Continuous cerebral spinal fluid drainage associated with complications in patients admitted with subarachnoid hemorrhage

Abstract

Object Cerebral artery vasospasm is a major cause of death and disability in patients recovering from subarachnoid hemorrhage (SAH). Although the exact cause of vasospasm is unknown, one body of research suggests that clearing blood products by CSF drainage is associated with a lower frequency and severity of vasospasm. There are multiple approaches to facilitating CSF drainage, but there is inadequate evidence to determine the best practice. The purpose of this study was to explore whether continuous or intermittent CSF drainage was superior for reducing vasospasm. Methods The authors performed a randomized clinical trial. Within 72 hours of admission for SAH, patients with an external ventricular drain (EVD) were randomized to undergo continuous CSF drainage with intermittent intracranial pressure (ICP) monitoring (open-EVD group) or continuous ICP monitoring with intermittent CSF drainage (monitor-ICP group). Results After 60 patients completed the study, an interim analysis was performed. The complication rate of 52.9% for the open-EVD group was significantly higher than the 23.1% complication rate for the monitor-ICP group (OR 3.75, 95% CI 1.21–11.66, p = 0.022). These results were reported to the Data Safety and Monitoring Board and enrollment was terminated. The odds ratio of vasospasm for the open-EVD versus monitor-ICP group was not significant (OR 0.44, 95% CI 0.13–1.45, p = 0.177). Conclusions Continuous CSF drainage with intermittent ICP monitoring is associated with a higher rate of complications than continuous ICP monitoring with intermittent CSF drainage, but there is no difference between the two types of monitoring in vasospasm. Clinical trial registration no.: NCT01169454 (clinicaltrials.gov).

The burden and risk factors of ventriculostomy occlusion in a high-volume cerebrovascular practice: results of an ongoing prospective database

“…While this study is the first prospective study designed to monitor the primary outcome of EVD occlusion, the results are, for the most part, consistent with published literature from retrospective series. The incidence of occlusion documented in this study falls within the range of previous studies that suggested nonpatent EVD in 19% to 47% of patients; 3,4,15 however, the need for replacement is much higher than in previous retrospective studies, which have suggested a rate of 1% to 7%. [1][2][3]5,8,9,20 The reasons for higher permanent occlusion documented in the present study are likely multifactorial, but could be related to more rigorous prospective monitoring and reporting of occlusion in this study in comparison with retrospective studies, which likely failed to identify a subset of occlusions due to inadequate documentation, and/or a high-volume academic neurosurgical patient population with a large proportion of subarachnoid hemorrhage and otherwise complex patients, which may be a higher risk patient population for occlusion.…”

“…Olson et al, in a randomized study comparing continuous versus intermittent drainage, showed a significantly lower occlusion rate with intermittent drainage than continuous drainage. 15 However, occlusion was poorly defined in this study and was not the primary outcome of this trial. The present study suggests that strategies for improving procedures that increase the incidence of ideal catheter position, as well as the preferential selection of larger diameter catheters, may potentially reduce the incidence of occlusion and need for replacement.…”

“…[1][2][3]5,8,9,20 Furthermore, in a Nationwide Inpatient Sample database study of more than 101,000 hospitalizations in which ventriculostomy was performed, nearly 6% of patients required at least 1 additional ventriculostomy procedure. 18 Studies have demonstrated nonpatent EVD in 19% to 47% of patients; 3,4,15 however, no study to date has prospectively evaluated EVD occlusion as a primary end point, reported on the number of catheter irrigations performed, or identified the risk factors for EVD occlusion.…”

Management of raised intracranial pressure in aneurysmal subarachnoid hemorrhage: time for a consensus?

“…Continuous drainage has been shown to be associated with worse adverse events in aSAH 57 "High-dose barbiturate administration is recommended to control elevated ICP refractory to maximum standard medical and surgical treatment"…”

“…The investigators found that the overall rate of complications (EVD blockage, infection, CSF leak, hemorrhage) was higher in the continuous drainage group, but there were no significant differences in ICP control, rates of delayed cerebral ischemia (DCI), or functional outcomes. 57 The optimal duration of CSF diversion, and the techniques for EVD weaning, were not explored in this study and remain the target of future investigation.…”