Neurosurgery Blog: CSF Diversion in Aneurysmal Subarachnoid Hemorrhage: How Low Should We Go? (S25.002)

Monday, April 21, 2014

CSF Diversion in Aneurysmal Subarachnoid Hemorrhage: How Low Should We Go? (S25.002)

Neurology recent issues

OBJECTIVE: To evaluate the feasibility of randomizing patients with aneurysmal subarachnoid hemorrhage (aSAH) and hydrocephalus to "aggressive" vs "conventional" cerebrospinal (CSF) drainage.BACKGROUND: External ventricular drains (EVDs) are indicated for CSF drainage for acute obstructive hydrocephalus due to aSAH. There is no data available to support the optimal rate or duration of CSF drainage.DESIGN/METHODS: A 2-center, prospective, randomized pilot study of adult patients with aSAH requiring EVD for acute hydrocephalus. Patients were randomized to: 1) aggressive CSF drainage with EVD open to 5 mmHg, or 2) conventional CSF drainage with EVD open to 15 mmHg. Patients were randomized within 24 hours of EVD placement. In the aggressive arm, EVD was kept at 5 mmHg for 7 days until a weaning trial could be attempted. EVD of patients in the conventional arm could be weaned at the discretion of the clinician for treatment of hydrocephalus. A per-protocol analysis was performed.RESULTS: 20 patients were included; 13 patients in the aggressive group. Median age was 54 years (IQR 47-72). Aneurysm was treated by endovascular coiling in 15 (75%) and by surgical clipping in 5 (25%). Twelve patients (60%) were poor clinical grade (WFNS grade IV-V) at nadir, and 4 patients (20%) remained poor-grade following CSF drainage. In the aggressive group, there was a trend towards more daily CSF output (median 220 cc vs 187 cc, p=0.09) and higher rate of ventriculoperitoneal shunt placement n=10,( 77%) vs. 2 (29%), p=0.06). Duration of EVD placement was longer in the aggressive arm median 11.5 days (IQR 7-15) vs. 8 days (8-15), p=0.53.CONCLUSIONS: Randomizing aSAH patients with acute hydrocephalus to different degrees of CSF diversion is feasible. Results from this small pilot study suggest that a more aggressive approach to CSF diversion may be associated with higher rates of VP shunt placement, but this needs further investigation.

Disclosure: Dr. Fugate has nothing to disclose. Dr. Rabinstein has received royalty payments from Elsevier and Oxford. Dr. Rabinstein has received research support from DJO Global. Dr. Wijdicks has received personal compensation in an editorial capacity for Neurocritical Care. Dr. Lanzino has nothing to disclose.

Original Article: http://www.neurology.org/cgi/content/short/82/10_Supplement/S25.002?rss=1