External Lumbar Drainage Research Articles

Mechanical Complications of External Ventricular and Lumbar Drains

External ventricular drain (EVD) and lumbar drain insertion are 2 of the most commonly performed neurosurgical procedures worldwide for acute hydrocephalus. Mechanical complications, such as obstruction or cerebrospinal fluid (CSF) leakage, are often seen and may contribute toward significant patient morbidity. Different CSF drainage methods are advocated to reduce the incidence of complications, but evidence regarding comparative effectiveness is limited. In this single-center prospective cohort study, the incidence of mechanical complications and associated interventional factors, including choice of drain, collecting system, and location, were studied in patients requiring CSF diversion for acute hydrocephalus. Univariate analyses were performed to explore trends within the data, followed by a repeated-measures mixed-effects regression to determine the independent influence of drain device on mechanical failure. Sixty-one patients required CSF diversion between January 2020 and March 2021, via 3 different drain types (lumbar drain, tunneled, and bolted EVD) and 2 collection systems (LiquoGuard 7 and AccuDrain), performed in either theater or intensive care. Twenty-one patients (39%) experienced a mechanical complication, with blockage being the most common. Multivariate analyses showed that bolted EVDs (odds ratio, 0.08; confidence interval, 0.01-0.58) and LiquoGuards (OR, 0.23; CI, 0.08-0.69) were significantly associated with fewer mechanical complications compared with tunneled EVDs and gravity-based collection systems, respectively (P ≤ 0.01). Drain device has an influence on the occurrence of EVD-related complications. These preliminary findings suggest that choosing bolted EVDs and motor-assisted drainage can reduce drain-associated mechanical failure. A randomized controlled trial comparing drain devices is required to confirm these findings.

Trends in Utilization of Temporary and Permanent Cerebrospinal Fluid Diversion and Catheter Cerebral Angiography for Patients with Aneurysmal Subarachnoid Hemorrhage in the United States

We sought to analyze the rate of utilization of methods of cerebrospinal fluid diversion over time in a nationally representative cohort of patients admitted with aneurysmal subarachnoid hemorrhage (aSAH). The Nationwide Inpatient Sample was queried for patients admitted with aSAH from 2006 to 2018. Patients who received external ventricular drainage (EVD), lumbar drainage, ventriculoperitoneal shunt (VPS), and cerebral angiography were then identified. A Cochrane-Armitage test was conducted to assess the linear trend of proportions of EVD, lumbar drains, VPS, and mean cerebral angiograms per admission. Four regression analyses were conducted to infer the association of baseline variables to EVD, lumbar drain, VPS, and mean number of cerebral angiographies. A total of 133,567 admissions were identified from 2006-2018 involving aSAH. Of these, 41.82% received EVD, 6.22% received lumbar drainage, 10.58% received VPS, and 75.03% had cerebral angiograms. There was an average upward trend of 1.57% in annual EVD utilization, downward trend of -0.28% in utilization of lumbar drainage, no changes in VPS utilization, and an upward trend of 0.04 angiograms per year (P < 0.001). There was a higher proportion of Black patients treated with EVD and VPS in both urban teaching hospitals and large hospitals. Our results show the temporal trends in utilization of temporary and permanent methods of cerebrospinal fluid diversion and catheter cerebral angiography among patients with aSAH in the United States. The underutilization of VPS following EVD and the differences in EVD and VPS utilization depending on race and hospital size deserve further exploration.

Cerebral salt wasting syndrome caused by external lumbar drainage in a patient with chronic hydrocephalus

In cases of hyponatremia induced by brain damage, it is important to distinguish between the syndrome of inappropriate anti-diuretic hormone secretion (SIADH) and cerebral salt wasting syndrome. A ventriculoperitoneal (VP) shunt is the standard treatment for hydrocephalus, and external lumbar drainage (ELD) is an option to evaluate the effect of a VP shunt. However, ELD has potential complications, such as subarachnoid hemorrhage, meningitis, and rarely hyponatremia. Therefore, we report a case of a patient with cerebral salt-wasting syndrome resulting from ELD to treat normal-pressure hydrocephalus during the rehabilitation of acute ischemic stroke.

