and support earlier adaptation of therapeutic strategies, avoiding delays in escalation and facilitating timely transition to tier-three interventions. The success rate observed in our study is consistent with the limited data previously published who reported that EVD successfully controlled intracranial hypertension in 40 to 50% of patients with TBI[ 12 , 16 ]. However, this success rate underscores the need to better identify which patients are most likely to benefit from EVD. To our knowledge, no clinical or radiological criteria have been clearly established to identify TBI patients most likely to benefit from EVD and our study is the first to provide early insights into this question. As such, our findings cannot be directly compared to prior literature, which has focused on the general efficacy or safety of EVD rather than patient selection. However, the factors associated with EVD success in our study are consistent with the underlying pathophysiology of intracranial compliance[ 22 – 24 ]. Intracranial compliance refers to the capacity of the intracranial compartment to accommodate volume changes without a significant rise in ICP. According to the Monro-Kellie doctrine, any increase in the volume of one of the three intracranial compartments — brain parenchyma, cerebral blood volume, or cerebrospinal fluid (CSF) — must occur at the expense of another. This compliance is primarily maintained by the displacement of venous blood and CSF from the intracranial space, but intracranial compliance is limited. Once these compensatory mechanisms are exhausted, even small increases in intracranial volume result in disproportionate elevations in ICP. Our findings align with these physiological mechanisms. Lower levels of sedation and a normal aspect of basal cisterns probably reflecting less severe ICH and better intracranial compliance. The normal appearance of basal cisterns on CT imaging may serve as an indirect indicator of intracranial CSF reserve, itself being one of the component of cerebral compensatory reserve[ 25 ]. The concept of cerebral compensatory is thus intrinsically linked to the CSF reserve and a higher CSF reserve reflects a greater ability to respond to therapeutic interventions such as CSF drainage. Although the daily difference in CSF volume drained did not reach statistical significance, the observed trend and the overall CSF volume drained appears to support this concept of CSF reserve, with higher drainage volumes in the success group. At the opposite, when intracranial hypertension is already severe both clinically and radiologically prior to CSF drainage, it is likely that the brain's compensatory mechanisms have already been exhausted. In such cases, EVD alone may be insufficient to produce a significant reduction in intracranial pressure. This situation may be further aggravated by the presence of extracranial injuries, particularly thoracic trauma. Thoracic injuries have been associated with less favorable neurological outcomes following TBI, likely due to their contribution to the systemic inflammatory response and their propensity to induce hypoxia and hypercapnia—two key factors known to aggravate intracranial hypertension[ 26 ]. Noteworthy, the variables identified in multivariate analysis, when considered individually, do not reliably predict failure, likely reflecting inter-individual differences in cerebral compliance. Therefore, beyond pre-EVD characteristics, it is crucial to integrate post-EVD indicators to identify patients at risk of inadequate ICH control. Our findings suggest that when CSF drainage is effective, clinical improvement typically occurs rapidly, with sedation often reduced or discontinued within the first 24 hours, potentially shortening both sedation duration. The absence of such early improvement should prompt consideration of timely escalation to tier-three therapies. Perspective Intracranial compliance reserve appears to play a key role in the success of EVD and once intracranial compliance is severely impaired, EVD may no longer be sufficient to control intracranial hypertension. This highlights the potential value of individualized strategies to detect early signs of compliance deterioration to optimize EVD placement and patient selection. The P1/P2 ratio, which quantifies the relationship between the percussion wave (P1) and the tidal wave (P2) — reflecting the elastic properties of brain tissue — is the most validated measure of compliance. The ICP waveform shape (e.g., the shape index or the compensatory reserve index) has also emerged as a reliable indicator of intracranial compliance. More recently, advanced brain imaging segmentation techniques may offer a promising approach to predict the severity of intracranial hypertension by allowing a more precise assessment of structural changes[ 27 , 28 ]. Early identification of such patients may allow for earlier CSF drainage, potentially before refractory ICH develops, and improve the chances of a favorable response to treatment. This is particularly interesting given that the compression of the ventricular system could lead to a CSF shift from the cerebral cisterns to the brain through the para-vascular spaces, thereby worsening brain edema[ 29 ]. CSF drainage might reduce venous pressure and cisterna compression and facilitate interstitial fluid drainage, thereby limiting brain edema and act as a prevention tool to prevent[ 30 , 31 ]. In our study, later placement of the drain was associated with a higher likelihood of treatment success. However, these findings should be interpreted with caution, as the association likely reflects the severity and timing of ICH rather than a direct benefit of delayed EVD placement. The study was not designed for this question, and we cannot determine whether earlier drainage— as a preemptive treatment—might have prevented the development of refractory ICH or could have improved long-term prognosis[ 32 ]. Limitations This report has some limitations, and the results should be interpreted cautiously. First, the possibility of unmeasured confounders could have fault to identify significant results. Second, to characterize basal cisterns and ventricular size, we adopted a pragmatic classification system, given the absence of a standardized or widely validated approach in the current medical literature. Though this method lacks formal validation, it reflects common clinical practice and offers a reproducible framework for clinicians. Third, to ensure that centers were applying a consistent treatment strategy, we deliberately shortened the inclusion period. However, we cannot exclude the possibility that some patients may have directly received Tier 3 interventions such as secondary decompressive craniectomy, as local conditions—mass effect or hematoma—might have prevented the placement of an external ventricular drain[ 33 ]. Finally, a major limitation of this study is the absence of long-term outcome such as 6-month Glasgow Outcome Scale data in our national registry, which prevented a comprehensive analysis of neurological outcomes in this cohort[ 34 ]. Conclusions In this multicenter cohort of refractory traumatic ICH, EVD effectively controlled intracranial pressure in half of the cases, with a low complication rate. EVD efficacy was associated with lower ICP values, lower level of sedation, preserved basal cisterns and a slower onset of intracranial hypertension prior to EVD insertion. Abbreviations EVD External ventricular drainage TBI Traumatic brain injury ICP Intracranial pressure ICH Intracranial hypertension CT Computer tomography CSF Cerebrospinal fluid ISS Injury Severity Score SAPS II Simplified acute physiology score Declarations We confirm that the manuscript is original, complies with all instructions to authors. Authors ‘Contributions All authors have made substantial contributions to this work and have approved the final version of the manuscript. Data collection and quality control: All Authors. Concept and design: JDM, BC, CG, BC Statistical analysis: BC. Interpretation of data: JDM, BC, BC. Writing original draft: JDM, BC, BC, CG. Writing review and editing: all authors. We confirm that all authors have approved the final version. We confirm that the manuscript has not been published, and is not under consideration elsewhere. Ethics approval The TraumaBase group obtained approval for retrospective data use, from the Institutional Review Board (Comité de Protection des Personnes, Paris VI, Pitié, president Pr Laurent Lacapelle, Bâtiment de la Force, 47 Boulevard de l’Hôpital, 75651 Paris Cedex 13, 28 November 2012) and from the Advisory Committee for Information Processing in Health Research (Comité consultatif sur le traitement de l’information en matière de recherche dans le domaine de la santé, authorisation 11.305bis) and from the National Commission for Data Protection (Commission Nationale de l’Informatique et des Libertés, authorisation 911461). This study has been approved by the ethics committee of the French Society of Anesthesiology and Intensive Care (SFAR) IRB: 00010254 ‐ 2024 – 114 Competing interests The authors declare that they have no known conflict of interest in relationship to this work. We confirm the use of reporting checklist Funding The Traumabase registry is funded by several Agence régionale de Santé (Île‑de‑France, Occitanie, Grand‑est, Haut‑de‑France, Auvergne‑Rhône‑Alpes). The Traumabase registry is also funded by the French road safety observatory (Observatoire National Interministériel de la Sécurité Routière). