Volume Of Cerebrospinal Fluid Drainage Research Articles

Clinical Experience with Off-Label Intrathecal Administration of Selected Antibiotics in Adults: An Overview with Pharmacometric Considerations.

Drain-associated intracerebral infections are life-threatening emergencies. Their treatment is challenging due to the limited penetration of antibiotics to the site of infection, resulting in potentially inadequate exposure. The emergence of multidrug-resistant pathogens might force the use of off-label intrathecal (IT) doses of antibiotics. We reviewed the literature on general aspects determining intrathecal dosing regimen, using pharmacometric knowledge. We summarised clinical experience with IT doses of antibiotics that are usually not used intrathecally, as well as the outcome of the cases and concentrations reached in the cerebrospinal fluid (CSF). Factors determining the IT regimen are the size of the ventricle system and the CSF drainage volume. With regard to pharmacometrics, pharmacokinetic/pharmacodynamic indices are likely similar to those in non-cerebral infections. The following number (N) of cases were described: benzylpenicillin (>50), ampicillin (1), ceftazidime (2), cephaloridine (56), ceftriaxone (1), cefotiam (1), meropenem (57), linezolid (1), tigecycline (15), rifampicin (3), levofloxacin (2), chloramphenicol (3) and daptomycin (8). Many side effects were reported for benzylpenicillin in the 1940-50s, but for the other antibiotics, when administered correctly, all side effects were minor and reversible. These data might help when choosing an IT dosing regimen in case there is no alternative option due to antimicrobial resistance.

The Role of Recorded Volume of Cerebrospinal Fluid Output in Predicting Modified Rankin Scale Score at Discharge in Patients with Subarachnoid Hemorrhages (DROPSS)

Introduction. External ventricular drain (EVD) placement is common among aneurysmal subarachnoid hemorrhage (aSAH). Draining cerebrospinal fluid (CSF) from the EVD is also common, yet little is known about how much to drain, the length of time to drain, or how drainage impacts patient outcomes.
 Aim. The purpose of this study is to correlate amount of CSF drainage to patient outcomes, via modified Rankin Score (mRS).
 Material and Methods. This retrospective review of data located in a local hospital-based registry and electronic medical record. A linear mixed effects model was constructed to examine CSF drainage volume as a predictor of mRS at discharge.
 Results. Data from 82 patients was included in this analysis. There was no statistically significant relationship between CSF totals and mRS at hospital discharge (p = 0.3614, r² = 0.01). After controlling for age, Hunt and Hess score, and subject as random effect, there was still no significant relationship between CSF drained and mRS score at hospital discharge (p = .9042).
 Conclusions. There is no correlation between the total volume of CSF drained and mRS at discharge. Future research should explore CSF drainage documentation practices. (JNNN 2022;11(2):43–48)
 Key Words: acute care, aneurysmal subarachnoid hemorrhage, cerebrospinal fluid, external ventricular drain, patient outcomes

Reconsidering Ventriculoperitoneal Shunt Surgery and Postoperative Shunt Valve Pressure Adjustment: Our Approaches Learned From Past Challenges and Failures.

Treatment for idiopathic normal pressure hydrocephalus (iNPH) continues to develop. Although ventriculoperitoneal shunt surgery has a long history and is one of the most established neurosurgeries, in the 1970s, the improvement rate of iNPH triad symptoms was poor and the risks related to shunt implantation were high. This led experts to question the surgical indication for iNPH and, over the next 20 years, cerebrospinal fluid (CSF) shunt surgery for iNPH fell out of favor and was rarely performed. However, the development of programmable-pressure shunt valve devices has reduced the major complications associated with the CSF drainage volume and appears to have increased shunt effectiveness. In addition, the development of support devices for the placement of ventricular catheters including preoperative virtual simulation and navigation systems has increased the certainty of ventriculoperitoneal shunt surgery. Secure shunt implantation is the most important prognostic indicator, but ensuring optimal initial valve pressure is also important. Since over-drainage is most likely to occur in the month after shunting, it is generally believed that a high initial setting of shunt valve pressure is the safest option. However, this does not always result in sufficient improvement of the symptoms in the early period after shunting. In fact, evidence suggests that setting the optimal valve pressure early after shunting may cause symptoms to improve earlier. This leads to improved quality of life and better long-term independent living expectations. However, in iNPH patients, the remaining symptoms may worsen again after several years, even when there is initial improvement due to setting the optimal valve pressure early after shunting. Because of the possibility of insufficient CSF drainage, the valve pressure should be reduced by one step (2–4 cmH2O) after 6 months to a year after shunting to maximize symptom improvement. After the valve pressure is reduced, a head CT scan is advised a month later.

