Analysis of Cerebral Spinal Fluid Drainage and Intracranial Pressure Peaks in Patients with Subarachnoid Hemorrhage

Anton Früh; Peter Truckenmüller; David Wasilewski; Peter Vajkoczy; Stefan Wolf; Earlydrain Study Group

doi:10.1007/s12028-024-01981-9

Analysis of Cerebral Spinal Fluid Drainage and Intracranial Pressure Peaks in Patients with Subarachnoid Hemorrhage

Neurocrit Care. 2024 Apr 15. doi: 10.1007/s12028-024-01981-9. Online ahead of print.

Authors

Anton Früh^{1

2}, Peter Truckenmüller¹, David Wasilewski¹, Peter Vajkoczy¹, Stefan Wolf³; Earlydrain Study Group

Affiliations

¹ Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
² BIH Charité Junior Digital Clinician Scientist Program, BIH Biomedical Innovation Academy, Charitéplatz 1, 10117, Berlin, Germany.
³ Department of Neurosurgery, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany. stefan.wolf@charite.de.

PMID: 38622488
DOI: 10.1007/s12028-024-01981-9

Abstract

Background: After aneurysmal subarachnoid hemorrhage (aSAH), elevated intracranial pressure (ICP) due to disrupted cerebrospinal fluid (CSF) dynamics is a critical concern. An external ventricular drainage (EVD) is commonly employed for management; however, optimal strategies remain debated. The randomized controlled Earlydrain trial showed that an additional prophylactic lumbar drainage (LD) after aneurysm treatment improves neurological outcome. We performed a post hoc investigation on the impact of drainage volumes and critical ICP values on patient outcomes after aSAH.

Methods: Using raw patient data from Earlydrain, we analyzed CSF drainage amounts and ICP measurements in the first 8 days after aSAH. Outcomes were the occurrence of secondary infarctions and the score on the modified Rankin scale after 6 months, dichotomized in values of 0-2 as favorable and 3-6 as unfavorable. Repeated measurements were considered with generalized estimation equations.

Results: Earlydrain recruited 287 patients, of whom 221 received an EVD and 140 received an LD. Higher EVD volumes showed a trend to more secondary infarctions (p = 0.09), whereas higher LD volumes were associated with less secondary infarctions (p = 0.009). The mean total CSF drainage was 1052 ± 659 mL and did not differ concerning infarction and neurological outcome. Maximum ICP values were higher in patients with poor outcomes but not related to drainage volumes via EVD. After adjustment for aSAH severity and total CSF drainage, higher LD volume was linked to favorable outcome (per 100 mL: odds ratio 0.61 (95% confidence interval 0.39-0.95), p = 0.03), whereas higher EVD amounts were associated with unfavorable outcome (per 100 mL: odds ratio 1.63 (95% confidence interval 1.05-2.54), p = 0.03).

Conclusions: Findings indicate that effects of CSF drainage via EVD and LD differ. Higher amounts and higher proportions of LD volumes were associated with better outcomes, suggesting a potential quantity-dependent protective effect. Optimizing LD volume and mitigating ICP spikes may be a strategy to improve patient outcomes after aSAH.

Clinical trial registration: ClinicalTrials.gov identifier: NCT01258257.

Keywords: Cerebrospinal fluid; Intracranial pressure; Lumbar drainage; Subarachnoid hemorrhage.

Associated data

ClinicalTrials.gov/NCT01258257