Early Recognition of Lumbar Overdrainage by Lumboventricular Pressure Gradient

Staykov, Dimitre; Speck, Verena; Volbers, Bastian; Wagner, Ingrid; Saake, Marc; Doerfler, Arnd; Schwab, Stefan; Bardutzky, Juergen

doi:10.1227/neu.0b013e31820c0274

Cited by 26 publications

(18 citation statements)

References 14 publications

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“…Careful CSF-drainage via the lumbar route may still be feasible in case of high intracranial pressure [14], but again this is at the discretion of the local investigator. A method of detecting the safety of lumbar CSF diversion may be determining the gradient of lumbar versus intracranial CSF pressure [15]. Albeit promising, the Earlydrain investigators explicitly rate this approach preliminary and experimental.…”

Section: Methodsmentioning

confidence: 99%

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EARLYDRAIN- outcome after early lumbar CSF-drainage in aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial

Bardutzky

Witsch

Jüttler

et al. 2011

Trials

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BackgroundAneurysmal subarachnoid hemorrhage (SAH) may be complicated by delayed cerebral ischemia, which is a major cause of unfavorable clinical outcome and death in SAH-patients. Delayed cerebral ischemia is presumably related to the development of vasospasm triggered by the presence of blood in the basal cisterns. To date, oral application of the calcium antagonist nimodipine is the only prophylactic treatment for vasospasm recognized under international guidelines.In retrospective trials lumbar drainage of cerebrospinal fluid has been shown to be a safe and feasible measure to remove the blood from the basal cisterns and decrease the incidence of delayed cerebral ischemia and vasospasm in the respective study populations. However, the efficacy of lumbar drainage has not been evaluated prospectively in a randomized controlled trial yet.Methods/DesignThis is a protocol for a 2-arm randomized controlled trial to compare an intervention group receiving early continuous lumbar CSF-drainage and standard neurointensive care to a control group receiving standard neurointensive care only. Adults suffering from a first aneurysmal subarachnoid hemorrhage whose aneurysm has been secured by means of coiling or clipping are eligible for trial participation. The effect of early CSF drainage (starting < 72 h after securing the aneurysm) will be measured in the following ways: the primary endpoint will be disability after 6 months, assessed by a blinded investigator during a personal visit or standardized telephone interview using the modified Rankin Scale. Secondary endpoints include mortality after 6 months, angiographic vasospasm, transcranial Doppler sonography (TCD) mean flow velocity in both middle cerebral arteries and rate of shunt insertion at 6 months after hospital discharge.DiscussionHere, we present the study design of a multicenter prospective randomized controlled trial to investigate whether early application of a lumbar drainage improves clinical outcome after aneurysmal subarachnoid hemorrhage.Trial registrationwww.clinicaltrials.gov Identifier: NCT01258257

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Section: Methodsmentioning

confidence: 99%

“…In patients with increased intracranial pressure, careful lumbar drainage of CSF may be a possible treatment even in case of compressed basal cisterns [14]. A feasible strategy to enhance safety is determination of the lumbar-cranial pressure gradient and cessation of lumbar CSF diversion in patients with increasing pressure difference [15]. …”

Section: Methodsmentioning

confidence: 99%

EARLYDRAIN- outcome after early lumbar CSF-drainage in aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial

Bardutzky

Witsch

Jüttler

et al. 2011

Trials

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“…It might alternatively be expressed as intracranial hypotension, brain sag, sinking brain syndrome, sinking skin flap syndrome or CSF hypovolemia according to different reports and personal preference [51,52,59,60]. And the clinical presentations of CSF overdrainage range from mere headache, cranial nerve palsy, mental state alteration, pneumocephalus, and intracranial hemorrhage to death [8,9,51,52,57,[59][60][61]. The commonly accepted mechanism of CSF overdrainage is downward displacement of intracranial contents due to the pressure gradient between the intracranial and intrathecal compartments [8,51,59,61].…”

Section: Csf Overdrainagementioning

confidence: 99%

“…And the clinical presentations of CSF overdrainage range from mere headache, cranial nerve palsy, mental state alteration, pneumocephalus, and intracranial hemorrhage to death [8,9,51,52,57,[59][60][61]. The commonly accepted mechanism of CSF overdrainage is downward displacement of intracranial contents due to the pressure gradient between the intracranial and intrathecal compartments [8,51,59,61]. Although identification of brain sagging, venous engorgement, dura enhancement, pituitary enhancement and subdural fluid collection on MRI is superior [8,59,61,62], emergent CT combined with clinical presentation may be more convenient and practical in reaching the diagnosis of CSF overdrainage in daily practice [52,60].…”

Section: Csf Overdrainagementioning

confidence: 99%

“…The commonly accepted mechanism of CSF overdrainage is downward displacement of intracranial contents due to the pressure gradient between the intracranial and intrathecal compartments [8,51,59,61]. Although identification of brain sagging, venous engorgement, dura enhancement, pituitary enhancement and subdural fluid collection on MRI is superior [8,59,61,62], emergent CT combined with clinical presentation may be more convenient and practical in reaching the diagnosis of CSF overdrainage in daily practice [52,60]. The most commonly reported findings on head CT include effacement of the basal cisterns, ventricular collapse, diffuse edema, pneumocephalus and subdural fluid collection [59,60].…”