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. Acknowledgment The Traumabase group, listed as contributors: Arthur James, Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital; Fanny Bounes, CHU de Toulouse – Rangueil; Mickael Cardinale, Military Teaching Hospital Sainte Anne; Anne Galland, Hôpital Européen Georges Pompidou, AP-HP; Alexandre Bourgeois, CHRU Lille; Pierre Etienne Leblanc, Hôpital Bicêtre, APHP; Anatole Harrois, Hôpital Bicêtre, APHP; Paer-Selim Abback, CHU Tours References Paget L-M, Boutonnet M, Moyer J-D, Delhaye N, D’Aranda E, Beltzer N, et al. Trauma centre admissions for traumatic brain injury in France: One-year epidemiological analysis of prospectively collected data. Anaesth Crit Care Pain Med. 2021;40:100804. Stocchetti N, Maas AIR. Traumatic intracranial hypertension. N Engl J Med. 2014;370:2121–30. Vik A, Nag T, Fredriksli OA, Skandsen T, Moen KG, Schirmer-Mikalsen K, et al. 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A management algorithm for adult patients with both brain oxygen and intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive Care Med. 2020;46:919–29. Meyfroidt G, Bouzat P, Casaer MP, Chesnut R, Hamada SR, Helbok R, et al. Management of moderate to severe traumatic brain injury: an update for the intensivist. Intensive Care Med. 2022;48:649–66. Liu H, Wang W, Cheng F, Yuan Q, Yang J, Hu J, et al. External Ventricular Drains versus Intraparenchymal Intracranial Pressure Monitors in Traumatic Brain Injury: A Prospective Observational Study. World Neurosurg. 2015;83:794–800. Griesdale DEG, McEwen J, Kurth T, Chittock DR. External ventricular drains and mortality in patients with severe traumatic brain injury. Can J Neurol Sci J Can Sci Neurol. 2010;37:43–8. Kerr ME, Weber BB, Sereika SM, Wilberger J, Marion DW. Dose response to cerebrospinal fluid drainage on cerebral perfusion in traumatic brain-injured adults. Neurosurg Focus. 2001;11:E1. Timofeev I, Dahyot-Fizelier C, Keong N, Nortje J, Al-Rawi PG, Czosnyka M, et al. Ventriculostomy for control of raised ICP in acute traumatic brain injury. Acta Neurochir Suppl. 2008;102:99–104. Akbik OS, Krasberg M, Nemoto EM, Yonas H. Effect of Cerebrospinal Fluid Drainage on Brain Tissue Oxygenation in Traumatic Brain Injury. J Neurotrauma. 2017;34:3153–7. Candanedo C, Doron O, Hemphill JC, Ramirez de Noriega F, Manley GT, Patal R, et al. Characterizing the Response to Cerebrospinal Fluid Drainage in Patients with an External Ventricular Drain: The Pressure Equalization Ratio. Neurocrit Care. 2019;30:340–7. Lescot T, Boroli F, Reina V, Chauvet D, Boch A-L, Puybasset L. Effect of continuous cerebrospinal fluid drainage on therapeutic intensity in severe traumatic brain injury. Neurochirurgie. 2012;58:235–40. Moyer J-D, Elouahmani S, Codorniu A, Abback P-S, Jeantrelle C, Goutagny S et al. External ventricular drainage for intracranial hypertension after traumatic brain injury: is it really useful? Eur J Trauma Emerg Surg Off Publ Eur Trauma Soc. 2022. Moyer J-D, Hamada SR, Josse J, Auliard O, Gauss T, Traumabase Group. Trauma reloaded: Trauma registry in the era of data science. Anaesth Crit Care Pain Med. 2021;40:100827. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335:806–8. Marshall LF, Marshall SB, Klauber MR, Clark MVB, Eisenberg HM, Jane JA, et al. A new classification of head injury based on computerized tomography. J Neurosurg. 1991;75:S14–20. Tunkel AR, Hasbun R, Bhimraj A, Byers K, Kaplan SL, Scheld WM, et al. 2017 Infectious Diseases Society of America’s Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis Off Publ Infect Dis Soc Am. 2017;64:e34–65. Noguchi K, Gel YR, Brunner E, Konietschke F. nparLD: An R Software Package for the Nonparametric Analysis of Longitudinal Data in Factorial Experiments. J Stat Softw [Internet]. 2012 [cited 2025 May 25];50. Available from: http://www.jstatsoft.org/v50/i12/ Langfitt TW, Weinstein JD, Kassell NF. CEREBRAL VASOMOTOR PARALYSIS PRODUCED BY INTRACRANIAL HYPERTENSION. Neurology. 1965;15:622–41. Bögli SY, Beqiri E, Olakorede I, Cherchi MS, Smith CA, Chen X, et al. Unlocking the potential of high-resolution multimodality neuromonitoring for traumatic brain injury management: lessons and insights from cases, events, and patterns. Crit Care. 2025;29:139. Portella G, Cormio M, Citerio G, Contant C, Kiening K, Enblad P, et al. Continuous cerebral compliance monitoring in severe head injury: its relationship with intracranial pressure and cerebral perfusion pressure. Acta Neurochir (Wien). 2005;147:707–13. discussion 713. Fernando SM, Tran A, Cheng W, Rochwerg B, Taljaard M, Kyeremanteng K, et al. Diagnosis of elevated intracranial pressure in critically ill adults: systematic review and meta-analysis. BMJ. 2019;366:l4225. Schieren M, Wappler F, Wafaisade A, Lefering R, Sakka SG, Kaufmann J, et al. Impact of blunt chest trauma on outcome after traumatic brain injury– a matched-pair analysis of the TraumaRegister DGU®. Scand J Trauma Resusc Emerg Med. 2020;28:21. Shan Y, Xue Y, Zhu J, Vande Vyvere T, Pisică D, Maas A, et al. Development and validation of intracranial hypertension prediction models based on radiomic features in patients with traumatic brain injury: an exploratory study based on CENTER-TBI data. Crit Care. 2025;29:100. Zhang L, Zhuang Q, Wu G, Yu J, Shi Z, Yuan Q, et al. Combined Radiomics Model for Prediction of Hematoma Progression and Clinical Outcome of Cerebral Contusions in Traumatic Brain Injury. Neurocrit Care. 2022;36:441–51. Cherian I, Beltran M, Landi A, Alafaci C, Torregrossa F, Grasso G. Introducing the concept of CSF-shift edema in traumatic brain injury. J Neurosci Res. 2018;96:744–52. Iliff JJ, Wang M, Liao Y, Plogg BA, Peng W, Gundersen GA et al. A Paravascular Pathway Facilitates CSF Flow Through the Brain Parenchyma and the Clearance of Interstitial Solutes, Including Amyloid β. Sci Transl Med [Internet]. 2012 [cited 2023 Mar 14];4. Available from: https://www.science.org/doi/ 10.1126/scitranslmed.3003748 Hussain R, Tithof J, Wang W, Cheetham-West A, Song W, Peng W, et al. Potentiating glymphatic drainage minimizes post-traumatic cerebral oedema. Nature. 2023;623:992–1000. Taylor JD, Bailey M, Cooper DJ, French C, Menon DK, Nichol AD, et al. Association Between Early External Ventricular Drain Insertion and Functional Outcomes 6 Months Following Moderate-to-Severe Traumatic Brain Injury. J Neurotrauma. 2024;41:1364–74. Cnossen MC, Huijben JA, van der Jagt M, Volovici V, van Essen T, Polinder S, et al. Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. Crit Care Lond Engl. 2017;21:233. McCrea MA, Giacino JT, Barber J, Temkin NR, Nelson LD, Levin HS, et al. Functional Outcomes Over the First Year After Moderate to Severe Traumatic Brain Injury in the Prospective, Longitudinal TRACK-TBI Study. JAMA Neurol. 2021;78:982–92. 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Alpes","correspondingAuthor":false,"prefix":"","firstName":"Benoit","middleName":"","lastName":"Champigneulle","suffix":""}],"badges":[],"createdAt":"2025-07-02 10:30:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7028290/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7028290/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s12028-025-02394-y","type":"published","date":"2025-10-09T15:56:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87045293,"identity":"be3ebfed-fd03-479b-a622-d90972d72c88","added_by":"auto","created_at":"2025-07-18 14:30:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":40595,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStudy flow chart\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eTBI: traumatic brain injury; EVD: extra-ventricular drainage; ICP: intracranial pressure.\u003c/p\u003e","description":"","filename":"Fig1FlowChart.png","url":"https://assets-eu.researchsquare.com/files/rs-7028290/v1/58aa80e5f211ff673af1c894.png"},{"id":87046460,"identity":"e2b94b5e-c87e-4307-8aae-93186d2a3476","added_by":"auto","created_at":"2025-07-18 14:38:09","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2447697,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAlluvial diagram showing the evolution of management strategies and outcomes at ICU discharge\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe diagram illustrates patient trajectories from initial clinical presentation through different treatment interventions—including EVD insertion and sedation strategies—to neurological outcome at ICU discharge\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7028290/v1/a0c0157107d73c72c7549b8b.png"},{"id":87045294,"identity":"3890812a-b19a-48e9-a7ce-24e950744be1","added_by":"auto","created_at":"2025-07-18 14:30:09","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":29756,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDaily intracranial pressure trends (panel A) and daily cumulative cerebrospinal fluid drainage volume (panel B) before and after external ventricular drainage according to the success or the failure of EVD therapy.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEVD: extra-ventricular drainage; ICP: intracranial pressure, CSF cerebro-spinal fluid.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBoxplots represent the median with 25\u003c/em\u003e\u003csup\u003e\u003cem\u003eth\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e and 75\u003c/em\u003e\u003csup\u003e\u003cem\u003eth\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e percentiles (lower and upper hinges). Whiskers extend from the corresponding hinge to the highest or lowest value not further than 1.5 × interquartile range. For clarity, outliers were not represented.