The Value of the Correlation Coefficient Between the ICP Wave Amplitude and the Mean ICP Level (RAP) Combined With the Resistance to CSF Outflow (Rout) for Early Prediction of the Outcome Before Shunting in Posttraumatic Hydrocephalus.

ObjectiveTo evaluate the value of the correlation coefficient between the ICP wave amplitude and the mean ICP level (RAP) and the resistance to CSF outflow (Rout) in predicting the outcome of patients with post-traumatic hydrocephalus (PTH) selected for shunting.Materials and MethodsAs a training set, a total of 191 patients with PTH treated with VP shunting were retrospectively analyzed to evaluate the potential predictive value of Rout, collected from pre-therapeutic CSF infusion test, for a desirable recovery level (dRL), standing for the modified rankin scale (mRS) of 0–2. Eventually, there were 70 patients with PTH prospectively included as a validation set to evaluate the value of Rout-combined RAP as a predictor of dRL. We calculated Rout from a CSF infusion test and collected RAP during continuous external lumbar drainage (ELD). Maximum RAP (RAPmax) and its changes relative to the baseline (ΔRAPmax%) served as specific parameters of evaluation.ResultsIn the training set, Rout was proved to be a significant predictor of dRL to shunting, with the area under the curve (AUC) of 0.686 (p < 0.001) in receiver-operating characteristic (ROC) analysis. In the validation set, Rout alone did not present a significant value in the prediction of desirable recovery level (dRL). ΔRAPmax% after 1st or 2nd day of ELD both showed significance in predicting of dRL to shunting with the AUC of 0.773 (p < 0.001) and 0.786 (p < 0.001), respectively. Significantly, Rout increased the value of ΔRAPmax% in the prediction of dRL with the AUC of 0.879 (p < 0.001), combining with ΔRAPmax% after the 1st and 2nd days of ELD. RAPmax after the 1st and 2nd days of ELD showed a remarkable predictive value for non-dRL (Levels 3-6 in Modified Rankin Scale) with the AUC of 0.891 (p < 0.001) and 0.746 (p < 0.001).ConclusionBoth RAP and Rout can predict desirable recovery level (dRL) to shunting in patients with PTH in the early phases of treatment. A RAP-combined Rout is a better dRL predictor for a good outcome to shunting. These findings help the neurosurgeon predict the probability of dRL and facilitate the optimization of the individual treatment plan in the event of ineffective or unessential shunting.

Bacteremia Is a Risk Factor for Cerebrospinal Fluid Infection in Patients with Cerebrospinal Fluid Drains—A Retrospective Study

There is little evidence on the role of prior infection in patients with external ventricular drains (EVDs) and lumbar drains (LDs). In this study, our aim is to investigate whether previous bacteremia is a risk factor for cerebrospinal fluid drain infection (CSFDI) in patients with EVDs and LDs and to describe the microorganisms implicated. We designed a retrospective, single-center cohort study. We recorded patients’ demographic and clinical characteristics, as well as microbiology laboratory data. We used non-parametric statistical methods to identify possible risk factors for CSFDI. We found 799 neurosurgical admissions during the study period, 70 of which fulfilled the inclusion criteria. Acinetobacter baumannii was the most frequent single pathogen isolated in the cerebrospinal fluid (CSF). Acinetobacter baumannii bacteremia was more common in patients with Acinetobacter baumannii CSFDI (p = 0.01). The distribution of the pathogens in the CSF differed from that of the pathogens isolated in blood (p = 0.001). In the univariate analysis, prior bacteremia was more common in patients with CSFDI (p = 0.027), but, in the multivariate model, prior bacteremia was not identified as an independent risk factor (OR = 0.456, CI: 0.138–1.512, p = 0.2). In an ICU population, the most frequently isolated pathogens were Gram-negative Enterobacteriaceae and Acinetobacter baumannii. Previous bacteremia was significantly more probable among patients with EVDs or LDs who developed a CSFDI, and its role warrants further investigation.

