Update on intrathecal management of cerebral vasospasm: a systematic review and meta-analysis

Abstract

OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) accounts for a relatively small portion of strokes but has the potential to cause permanent neurological deficits. Vasospasm with delayed ischemic neurological deficit is thought to be responsible for much of the morbidity associated with aSAH. This has illuminated some treatment options that have the potential to target specific components of the vasospasm cascade. Intrathecal management via lumbar drain (LD) or external ventricular drain (EVD) offers unique advantages in this patient population. The aim of this review was to provide an update on intrathecal vasospasm treatments, emphasizing the need for larger-scale trials and updated protocols using data-driven evidence. METHODS A search of PubMed, Ovid MEDLINE, and Cochrane databases included the search terms (subarachnoid hemorrhage) AND (vasospasm OR delayed cerebral ischemia) AND (intrathecal OR intraventricular OR lumbar drain OR lumbar catheter) for 2010 to the present. Next, a meta-analysis was performed of select therapeutic regimens. The primary endpoints of analysis were vasospasm, delayed cerebral ischemia (DCI), cerebral infarction, and functional outcome. RESULTS Twenty-nine studies were included in the analysis. There were 10 studies in which CSF drainage was the primary experimental group. Calcium channel antagonists were the focus of 7 studies. Fibrinolytics and other vasodilators were each examined in 6 studies. The meta-analysis included studies examining CSF drainage via LD (n = 4), tissue plasminogen activator in addition to EVD (n = 3), intraventricular nimodipine (n = 2), and cisternal magnesium (n = 2). Results showed that intraventricular nimodipine decreased vasospasm (OR 0.59, 95% CI 0.37–0.94; p = 0.03). Therapies that significantly reduced DCI were CSF drainage via LD (OR 0.47, 95% CI 0.25–0.88; p = 0.02) and cisternal magnesium (OR 0.27, 95% CI 0.07–1.02; p = 0.05). CSF drainage via LD was also found to significantly reduce the incidence of cerebral infarction (OR 0.35, 95% 0.24–0.51; p < 0.001). Lastly, functional outcome was significantly better in patients who received CSF drainage via LD (OR 2.42, 95% CI 1.39–4.21; p = 0.002). CONCLUSIONS The authors’ results showed that intrathecal therapy is a safe and feasible option following aSAH. It has been shown to attenuate cerebral vasospasm, reduce the incidence of DCI, and improve clinical outcome. The authors support the use of intrathecal management in the prevention and rescue management of cerebral vasospasm. More randomized controlled trials are warranted to determine the best combination of pharmaceutical agents and administration route in order to formulate a standardized treatment approach.

Neuroradiological diagnosis and therapy of cerebral vasospasm after subarachnoid hemorrhage

“…Comparisons of the effectiveness of enteral and intravenous DCI prophylaxis with nimodipine cannot yet be definitively evaluated [14]. Moreover, intrathecal therapies are described in connection with CVS and have been endorsed with the focus being placed on nimodipine in the form of slow-release microparticles in addition to the use of, e. g., magnesium [13,15,16]. However, a clear recommendation is lacking here as for endovascular spasm therapy (EST).…”

“…Ferner sind auch intrathekale Therapien im Zusammenhang mit ZVS beschrieben und befürwortet worden, wobei neben der Anwendung von z. B. Magnesium der Fokus auf wiederum Nimodipin in Form von sich langsam freisetzenden Mikropartikeln gelegt wird [13,15,16].…”

Lumboperitoneal shunt and ventriculoperitoneal shunt for chronic hydrocephalus after aneurysmal subarachnoid hemorrhage: a comparison

“…Although it has a short duration and a low clearance rate of bloody cerebrospinal fluid, it is the preferred method for relieving acute hydrocephalus ( 7 ). Ventricular and lumbar drainage can enhance cerebrospinal fluid circulation and facilitate the elimination of toxic substances in bloody cerebrospinal fluid ( 8 ). Previous studies have shown that acute hydrocephalus is caused by blockage of cerebrospinal fluid (CSF) outflow from the ventricular system, whereas chronic hydrocephalus is associated with arachnoid granulations and fibrosis of the leptomeninges caused by aSAH.…”

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

“…Efforts to remove the blood in the basal cisterns as the causative agent for vasospasm by surgery, cisternal, or external ventricular drainage showed mixed results . In retrospective studies, prophylactic lumbar drainage of cerebrospinal fluid was associated with favorable outcome . A plausible mechanism of action is increased removal of blood and its degradation products using gravity.…”

“… 8 , 9 , 10 In retrospective studies, prophylactic lumbar drainage of cerebrospinal fluid was associated with favorable outcome. 11 , 12 A plausible mechanism of action is increased removal of blood and its degradation products using gravity. However, the prospective Lumbar Drainage in Subarachnoid Haemorrhage (LUMAS) trial randomizing 210 patients was unable to confirm a benefit of lumbar drains.…”