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7028290/v1/34549d96b144669df334962d.png"},{"id":93419823,"identity":"83723b2e-6c44-4dd4-8e43-5a6cffc31c75","added_by":"auto","created_at":"2025-10-13 16:08:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3826003,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7028290/v1/0b171250-acca-4aff-b607-46c963d4ed45.pdf"},{"id":87048260,"identity":"abac81d3-ea5b-4648-ac76-867755b52cf3","added_by":"auto","created_at":"2025-07-18 14:46:09","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16971,"visible":true,"origin":"","legend":"","description":"","filename":"checklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-7028290/v1/8888df5147cb07db3fc9d9a4.docx"},{"id":87046458,"identity":"5475b75c-b137-4416-871f-2a84b3951dc2","added_by":"auto","created_at":"2025-07-18 14:38:09","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":20290,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-7028290/v1/bf8a84b12d3c3554aaffdd6c.docx"}],"financialInterests":"","formattedTitle":"Efficacy and Predictors of Success of External Ventricular Drainage for The Management of Traumatic Intracranial Hypertension: A Retrospective Multicenter Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTraumatic brain injury (TBI) is a major public health concern affecting mostly young, victims of road traffic accidents, and elderly, victims of falls[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Among patients with severe TBI, intracranial hypertension (ICH) is a critical secondary complication, typically resulting from the combined mass effect of hematomas, cerebral contusions, and diffuse swelling[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The development of increased intracranial pressure (ICP) in patients with traumatic brain injury is associated with a higher risk of death and poor outcome[\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e–\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. If left untreated, rising ICP can lead to cerebral herniation, cerebral circulatory arrest and death. Management of elevated ICP in TBI is based on a tiered therapeutic framework, progressing from first-line interventions to more invasive measures such as barbiturate-induced coma, secondary decompressive craniectomy, or mild hypothermia[\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e–\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Among available interventions, external ventricular drainage (EVD) offers a dual benefit: continuous cerebrospinal fluid (CSF) diversion and real-time ICP monitoring[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. By draining intraventricular fluid, EVD reduces ICP and improves intracranial compliance, which may secondarily enhance cerebral perfusion by optimizing the balance between arterial inflow and intracranial resistance. Several studies have demonstrated reductions in ICP and improvements in cerebral perfusion pressure following EVD placement[\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e–\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, despite its widespread use, high-quality evidence on EVD’s role in reducing the need for therapeutic escalation remains scarce. Most available data are retrospective, from single-center studies, and with a limited external validity[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. One such study reported a 40% success rate—defined as avoidance of progression to more aggressive therapies—with a low incidence of complications. Nevertheless, its retrospective, monocentric design and extended inclusion period limit the generalizability of the findings. Considering these limitations, a multicenter study is warranted to better characterize the real-world effectiveness and safety profile of EVD in the management of ICP after TBI. Such an approach may help identify clinical or radiological predictors of EVD success and refine therapeutic decision-making. This study aims to evaluate the effectiveness of EVD in controlling intracranial pressure and reducing the need for therapeutic escalation in a multicenter cohort, and to identify clinical and radiological factors associated with treatment success.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis retrospective cohort study was conducted between 1st January 2019 and 31st December 2022 across nine level 1 trauma centers in France participating in the Traumabase\u003csup\u003e®\u003c/sup\u003e registry (supplementary material 1). The Traumabase\u003csup\u003eⓇ\u003c/sup\u003e registry is a comprehensive database that compiles trauma cases from 31 hospitals nationwide[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Guidelines for reporting this retrospective study were from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement (supplementary material 2)[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eData source\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll patients aged 16 years or older with TBI (defined as bleeding on the initial brain CT scan) and ICP monitoring (using an intraparenchymal probe) admitted to intensive care unit were screened for inclusion. All patients who developed ICH during their ICU stay and required EVD for CSF drainage to control ICP were included. Patients that required EVD after primary decompressive craniectomy or for posttraumatic hydrocephalus were excluded. Data for all participating patients were extracted from the Traumabase\u003csup\u003e®\u003c/sup\u003e registry and completed by review of the medical charts.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTrauma brain injury management\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll participating centers reported adherence to a shared, stepwise, protocol-based approach for the management of TBI, grounded in national French recommendations and international guidelines, including those of the Seattle International Brain Injury Consensus Conference (SIBICC)[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. While treatment decisions remained the responsibility of local teams, they were made within this common framework. Across all centers, EVD was used exclusively for the therapeutic management of ICH—not for ICP monitoring— when maximal medical therapies (tier-one therapies) failed to control ICP (ICP \u0026gt; 22 mmHg for at least 10 minutes) (supplementary material 3). Placement decisions were individualized through multidisciplinary discussions.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEVD management\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn all participating centers, drain placement was performed by the neurosurgical team following each center’s local protocol. Across all participating sites, catheter insertion was guided by standard anatomical landmarks. When considered necessary, neuronavigation\u003cb\u003e-\u003c/b\u003eassited surgery were used to ensure accurate placement. EVD management, including the choice of continuous or intermittent drainage and the selected drainage height, was left to the discretion of each participating center.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe collected data included demographic characteristics (age, sex, height, weight, and mechanism of injury), as well as prehospital clinical parameters. These included the initial Glasgow Coma Scale (GCS) score, the presence of pupillary abnormalities (unilateral or bilateral mydriasis), hemodynamic and respiratory status at the time of prehospital assessment and administered therapeutics (orotracheal intubation and mechanical ventilation, norepinephrine and osmotherapy). Upon hospital admission, the presence of hemorrhagic shock—defined as the transfusion of six or more units of packed red blood cells within 24 hours—and initial laboratory findings (platelets, prothrombin time and fibrinogen levels) were recorded. Injury severity was assessed on initial whole-body CT using the Abbreviated Injury Scale (AIS), with the maximum AIS recorded for each body region (head, face, chest, abdomen, and lower extremities). The initial brain CT-scan was also used to determine the Marshall classification score[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In the intensive care unit, the number of sedative drugs (one sedative drugs: midazolam or propofol; combination: propofol and midazolam), the use of osmotherapy (20% mannitol or hypertonic saline) or barbiturate before and after EVD placement were documented. Intracranial pressure measurements were collected from the day prior to EVD placement up to day 4 post-procedure. The volume of daily cerebrospinal fluid collected through EVD was recorded over the same period. Brain imaging data on the last CT scan before drain insertion, including ventricular size and visibility of the basal cisterns, were jointly assessed by a senior radiologist and the attending intensivist at each participating center. Complications related to EVD were noted, including catheter obstruction requiring replacement, and accidental catheter removal. Potential hemorrhagic complications induced by EVD placement were described on the first post-EVD brain CT scan. Healthcare associated ventriculitis was defined according to the 2017 Infectious Diseases Society of America's Clinical Practice Guidelines[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A CSF culture was mandatory to establish the diagnosis of ventriculitis. Clinical outcomes included length of stay in the intensive care unit, in-hospital mortality and the Glasgow Outcome Scale–Extended (GOS-E) at ICU discharge.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOutcomes\u003c/b\u003e\u003c/p\u003e\u003cp\u003eEVD success was defined as the ability of EVD to avoid a rebound of ICP requiring the use of the third-tier therapies (mild hypothermia, secondary decompressive craniectomy, barbiturate coma) or a decision to withdraw life-sustaining treatment (WLST) due to both refractory ICH and severity of brain injury lesions. Conversely, EVD failure was defined as a lack of ICP control requiring third-tier therapies or a decision to WLST after the implementation of the EVD. A good outcome at ICU discharge was defined as GOS-E ≥ 4.