Section: Csf Overdrainagementioning

confidence: 99%

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Some cool considerations of external lumbar drainage during its widespread application in neurosurgical practice: a long way to go

Zhang

Zhao

et al. 2016

Chin Neurosurg Jl

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External lumbar drainage (ELD) has gained wide popularity in neurosurgical practice since its' first introduction by F. Vourc'h in 1963. It manifests encouraging prospects in control of refractory intracranial hypertension, prevention of complications secondary to aneurysmal subarachnoid hemorrhage, prediction of shunt respondency in normal pressure hydrocephalus, management of cerebrospinal fluid (CSF) leakage, and application in bacterial meningitis and ventriculitis. But many questions on the efficacy and safety of ELD are remained to be answered by future studies. CSF overdrainage and ELD-related meningitis are the two most common and fatal complications due to inappropriate usage of ELD. Randomized controlled trials are badly in need to more safely and rationally guide the clinical application of ELD.

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Effectiveness of Lumbar Cerebrospinal Fluid Drain Among Patients With Aneurysmal Subarachnoid Hemorrhage

Wolf,

Mielke,

Barner

et al. 2023

JAMA Neurol

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ImportanceAfter aneurysmal subarachnoid hemorrhage, the use of lumbar drains has been suggested to decrease the incidence of delayed cerebral ischemia and improve long-term outcome.ObjectiveTo determine the effectiveness of early lumbar cerebrospinal fluid drainage added to standard of care in patients after aneurysmal subarachnoid hemorrhage.Design, Setting, and ParticipantsThe EARLYDRAIN trial was a pragmatic, multicenter, parallel-group, open-label randomized clinical trial with blinded end point evaluation conducted at 19 centers in Germany, Switzerland, and Canada. The first patient entered January 31, 2011, and the last on January 24, 2016, after 307 randomizations. Follow-up was completed July 2016. Query and retrieval of data on missing items in the case report forms was completed in September 2020. A total of 20 randomizations were invalid, the main reason being lack of informed consent. No participants meeting all inclusion and exclusion criteria were excluded from the intention-to-treat analysis. Exclusion of patients was only performed in per-protocol sensitivity analysis. A total of 287 adult patients with acute aneurysmal subarachnoid hemorrhage of all clinical grades were analyzable. Aneurysm treatment with clipping or coiling was performed within 48 hours.InterventionA total of 144 patients were randomized to receive an additional lumbar drain after aneurysm treatment and 143 patients to standard of care only. Early lumbar drainage with 5 mL per hour was started within 72 hours of the subarachnoid hemorrhage.Main Outcomes and MeasuresPrimary outcome was the rate of unfavorable outcome, defined as modified Rankin Scale score of 3 to 6 (range, 0 to 6), obtained by masked assessors 6 months after hemorrhage.ResultsOf 287 included patients, 197 (68.6%) were female, and the median (IQR) age was 55 (48-63) years. Lumbar drainage started at a median (IQR) of day 2 (1-2) after aneurysmal subarachnoid hemorrhage. At 6 months, 47 patients (32.6%) in the lumbar drain group and 64 patients (44.8%) in the standard of care group had an unfavorable neurological outcome (risk ratio, 0.73; 95% CI, 0.52 to 0.98; absolute risk difference, −0.12; 95% CI, −0.23 to −0.01; P = .04). Patients treated with a lumbar drain had fewer secondary infarctions at discharge (41 patients [28.5%] vs 57 patients [39.9%]; risk ratio, 0.71; 95% CI, 0.49 to 0.99; absolute risk difference, −0.11; 95% CI, −0.22 to 0; P = .04).Conclusion and RelevanceIn this trial, prophylactic lumbar drainage after aneurysmal subarachnoid hemorrhage lessened the burden of secondary infarction and decreased the rate of unfavorable outcome at 6 months. These findings support the use of lumbar drains after aneurysmal subarachnoid hemorrhage.Trial RegistrationClinicalTrials.gov Identifier: NCT01258257

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Early Recognition of Lumbar Overdrainage by Lumboventricular Pressure Gradient

Abstract: Lumbar overdrainage should be avoided in severe SAH, and lumboventricular pressure measurement may be a useful monitoring tool. Herniation due to lumbar overdrainage is a feared complication that can be avoided by following a strict LD management protocol.

Cited by 26 publications

References 14 publications

EARLYDRAIN- outcome after early lumbar CSF-drainage in aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial

EARLYDRAIN- outcome after early lumbar CSF-drainage in aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial

Some cool considerations of external lumbar drainage during its widespread application in neurosurgical practice: a long way to go

Effectiveness of Lumbar Cerebrospinal Fluid Drain Among Patients With Aneurysmal Subarachnoid Hemorrhage

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