Coverage of visible intercostal and lumbar segmental arteries can predict the volume of cerebrospinal fluid drainage in elective endovascular repair of descending thoracic and thoracoabdominal aortic disease: a pilot study.

Our goal was to identify anatomical and physiological factors that could predict the amount of cerebrospinal fluid (CSF) drainage in patients undergoing elective endovascular repair of descending thoracic and thoracoabdominal aortic disease. All consecutive elective endovascular procedures performed for descending thoracic or thoracoabdominal aortic disease between January 2015 and December 2017 were included in the study. Routine use of CSF drainage was established in all patients. The goal of drainage was to reach a spinal fluid pressure of 10-12 mmHg by draining in 5-15-ml aliquots. The number of visible intercostal and lumbar segmental arteries (SAs) was evaluated before and after endovascular repair. The covering ratio of SAs was calculated as covered preoperative SAs/total preoperative SAs. Twenty-four consecutive patients were included in the final analysis. The indication for the intervention was a descending thoracic aneurysm in 13 cases, a thoracoabdominal aneurysm in 4 cases and a chronic type B dissection in 7 cases. The procedure performed was thoracic endovascular aortic repair in 20 cases and fenestrated endovascular aneurysm repair in 4 cases. None of the patients developed spinal cord ischaemia. The mean volume of CSF drained was 46 ml. The mean length of aortic coverage was 231 mm. The mean number of total preoperative SAs and of covered preoperative SAs was, respectively, 22 and 9. The volume of CSF drained was significantly correlated with all these variables (length of aortic coverage, total visible SAs and covered SAs), but the most powerful correlation was individuated with the covering ratio of SAs. Our findings suggest that the percentage of intercostal and lumbar SAs covered by placement of a stent graft can predict the volume of CSF drained in patients undergoing elective endovascular repair of descending thoracic and thoracoabdominal aortic disease.

Volume of cerebrospinal fluid drainage as a predictor for pretreatment aneurysmal rebleeding.

OBJECTIVE Initiation of external CSF drainage has been associated with a significant increase in rebleeding probability after aneurysmal subarachnoid hemorrhage (aSAH). However, the implications for acute management are uncertain. The purpose of this study was to evaluate the role of the amount of drained CSF on aneurysmal rebleeding. METHODS Consecutive patients with aSAH were analyzed retrospectively. Radiologically confirmed cases of aneurysmal in-hospital rebleeding were identified and predictor variables for rebleeding were retrieved from hospital records. Clinical predictors were identified through multivariate analysis, and logistic regression analysis was performed to ascertain the cutoff value for the rebleeding probability. RESULTS The study included 194 patients. Eighteen cases (9.3%) of in-hospital rebleeding could be identified. Using multivariate analysis, in-hospital rebleeding was significantly associated with initiation of CSF drainage (p = 0.001) and CSF drainage volume (63 ml [interquartile range (IQR) 55-69 ml] vs 25 ml [IQR 10-35 ml], p < 0.001). Logistic regression showed that 58 ml of CSF drainage within 6 hours results in a 50% rebleeding probability. The relative risk (RR) for rebleeding after drainage of more than 60 ml in 6 hours was 5.4 times greater compared with patients with less CSF drainage (RR 5.403, 95% CI 2.481-11.767; p < 0.001, number needed to harm = 1.687). CONCLUSIONS Volume of CSF drainage was highly correlated with the probability of in-hospital aneurysmal rebleeding. These findings suggest that the rebleeding probability can be affected in acute management should the placement of an external ventricular catheter be necessary. This finding necessitates meticulous control of the amount of drained CSF and the development of a definitive treatment protocol for this group of patients.

Comparison of drainage efficiency between unilateral and bilateral external ventricular drainage in intraventricular hemorrhage with hydrocephalus