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eCategorical variables were expressed as absolute counts and percentages (%). As their distributions were mostly skewed, continuous variables were expressed as median [25th ,75th percentiles].\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFactors associated with EVD success\u003c/strong\u003e\u003c/p\u003e\u003cp\u003ea univariate analysis was first performed between EVD success and EVD failure subgroup of patients, using a Fisher’s exact or a Pearson’s Chi-squared test as appropriate for the categorical variables and using a Mann-Whitney \u003cem\u003eU\u003c/em\u003e test for the continuous variables. No imputation was performed for missing values. To identify independent predictors of EVD success, a multivariate logistic regression was afterward performed using a backward stepwise selection and initially including the variables with a p-value \u0026lt; 0.20 in the univariate analysis as potential predictors. Multicollinearity among predictors was ruled out using variance inflation factors computation. Good-of-fitness of the final model was assessed by the Hosmer–Lemeshow test.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eChanges in therapeutic after EVD insertion\u003c/strong\u003e\u003c/p\u003e\u003cp\u003ean alluvial plot was generated to visualize the transition in term of hypnotic sedative regimen or third tier therapy requirement, following EVD placement in accordance with the EVD success or failure.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eChanges in ICP trends and cerebrospinal fluid drainage volume\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe trend in maximal ICP value recorded by day (24 hours before EVD insertion, then until 4 days after) and as well as the cerebrospinal fluid volume drained by day following EVD placement were compared among the EVD failure and the EVD success subgroups of patients. As the data did not fulfill the required assumptions for a linear mixed-effect model, a non-parametric approach for repeated measures was used using the \u003cem\u003enparLD\u003c/em\u003e R package to test the two-way interaction of EVD success × time. In case of significant interaction, between-group post-hoc comparisons tests were performed at each time point using Mann-Whitney \u003cem\u003eU\u003c/em\u003e test with Bonferroni corrections[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAll tests were two sided, and a \u003cem\u003ep\u003c/em\u003e-value of \u0026lt; 0.05 was considered significant. All statistical analyses were performed using the R software (v.4.4.1, The R Foundation for Statistical Computing, Vienna, Austria) and GraphPad Prism (v.9.5.0, GraphPad Software, Boston, MA, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eStudy population\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAmong 912 patients admitted for TBI and who underwent ICP monitoring across the nine participating centers during the study period, 176 patients treated with EVD were included (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the key characteristics of the study cohort. Patients were mostly young males and presented with a median initial GCS of 7 [IQR 4; 11]. The median ISS was 25 [19; 33] with a head AIS of 4 [4; 5]. The EVD insertion occurred after a median time of 17 [6; 49] hours after admission and the median length of CSF drainage was 9 [5; 14] days. Continuous EVD drainage was used in almost all patients (99%) (Supplementary materials 4). Glasgow outcome scale at hospital discharge was 2 [1; 4] (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of the overall population according to the success or failure of extra ventricular drain.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMissing values\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;176)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEVD failure\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;88)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eEVD success\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;88)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eClinical characteristics\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41 [26,\u0026nbsp;57]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38 [27,\u0026nbsp;55]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45 [26,\u0026nbsp;59]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e150 (85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e74 (84)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e76\u0026nbsp;(86)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e175 [170,\u0026nbsp;180]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e176 [170,\u0026nbsp;180]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e175 [170,\u0026nbsp;180]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight (kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e78 [70,\u0026nbsp;86]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81 [71,\u0026nbsp;86]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75 [65,\u0026nbsp;85]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrehospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCause of injury, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Road traffic accident\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84 (48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44 (50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e40 (45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Fall\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74 (42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33 (38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e41 (47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Other\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 (8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInitial Glasgow Coma Scale score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 [4,\u0026nbsp;10]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 [4,\u0026nbsp;11]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInitial motor Glasgow coma score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u0026nbsp;[1,\u0026nbsp;5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u0026nbsp;[1,\u0026nbsp;5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4\u0026nbsp;[1,\u0026nbsp;5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePupillary abnormalities, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49\u0026nbsp;(28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31\u0026nbsp;(36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18\u0026nbsp;(21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.028\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInitial arterial blood pressure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Systolic blood pressure (mmHg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e140 [120\u0026ndash;160]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e144 [127\u0026ndash;164]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e132 [120\u0026ndash;160]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Diastolic blood pressure (mmHg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e82 [70\u0026ndash;93]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85 [71\u0026ndash;98]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e82 [70\u0026ndash;90]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInitial Heart rate (beat/min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87 [72\u0026ndash;103]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e84 [72\u0026ndash;107]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e88 [72\u0026ndash;100]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEpisode of hypotension (SBP\u0026thinsp;\u0026lt;\u0026thinsp;110 mmHg), n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37 (27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16 (23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21 (31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEpisode of hypoxemia (SpO2\u0026thinsp;\u0026lt;\u0026thinsp;92%), n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (19)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9 (13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOsmotherapy (Mannitol or HSS), n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45 (54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27 (57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18 (50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOrotracheal Intubation, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e136\u0026nbsp;(80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69\u0026nbsp;(81)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e67\u0026nbsp;(78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital admission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHemorrhagic shock, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12 (14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHemoglobin (g/dL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.0 [11.4,\u0026nbsp;14.1]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.2 [11.6,\u0026nbsp;14.3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.0 [11.4,\u0026nbsp;14.0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlatelets (G/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e214 [169,\u0026nbsp;264]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e210 [165,\u0026nbsp;268]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e223 [172,\u0026nbsp;257]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePT ratio\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.06 [1.00,\u0026nbsp;1.20]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.12 [100,\u0026nbsp;1.21]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.05 [100,\u0026nbsp;1.20]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFibrinogen (g/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.40 [2.00,\u0026nbsp;2.90]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.30 [1.85,\u0026nbsp;2.85]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.40 [2.05,\u0026nbsp;2.90]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarshall score, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Diffuse Injury II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60 (34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23 (26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37 (42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Diffuse injury III\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31 (18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19 (22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12 (14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Diffuse Injury IV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8 (9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10 (11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Evacuated Mass lesion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18 (20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Non evacuated Mass lesion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39 (22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28 (32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11 (13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eISS score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e25 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; AIS head\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; AIS face\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 [0, 1]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 [0, 1]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 [0, 1]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; AIS Thorax\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 [0, 3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 [0, 3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 [0, 2]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.012\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; AIS abdomen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 [0, 0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 [0, 0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 [0, 0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; AIS extremities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 [0, 0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 [0, 0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 [0, 0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSAPS II score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47 [38, 57]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50 [39, 58]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e47 [38, 56]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eBefore extra ventricular drainage\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeurosurgical procedure (first 24h)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e73 (41)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e34 (39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e39 (44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICP monitoring, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e176 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e176 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e176 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSedative drugs, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; One sedative (propofol or midazolam)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77 (44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30 (34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e47 (53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Combination (propofol and midazolam)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e99 (56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e58 (66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e41 (47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBolus of osmotherapy, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e115 (65)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e63\u0026nbsp;(72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e52\u0026nbsp;(59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBolus of barbiturate, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22\u0026nbsp;(25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13\u0026nbsp;(15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNorepinephrine to maintain CPP at 60\u0026ndash;70 mmHg n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e176 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e88 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e88 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTranscranial Doppler upon admission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Pulsatility index\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.3 [1.0,\u0026nbsp;1.7]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.3 [1.0,\u0026nbsp;1.7]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.2 [1.0,\u0026nbsp;1.7]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Diastolic velocity (cm/s)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e102\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27 [17,\u0026nbsp;33]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21[15,\u0026nbsp;30]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30 [25,\u0026nbsp;37]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCisternal basal, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Normal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e112 (64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43 (49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e69 (78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Compressed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53 (30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35 (40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18 (20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Obliterated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLateral Ventricles, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Normal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80 (45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31 (35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e49 (56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Compressed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e79 (45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45 (51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e34 (39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Obliterated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5 (5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime from admission to EVD placement (hours)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 [6 ;\u0026nbsp;49]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u0026nbsp;[6;\u0026nbsp;31]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24\u0026nbsp;[6;\u0026nbsp;92]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eAfter extra ventricular drainage\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTier-three therapies \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Barbiturate coma, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30 (34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Hypothermia (32\u0026ndash;35\u0026deg;C), n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e49 (56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Decompressive craniectomy, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29 (16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29 (33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRefractory ICP leading to early WSTL, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23\u0026nbsp;(13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23 (26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSedative drugs within 24h after EVD, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; No sedative drug\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38 (22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e38 (43)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; One sedative (propofol or midazolam)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53 (30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e41 (47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Combination (propofol and midazolam)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85 (48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e76 (86)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9 (10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEVD duration (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 [5,\u0026nbsp;14]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 [2,\u0026nbsp;12]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11 [9,\u0026nbsp;15]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplications of extra ventricular drainage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHematoma on EVD path, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; \u0026lt;\u0026thinsp;1cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5 (6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; \u0026ge;\u0026thinsp;1cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVentriculitis, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5 (6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObstruction requiring drain replacement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10 (11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnintended ablation, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eOutcomes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICU mortality n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e81 (46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60\u0026nbsp;(68)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21\u0026nbsp;(24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICU length of stay (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24\u0026nbsp;[10,\u0026nbsp;39]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e29 [20, 43]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGOS-E at ICU discharge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 [1;\u0026nbsp;4]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 [1;\u0026nbsp;3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 [2;\u0026nbsp;5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eEVD: external ventricular drainage; SBP: systolic blood pressure; SpO2 ISS: Injury Severity Score; HSS: hypertonic saline solution; ICP: intracranial pressure; AIS: Abbreviated Injury Scale; PTr: Prothrombin Time ratio; GOS-E: Glasgow outcome scale extended; SAPS II: Simplified acute physiology score II, ICU: intensive care unit; CT: computer tomography.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eData were expressed as median (interquartile range [IQR]) for quantitative variables and count (percentage) for qualitative variables.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003e Thier-three therapies were combinate in some patients.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eRate and factors associated with success\u003c/b\u003e\u003c/p\u003e\u003cp\u003eEVD success occurred in 88 patients (50%). The clinical course following EVD insertion and ICU discharge outcome is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Among the 88 patients with EVD failure, 29 (16%) patients required a decompressive craniectomy (isolated or associated with another thier-three therapy), 49 (56%) patients received mild hypothermia (isolated or associated with another thier-three therapy) and in 23 cases (26%) refractory ICH led to an early decision to WLST (i.e., their-three therapy deemed futile).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn univariate analysis, the time from admission to drain insertion was longer in the success group compared to the failure group (24 [6; 92] vs 13 [6; 31], p\u0026thinsp;=\u0026thinsp;0.02). TBI and trauma severity respectively assessed by the initial GCS (7 [5; 11] \u003cem\u003evs\u003c/em\u003e. 6 [3; 9], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.31) and the ISS (25 [17; 29] \u003cem\u003evs\u003c/em\u003e. 25 [20; 33], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.10) did not differ between groups while thoracic injury severity, reflected by AIS thorax scores, (0 [0; 2] \u003cem\u003evs\u003c/em\u003e. 2 [0; 3], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.012) was lower in the success group. Biological parameters at admission did not differ between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBefore EVD, the maximal ICP was lower in the success group (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). A combination of sedative drugs and bolus of osmotherapy were administrated less frequently in the EVD success group (41 (47%) \u003cem\u003evs.\u003c/em\u003e 58 (66%) p\u0026thinsp;=\u0026thinsp;0.01). On the last brain CT-scan prior to EVD insertion, basal cisterns (69 (78%) \u003cem\u003evs.\u003c/em\u003e 43 (49%), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and ventricular size (31 (35%) \u003cem\u003evs\u003c/em\u003e. 49 (56%), \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.015) were more frequently described as normal in the EVD success group (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFollowing EVD, the maximal ICP decrease was significantly greater in the success group vs. the failure group (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA) whereas there was no statistical difference in daily CSF drainage between both group (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). In the success group, 38 patients (43%) were not receiving any sedative drugs 24 hours after drain insertion, whereas 76 patients (86%) in the failure group were receiving a combination of sedative drugs (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn multivariate analysis, several factors were independently associated with a lower likelihood of EVD success, including the severity of chest trauma (OR 0.79; 95% CI 0.64\u0026ndash;0.99, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.039), the use of combined sedative drugs (OR 0.28; 95% CI 0.12\u0026ndash;0.62, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), and the presence of obliterated basal cisterns on brain CT prior to EVD placement (OR 0.07; 95% CI 0.00\u0026ndash;0.39, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.013). Conversely, EVD placement occurring more than 24 hours after admission was independently associated with success (OR 3.07; 95% CI 1.41\u0026ndash;7.01, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFactors associated with external ventricular success in multivariate analysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOdds ratio (95% confidence interval)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAIS Thorax\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.79 (0.64\u0026ndash;0.99)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.039\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-EVD sedative drugs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; One sedative drug\u003c/p\u003e\u003cp\u003e\u0026bull; Combination of sedative drugs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003cp\u003e0.28 (0.12\u0026ndash;0.62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-EVD bolus of barbiturate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.49 (0.20\u0026ndash;1.16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-EVD bolus of osmotherapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.50 (0.23\u0026ndash;1.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.065\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCisternal basal on CT-scan before EVD placement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Normal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Compressed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.42 (0.19\u0026ndash;0.88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.023\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Obliterated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.07 (0.00\u0026ndash;0.39)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.013\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime from admission to EVD placement\u0026thinsp;\u0026ge;\u0026thinsp;24h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.07 (1.41\u0026ndash;7.01)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eGood-of-fitness Hosmer-Lemeshow p-value was 0.605.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eAIS: Abbreviated Injury Scale; EVD: external ventricular drainage, CT: computer tomography.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eComplications of EVD\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn 7 cases (4%) an EVD associated bacterial ventriculitis was documented. Four of them were related to gram-positive bacteria (\u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e) and three of them were relative to gram-negative bacteria \u003cem\u003e(Pseudomonas aeruginosa, Enterobacter cloacae, Citrobacter koseri)\u003c/em\u003e. In 18 patients (10%), an EVD associated intracranial hemorrhage was diagnosed on the first CT-scan after drain insertion; twelve patients (7%) had a hematoma\u0026thinsp;\u0026lt;\u0026thinsp;1cm and 6 (3%)\u0026thinsp;\u0026ge;\u0026thinsp;1cm along the drain. None required surgical management.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this multicenter cohort study, EVD used in a tiered approach allowed an effective control of refractory elevated intracranial pressure after TBI in approximately 50% of cases without major complications. Clinical and radiological markers of severe ICH such as the absence of basal cistern compression, and post-EVD parameters, including a more significant reduction in ICP, were associated with EVD efficiency. These findings may help refine patient selection in the future and support earlier adaptation of therapeutic strategies, avoiding delays in escalation and facilitating timely transition to tier-three interventions.