Lumbar Drainage of Cerebrospinal Fluid After Aneurysmal Subarachnoid Hemorrhage

Abstract

Background and Purpose— A single-center prospective randomized controlled trial has been conducted to determine if lumbar drainage of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage reduces the prevalence of delayed ischemic neurological deficit and improves clinical outcome. Methods— Patients with World Federation of Neurological Surgeons Grade 1 to 3 aneurysmal subarachnoid hemorrhage and modified Fisher Grades 2, 3, 4, and 3+4 were randomized to either the study group of standard therapy plus insertion of a lumbar drain or the control group of standard therapy alone. The primary outcome measure was the prevalence of delayed ischemic neurological deficit. Results— Two hundred ten patients with aneurysmal subarachnoid hemorrhage (166 female, 44 male; median age, 54 years; interquartile range, 45–62 years) were recruited into the control (n=105) and study (n=105) groups of the trial. World Federation of Neurological Surgeons grade was: 1 (n=139), 2 (n=60), and 3 (n=11); Fisher grade was: 2 (n=87), 3 (n=85), and 4 (n=38). The prevalence of delayed ischemic neurological deficit was 35.2% and 21.0% in the control and study groups, respectively ( P =0.021). The prevalence of a modified Rankin Scale score of 4, 5, or 6 at Day 10 and 6 months, respectively, was 62.5% and 18.6% in the control group and 44.8% and 19.8% in the study group ( P =0.009 and 0.83, respectively). Conclusions— Lumbar drainage of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage has been shown to reduce the prevalence of delayed ischemic neurological deficit and improve early clinical outcome but failed to improve outcome at 6 months after aneurysmal subarachnoid hemorrhage. Clinical Trial Registration— URL: www.clinicaltrials.gov . Unique identifier: NCT00842049.

Delayed neurological deterioration after subarachnoid haemorrhage

“…135 A randomized clini cal trial that included 210 patients found that lumbar drainage reduced the incidence of DCI, but at 6 months only trends towards reduction in cerebral infarction and improved outcome on the modified Rankin Scale were observed. 136 Cilostazol is a 2oxoquinoline derivative that inhib its phosphodiesterase 3 and has antithrombotic, vaso dilatory, antismooth muscle proliferation and cardiac inotropic and chronotropic effects. 137 A randomized, singleblind study of 109 patients undergoing clipping of ruptured aneurysms found that cilostazol significantly reduced angiographic vasospasm, DCI and cerebral infarction but had no effect on outcome.…”

The pathophysiology and treatment of delayed cerebral ischaemia following subarachnoid haemorrhage

“…Numerous methods have been investigated, including continuous cisternal drainage, lumbar drainage, as well as intrathecal administration of thrombolytics There are reports suggesting good success rates in decreasing the incidence of DCI with continuous cisternal drainage, however, a RCT has not been performed 169. Results from the first single-centre trial of early, continuous lumbar drainage hold promise, with a significant decrease in the incidence of DCI from 35% to only 21% 170. However, the study failed to demonstrate any long-term benefit in outcome.…”

Predictors of shunt dependency after aneurysmal subarachnoid hemorrhage: results of a single-center clinical trial

“…Moreover, early CSF drainage reduces the content of blood and protein in the CSF, thereby influencing the incidence of clogging in the intrinsic CSF draining system. Several authors have pointed out the importance of extensive CSF drainage during the first period after aSAH [1,12,18]. However, prolonged use of external ventricular drainage (EVD) carries the risk of infection.…”