Objective To explore the differences of the drainage efficiency between unilateral external ventricular drainage and bilateral external ventricular drainage in surgical treatment of intraventricular hemorrhage. Methods The clinical data of 56 patients with intraventricular hemorrhage treated by unilateral and bilateral external ventricular drainage were retrospectively analyzed. 24 cases were treated by unilateral external ventricular drainage (unilateral group), 32 cases were treated by bilateral external ventricular drainage (bilateral group). The hematoma clearance rate, duration of catheter drainage, the average daily cerebrospinal fluid (CSF) drainage volume, the times of injecting the urokinase and the average hospital days in the intensive care unit (ICU) were recorded, and compared between two groups. Results In the group of unilateral drainage tube and group of bilateral drainage tube, the clearance rate of hematoma was (74.6±8.7)% and (78.5±12.5)%, comparison between the two groups was not statistically significant(t=1.308, P=0.196); the daily CSF drainage volume was (124.6±40.2) ml and that was (139.6±41.7) ml, comparison between the two groups was not statistically significant(t=1.353, P=0.182); the times of injecting the urokinase was (4.42±1.26) and (4.06±1.39), comparison between the two groups was not statistically significant (t=0.998, P=0.323); the hospital stay in the ICU was (10.6±3.6) days and (13.3±5.0) days respectively, there was a significant difference between the two groups (t=2.243, P=0.029). The duration of catheter drainage in group of unilateral drainage tube was (5.0±1.7) days, and that was (6.6±2.2) days in group of bilateral drainage tube, and there was significant difference between the two groups (t=2.959, P=0.005). Conclusion The bilateral external drainage can not improve the hematoma clearance rate, reduce the times of injecting the urokinase and lower the hospitalization days in the ICU of the patients. Key words: Intraventricular hemorrhage; External ventricular drainage; The hematoma clearance rate

Impact of External Ventricular Drainage Volumes on Shunt Dependency after Subarachnoid Hemorrhage.

Background The indication for and the timing of a permanent shunt operation in patients following acute hydrocephalus (HC) after subarachnoid hemorrhage (SAH) remains controversial because risk factors for chronic HC fail to predict permanent shunt dependency. The amount of cerebrospinal fluid (CSF) drained via an external ventricular drain (EVD) may predict shunt dependency. Methods We conducted a retrospective study of our HC database from January 2006 to December 2011. All patients receiving an EVD due to acute HC after SAH were analyzed. The daily amount of drained CSF was documented until the EVD was removed or converted to a permanent shunt either immediately or during a follow-up period of 6 months. Results A total of 139 patients (48 male, 91 female; mean age: 57 ± 14 years) were eligible for the study. Mean duration of EVD was 16 ± 10 days (range: 4-60 days). A permanent shunt was necessary in 32% of cases (n = 45). The mean daily CSF volume was 139 ± 17 mL (range: 15-460 mL). Using repeated-measures analysis of variance, there was a significant difference of daily drained CSF volumes between both the groups in the first 15 days after the EVD. Conclusion Our results suggest that the daily amount of external CSF drainage volume in the acute state of SAH might influence the development of HC.

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

Hydrocephalus (HC) after aneurysmal subarachnoid hemorrhage (aSAH) is a common sequel. Proper selection of patients in need of permanent cerebrospinal fluid (CSF) diversion is, however, not straightforward. The aim of this study was to identify predictors of CSF shunt dependency following aSAH. We re-analyzed data acquired from aSAH patients previously enrolled in a prospective, controlled single-center clinical trial in which shunt dependency was not one of the end points. In the present study patients were allocated into two groups: those receiving a shunt (here denoted as shunt dependent) and those not receiving a shunt, based on a clinical decision process. Predictors of shunt dependency were identified by applying uni- and multivariable analysis. We tested a set of predefined possible risk factors based on the results of the clinical trial, including the impact of CSF drainage volume exceeding 1,500 ml during the 1st week after ictus. Ninety patients were included in the study. Significant predictors of shunt dependency were poor clinical grade at admission [odds ratio (OR) 4.7, 95% confidence interval (CI) 1.2-18.4], large amounts of subarachnoid blood (OR 3.8, 95% CI 1.0-14.0), large ventricular size on preoperative cerebral computer tomographic (CT) scans (OR 1.0, 95% CI 1.0-1.1), and CSF volume drainage exceeding 1,500 ml during the 1st week after the ictus (OR 16.3, 95% CI 4.0-67.1). Age ≥70 years, larger amounts of intraventricular blood, vertebrobasilar aneurysm, and endovascular treatment tended to increase the likelihood of receiving a shunt. Outcome was not significantly different between shunted and non-shunted patients. In this cohort of patients with clinical grade aSAH at admission, larger amounts of subarachnoid blood and large ventricular size on preoperative cerebral CT, and CSF drainage in excess of 1,500 ml during the 1st week after the ictus were significant predictors of shunt dependency. Shunt dependency did not hamper outcome.