\u003c/p\u003e\u003cp\u003eThe success rate observed in our study is consistent with the limited data previously published who reported that EVD successfully controlled intracranial hypertension in 40 to 50% of patients with TBI[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, this success rate underscores the need to better identify which patients are most likely to benefit from EVD. To our knowledge, no clinical or radiological criteria have been clearly established to identify TBI patients most likely to benefit from EVD and our study is the first to provide early insights into this question. As such, our findings cannot be directly compared to prior literature, which has focused on the general efficacy or safety of EVD rather than patient selection. However, the factors associated with EVD success in our study are consistent with the underlying pathophysiology of intracranial compliance[\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Intracranial compliance refers to the capacity of the intracranial compartment to accommodate volume changes without a significant rise in ICP. According to the Monro-Kellie doctrine, any increase in the volume of one of the three intracranial compartments \u0026mdash; brain parenchyma, cerebral blood volume, or cerebrospinal fluid (CSF) \u0026mdash; must occur at the expense of another. This compliance is primarily maintained by the displacement of venous blood and CSF from the intracranial space, but intracranial compliance is limited. Once these compensatory mechanisms are exhausted, even small increases in intracranial volume result in disproportionate elevations in ICP. Our findings align with these physiological mechanisms. Lower levels of sedation and a normal aspect of basal cisterns probably reflecting less severe ICH and better intracranial compliance. The normal appearance of basal cisterns on CT imaging may serve as an indirect indicator of intracranial CSF reserve, itself being one of the component of cerebral compensatory reserve[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The concept of cerebral compensatory is thus intrinsically linked to the CSF reserve and a higher CSF reserve reflects a greater ability to respond to therapeutic interventions such as CSF drainage. Although the daily difference in CSF volume drained did not reach statistical significance, the observed trend and the overall CSF volume drained appears to support this concept of CSF reserve, with higher drainage volumes in the success group. At the opposite, when intracranial hypertension is already severe both clinically and radiologically prior to CSF drainage, it is likely that the brain's compensatory mechanisms have already been exhausted. In such cases, EVD alone may be insufficient to produce a significant reduction in intracranial pressure. This situation may be further aggravated by the presence of extracranial injuries, particularly thoracic trauma. Thoracic injuries have been associated with less favorable neurological outcomes following TBI, likely due to their contribution to the systemic inflammatory response and their propensity to induce hypoxia and hypercapnia\u0026mdash;two key factors known to aggravate intracranial hypertension[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Noteworthy, the variables identified in multivariate analysis, when considered individually, do not reliably predict failure, likely reflecting inter-individual differences in cerebral compliance. Therefore, beyond pre-EVD characteristics, it is crucial to integrate post-EVD indicators to identify patients at risk of inadequate ICH control. Our findings suggest that when CSF drainage is effective, clinical improvement typically occurs rapidly, with sedation often reduced or discontinued within the first 24 hours, potentially shortening both sedation duration. The absence of such early improvement should prompt consideration of timely escalation to tier-three therapies.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePerspective\u003c/span\u003e\u003c/p\u003e\u003cp\u003eIntracranial compliance reserve appears to play a key role in the success of EVD and once intracranial compliance is severely impaired, EVD may no longer be sufficient to control intracranial hypertension. This highlights the potential value of individualized strategies to detect early signs of compliance deterioration to optimize EVD placement and patient selection. The P1/P2 ratio, which quantifies the relationship between the percussion wave (P1) and the tidal wave (P2) \u0026mdash; reflecting the elastic properties of brain tissue \u0026mdash; is the most validated measure of compliance. The ICP waveform shape (e.g., the shape index or the compensatory reserve index) has also emerged as a reliable indicator of intracranial compliance. More recently, advanced brain imaging segmentation techniques may offer a promising approach to predict the severity of intracranial hypertension by allowing a more precise assessment of structural changes[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Early identification of such patients may allow for earlier CSF drainage, potentially before refractory ICH develops, and improve the chances of a favorable response to treatment. This is particularly interesting given that the compression of the ventricular system could lead to a CSF shift from the cerebral cisterns to the brain through the para-vascular spaces, thereby worsening brain edema[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. CSF drainage might reduce venous pressure and cisterna compression and facilitate interstitial fluid drainage, thereby limiting brain edema and act as a prevention tool to prevent[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In our study, later placement of the drain was associated with a higher likelihood of treatment success. However, these findings should be interpreted with caution, as the association likely reflects the severity and timing of ICH rather than a direct benefit of delayed EVD placement. The study was not designed for this question, and we cannot determine whether earlier drainage\u0026mdash; as a preemptive treatment\u0026mdash;might have prevented the development of refractory ICH or could have improved long-term prognosis[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis report has some limitations, and the results should be interpreted cautiously. First, the possibility of unmeasured confounders could have fault to identify significant results. Second, to characterize basal cisterns and ventricular size, we adopted a pragmatic classification system, given the absence of a standardized or widely validated approach in the current medical literature. Though this method lacks formal validation, it reflects common clinical practice and offers a reproducible framework for clinicians. Third, to ensure that centers were applying a consistent treatment strategy, we deliberately shortened the inclusion period. However, we cannot exclude the possibility that some patients may have directly received Tier 3 interventions such as secondary decompressive craniectomy, as local conditions\u0026mdash;mass effect or hematoma\u0026mdash;might have prevented the placement of an external ventricular drain[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Finally, a major limitation of this study is the absence of long-term outcome such as 6-month Glasgow Outcome Scale data in our national registry, which prevented a comprehensive analysis of neurological outcomes in this cohort[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this multicenter cohort of refractory traumatic ICH, EVD effectively controlled intracranial pressure in half of the cases, with a low complication rate. EVD efficacy was associated with lower ICP values, lower level of sedation, preserved basal cisterns and a slower onset of intracranial hypertension prior to EVD insertion.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEVD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eExternal ventricular drainage\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTBI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTraumatic brain injury\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eICP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntracranial pressure\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eICH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntracranial hypertension\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputer tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCSF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCerebrospinal fluid\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eISS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInjury Severity Score\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSAPS II\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSimplified acute physiology score\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003col\u003e\n \u003cli\u003eWe confirm that the manuscript is original, complies with all instructions to authors.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eAuthors \u0026lsquo;Contributions\u0026nbsp;\u003c/u\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAll authors have made substantial contributions to this work and have approved the final version of the manuscript. Data collection and quality control: All Authors. Concept and design: JDM, BC, CG, BC Statistical analysis: BC. Interpretation of data: JDM, BC, BC. \u0026nbsp;Writing original draft: JDM, BC, BC, CG. Writing review and editing: all authors.\u0026nbsp;\u003c/p\u003e\n\u003col class=\"decimal_type\" start=\"3\"\u003e\n \u003cli\u003eWe confirm that all authors have approved the final version.\u003c/li\u003e\n \u003cli\u003eWe confirm that the manuscript has not been published, and is not under consideration elsewhere.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eEthics approval\u0026nbsp;\u003c/u\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe TraumaBase group obtained approval for retrospective data use, from the Institutional Review Board (Comit\u0026eacute; de Protection des Personnes, Paris VI, Piti\u0026eacute;, president Pr Laurent Lacapelle, B\u0026acirc;timent de la Force, 47 Boulevard de l\u0026rsquo;H\u0026ocirc;pital, 75651 Paris Cedex 13, 28 November 2012) and from the Advisory Committee for Information Processing in Health Research (Comit\u0026eacute; consultatif sur le traitement de l\u0026rsquo;information en mati\u0026egrave;re de recherche dans le domaine de la sant\u0026eacute;, authorisation 11.305bis) and from the National Commission for Data Protection (Commission Nationale de l\u0026rsquo;Informatique et des Libert\u0026eacute;s, authorisation 911461).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study has been approved by the ethics committee of the French Society of Anesthesiology and Intensive Care (SFAR) IRB: 00010254 ‐ 2024 \u0026ndash; 114\u003c/p\u003e\n\u003col start=\"6\"\u003e\n \u003cli\u003e\u003cu\u003eCompeting interests\u003c/u\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe authors declare that they have no known conflict of interest in relationship to this work.\u003c/p\u003e\n\u003col start=\"7\"\u003e\n \u003cli\u003eWe confirm the use of reporting checklist\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u0026nbsp;The Traumabase registry is funded by several Agence r\u0026eacute;gionale de Sant\u0026eacute; (\u0026Icirc;le‑de‑France, Occitanie, Grand‑est, Haut‑de‑France, Auvergne‑Rh\u0026ocirc;ne‑Alpes). The Traumabase registry is also funded by the French road safety observatory (Observatoire National Interminist\u0026eacute;riel de la S\u0026eacute;curit\u0026eacute; Routi\u0026egrave;re). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Traumabase group, listed as contributors: Arthur James, Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care, Piti\u0026eacute;-Salp\u0026ecirc;tri\u0026egrave;re Hospital; Fanny Bounes, CHU de Toulouse \u0026ndash; Rangueil; Mickael Cardinale, Military Teaching Hospital Sainte Anne; Anne Galland, H\u0026ocirc;pital Europ\u0026eacute;en Georges Pompidou, AP-HP; Alexandre Bourgeois, CHRU Lille; Pierre Etienne Leblanc, H\u0026ocirc;pital Bic\u0026ecirc;tre, APHP; Anatole Harrois, H\u0026ocirc;pital Bic\u0026ecirc;tre, APHP; Paer-Selim Abback, CHU Tours\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePaget L-M, Boutonnet M, Moyer J-D, Delhaye N, D\u0026rsquo;Aranda E, Beltzer N, et al. 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Anaesth Crit Care Pain Med. 2021;40:100827.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evon Elm E, Altman DG, Egger M, Pocock SJ, G\u0026oslash;tzsche PC, Vandenbroucke JP. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335:806\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarshall LF, Marshall SB, Klauber MR, Clark MVB, Eisenberg HM, Jane JA, et al. A new classification of head injury based on computerized tomography. J Neurosurg. 1991;75:S14\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTunkel AR, Hasbun R, Bhimraj A, Byers K, Kaplan SL, Scheld WM, et al. 2017 Infectious Diseases Society of America\u0026rsquo;s Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis Off Publ Infect Dis Soc Am. 2017;64:e34\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNoguchi K, Gel YR, Brunner E, Konietschke F. nparLD: An \u003cem\u003eR\u003c/em\u003e Software Package for the Nonparametric Analysis of Longitudinal Data in Factorial Experiments. J Stat Softw [Internet]. 2012 [cited 2025 May 25];50. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.jstatsoft.org/v50/i12/\u003c/span\u003e\u003cspan address=\"http://www.jstatsoft.org/v50/i12/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLangfitt TW, Weinstein JD, Kassell NF. CEREBRAL VASOMOTOR PARALYSIS PRODUCED BY INTRACRANIAL HYPERTENSION. Neurology. 1965;15:622\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eB\u0026ouml;gli SY, Beqiri E, Olakorede I, Cherchi MS, Smith CA, Chen X, et al. 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Introducing the concept of CSF-shift edema in traumatic brain injury. J Neurosci Res. 2018;96:744\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIliff JJ, Wang M, Liao Y, Plogg BA, Peng W, Gundersen GA et al. A Paravascular Pathway Facilitates CSF Flow Through the Brain Parenchyma and the Clearance of Interstitial Solutes, Including Amyloid β. Sci Transl Med [Internet]. 2012 [cited 2023 Mar 14];4. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.science.org/doi/\u003c/span\u003e\u003cspan address=\"https://www.science.org/doi/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1126/scitranslmed.3003748\u003c/span\u003e\u003cspan address=\"10.1126/scitranslmed.3003748\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHussain R, Tithof J, Wang W, Cheetham-West A, Song W, Peng W, et al. Potentiating glymphatic drainage minimizes post-traumatic cerebral oedema. Nature. 2023;623:992\u0026ndash;1000.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTaylor JD, Bailey M, Cooper DJ, French C, Menon DK, Nichol AD, et al. Association Between Early External Ventricular Drain Insertion and Functional Outcomes 6 Months Following Moderate-to-Severe Traumatic Brain Injury. J Neurotrauma. 2024;41:1364\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCnossen MC, Huijben JA, van der Jagt M, Volovici V, van Essen T, Polinder S, et al. Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. Crit Care Lond Engl. 2017;21:233.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcCrea MA, Giacino JT, Barber J, Temkin NR, Nelson LD, Levin HS, et al. Functional Outcomes Over the First Year After Moderate to Severe Traumatic Brain Injury in the Prospective, Longitudinal TRACK-TBI Study. JAMA Neurol. 2021;78:982\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"neurocritical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"neca","sideBox":"Learn more about [Neurocritical Care](http://link.springer.com/journal/12028)","snPcode":"12028","submissionUrl":"https://www.editorialmanager.com/neca/default2.aspx","title":"Neurocritical Care","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Traumatic brain injury, intracranial hypertension, external ventricular drain, ventriculostomy, cerebro-spinal fluid.","lastPublishedDoi":"10.21203/rs.3.rs-7028290/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7028290/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eExternal ventricular drainage (EVD) is commonly used to manage elevated intracranial pressure (ICP) following traumatic brain injury (TBI). However, evidence supporting its effectiveness in this context remains limited. This study aimed to evaluate the effectiveness of EVD in controlling elevated ICP and to identify clinical and radiological factors associated with its success.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e A multicenter retrospective cohort study was conducted between 1st January 2019 and 31 December 2022 across nine regional trauma centers in France participating in the Traumabase. All TBI patients with intracranial hypertension despite maximal medical therapy and treated with EVD were included. EVD success was defined as an efficient control of ICP avoiding the use of any third-tier therapy or avoiding a decision to withdraw life-sustaining treatment due to both refractory intracranial hypertension and severity of brain injury lesions.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA cohort of 176 TBI patients with EVD was constituted. Among them, 88 patients (50%) had sustained control of intracranial pressure after EVD. In multivariate analysis, sedation with a combination of sedative drugs (OR 0.28; 95% CI 0.12\u0026ndash;0.62, p\u0026thinsp;=\u0026thinsp;0.002), obliterated cisternal basal on the brain CT scan prior to EVD placement (OR 0.07; 95% CI 0.00-0.39, p\u0026thinsp;=\u0026thinsp;0.013) and severity of chest trauma (OR 0.79; 95% CI 0.64\u0026ndash;0.99, p\u0026thinsp;=\u0026thinsp;0.039) were factors associated with poor likelihood of EVD success. Conversely, EVD placement occurring more than 24 hours after admission was independently associated with success (OR 3.07; 95% CI 1.41\u0026ndash;7.01, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eIn this multicenter cohort of TBI patients with refractory ICH, EVD effectively controlled intracranial pressure in half of the cases. The effectiveness of EVD appears to depend on the severity and the rapidity of onset of traumatic intracranial hypertension.\u003c/p\u003e","manuscriptTitle":"Efficacy and Predictors of Success of External Ventricular Drainage for The Management of Traumatic Intracranial Hypertension: A Retrospective Multicenter Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-18 14:30:04","doi":"10.21203/rs.3.rs-7028290/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-07-14T23:02:45+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-14T22:17:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Neurocritical Care","date":"2025-07-14T16:35:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-10T19:39:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"Neurocritical Care","date":"2025-07-10T10:20:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"neurocritical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"neca","sideBox":"Learn more about [Neurocritical Care](http://link.springer.com/journal/12028)","snPcode":"12028","submissionUrl":"https://www.editorialmanager.com/neca/default2.aspx","title":"Neurocritical Care","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2c615c19-a069-47ac-839f-9b09d0e399ae","owner":[],"postedDate":"July 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T16:03:25+00:00","versionOfRecord":{"articleIdentity":"rs-7028290","link":"https://doi.org/10.1007/s12028-025-02394-y","journal":{"identity":"neurocritical-care","isVorOnly":false,"title":"Neurocritical Care"},"publishedOn":"2025-10-09 15:56:50","publishedOnDateReadable":"October 9th, 2025"},"versionCreatedAt":"2025-07-18 14:30:04","video":"","vorDoi":"10.1007/s12028-025-02394-y","vorDoiUrl":"https://doi.org/10.1007/s12028-025-02394-y","workflowStages":[]},"version":"v1","identity":"rs-7028290","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7028290","identity":"rs-7028290","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}