Risk factors of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage

To investigate risk factors for the occurrence of shunt-dependent hydrocephalus in patients with aneurysmal subarachnoid hemorrhage (aSAH). A cohort of 136 consecutive patients who were treated for ruptured aneurysms within 72 h after onset of aSAH from January 2011 to January 2013 were retrospectively analyzed. Lumbar drainage was performed during the surgery in all patients. The risk factors of shunt-dependent hydrocephalus were analyzed. Of 136 patients, 23 (16.91%) underwent shunt operation to treat shunt-dependent hydrocephalus. Univariate analysis showed that Hunt-Hess grade at admission (P<0.01), Fisher grade (P<0.01), the presence of intraventricular hemorrhage (P<0.01), location of ruptured aneurysm (P=0.001), and the average daily volume of cerebrospinal fluid drainage (CSF) (P=0.047) were associated with shunt-dependent hydrocephalus. The aSAH patients with poor Hunt-Hess grade at admission, high Fisher grade, the presence of intraventricular hemorrhage, ruptured aneurysm in posterior circulation, and abnormal average daily volume of CSF are more likely to develop shunt-depended hydrocephalus.

The Effect of Continuous Drainage of Cerebrospinal Fluid in Patients with Subarachnoid Hemorrhage: A Retrospective Analysis of 108 Patients

Abstract The effects of continuous drainage of cerebrospinal fluid (CSF) on vasospasm and hydrocephalus were analyzed retrospectively in 108 patients with subarachnoid hemorrhage (SAH) who were operated on for ruptured aneurysms within 48 hours of their onset. Ninety-two of these patients underwent a procedure for CSF drainage (cisternal drainage, ventricular drainage, lumbar drainage, or a combination of these). The duration, the total volume, and the average daily volume of CSF drainage were 10.4 ± 7.0 days (mean ± SD), 2034 ± 1566 ml, and 190 ± 65.3 ml, respectively. Patients with a greater drainage volume at a lower height of drainage in the early period after SAH developed more cerebral infarctions later (P &amp;lt; 0.025). The relationship between the total volume of CSF removed and shunt-dependent hydrocephalus was determined to be statistically significant (P &amp;lt; 0.005). Cerebral infarction and hydrocephalus after SAH were also found to be statistically associated (P &amp;lt; 0.001). Thus, continuous cerebrospinal fluid drainage should not be performed too readily in patients with SAH, because the removal of a large amount of CSF can induce cerebral vasospasm as well as hydrocephalus.

The effect of continuous drainage of cerebrospinal fluid in patients with subarachnoid hemorrhage

The effects of continuous drainage of cerebrospinal fluid (CSF) on vasospasm and hydrocephalus were analyzed retrospectively in 108 patients with subarachnoid hemorrhage (SAH) who were operated on for ruptured aneurysms within 48 hours of their onset. Ninety-two of these patients underwent a procedure for CSF drainage (cisternal drainage, ventricular drainage, lumbar drainage, or a combination of these). The duration, the total volume, and the average daily volume of CSF drainage were 10.4 +/- 7.0 days (mean +/- SD). 2034 +/- 1566 ml, and 190 +/- 65.3 ml, respectively. Patients with a greater drainage volume at a lower height of drainage in the early period after SAH developed more cerebral infarctions later (P less than 0.025). The relationship between the total volume of CSF removed and shunt-dependent hydrocephalus was determined to be statistically significant (P less than 0.005). Cerebral infarction and hydrocephalus after SAH were also found to be statistically associated (P less than 0.001). Thus, continuous cerebrospinal fluid drainage should not be performed too readily in patients with SAH, because the removal of a large amount of CSF can induce cerebral vasospasm as well as hydrocephalus.

Hydrocephalus following early operation on ruptured cerebral aneurysms--significance of long-term monitoring of intracranial pressure (author's transl)

A total of 128 cases with ruptured cerebral aneurysms were operated on within two weeks after subarachnoid hemorrhage (SAH) . Postoperatively, cerebrospinal fluid (CSF) was continuously drained from the lateral ventricle and the basal cistern. Using the intraventricular catheter, intracranial pressure (ICP) was monitored for an average of three weeks after operation. The development of normal pressure hydrocephalus (NPH) was estimated from ICP pattern and other diagnostic studies such as CT scan, infusion test and RI cisternography. NPH developed in 26% of these cases. Patients who had a large volume of CSF drainage of over 200 ml daily underwent shunt surgery in a higher proportion (56%). It was postulated that the defect of the subarachnoid space might be aggravated by CSF drainage. A total of 49 long-term recordings of ICP was obtained in 31 cases. Within two weeks after SAH, ICP was usually higher than 20 mmHg, but thereafter became lower. This early high pressure was mostly due to acute hydrocephalus and not to the so-called acute brain swelling. However, when mildly elevated ICP with B-wave lasted beyond the third week of SAH, almost all patients developed NPH. This characteristic pattern of ICP plays an important role in the development of NPH and is useful for selecting patients for shunt surgery. Vasospasm was a frequent concomitant of increased ICP, and patients with vasospasm underwent shunt surgery in rather high incidences (34%). Both vasospasm and hydrocephalus could be explained to be the result of blood clots in the subarachnoid space.