Prediction of Shunt Responsiveness in Suspected Patients With Normal Pressure Hydrocephalus Using the Lumbar Infusion Test: A Machine Learning Approach

Machine learning (ML) approaches can significantly improve the classical Rout-based evaluation of the lumbar infusion test (LIT) and the clinical management of the normal pressure hydrocephalus. To develop a ML model that accurately identifies patients as candidates for permanent cerebral spinal fluid shunt implantation using only intracranial pressure and electrocardiogram signals recorded throughout LIT. This was a single-center cohort study of prospectively collected data of 96 patients who underwent LIT and 5-day external lumbar cerebral spinal fluid drainage (external lumbar drainage) as a reference diagnostic method. A set of selected 48 intracranial pressure/electrocardiogram complex signal waveform features describing nonlinear behavior, wavelet transform spectral signatures, or recurrent map patterns were calculated for each patient. After applying a leave-one-out cross-validation training-testing split of the data set, we trained and evaluated the performance of various state-of-the-art ML algorithms. The highest performing ML algorithm was the eXtreme Gradient Boosting. This model showed a good calibration and discrimination on the testing data, with an area under the receiver operating characteristic curve of 0.891 (accuracy: 82.3%, sensitivity: 86.1%, and specificity: 73.9%) obtained for 8 selected features. Our ML model clearly outperforms the classical Rout-based manual classification commonly used in clinical practice with an accuracy of 62.5%. This study successfully used the ML approach to predict the outcome of a 5-day external lumbar drainage and hence which patients are likely to benefit from permanent shunt implantation. Our automated ML model thus enhances the diagnostic utility of LIT in management.

Combined ultrasound and fluoroscopy guided tunneled external lumbar drain placement in children.

External lumbar drain placement has been shown to be an efficacious and safe approach to managing various forms of intracranial hypertension in adult patients and children. The use of ultrasound guidance for lumbar punctures in young patients has been described however, but the modality is not routinely used for the placement of tunneled lumbar drains. In this report, two cases are presented that detail experience using ultrasound guidance for tunneled lumbar drains in children.

The Impact of Multimorbidity Burden, Frailty Risk Scoring, and 3-Directional Morphological Indices vs. Testing for CSF Responsiveness in Normal Pressure Hydrocephalus.

Objective: Multimorbidity burden across disease cohorts and variations in clinico-radiographic presentations within normal pressure hydrocephalus (NPH) confound its diagnosis, and the assessment of its amenability to interventions. We hypothesized that novel imaging techniques such as 3-directional linear morphological indices could help in distinguishing between hydrocephalus vs. non-hydrocephalus and correlate with responsiveness to external lumbar drainage (CSF responsiveness) within NPH subtypes.Methodology: Twenty-one participants with NPH were recruited and age-matched to 21 patients with Alzheimer’s Disease (AD) and 21 healthy controls (HC) selected from the Alzheimer’s Disease Neuroimaging Initiative (ADNI) database. Patients with NPH underwent testing via the NPH programme with external lumbar drainage (ELD); pre- and post-ELD MRI scans were obtained. The modified Frailty Index (mFI-11) was used to stratify the NPH cohort, including Classic and Complex subtypes, by their comorbidity and frailty risks. The quantitative imaging network tool 3D Slicer was used to derive traditional 2-dimensional (2d) linear measures; Evans Index (EI), Bicaudate Index (BCI) and Callosal Angle (CA), along with novel 3-directional (3d) linear measures; z-Evans Index and Brain per Ventricle Ratio (BVR). 3-Dimensional (3D) ventricular volumetry was performed as an independent correlate of ventriculomegaly to CSF responsiveness.Results: Mean age for study participants was 71.14 ± 6.3 years (18, 85.7% males). The majority (15/21, 71.4%) of participants with NPH comprised the Complex subtype (overlay from vascular risk burden and AD); 12/21 (57.1%) were Non-Responders to ELD. Frailty alone was insufficient in distinguishing between NPH subtypes. By contrast, 3d linear measures distinguished NPH from both AD and HC cohorts, but also correlated to CSF responsiveness. The z-Evans Index was the most sensitive volumetric measure of CSF responsiveness (p = 0.012). Changes in 3d morphological indices across timepoints distinguished between Responders vs. Non-Responders to lumbar testing. There was a significant reduction of indices, only in Non-Responders and across multiple measures (z-Evans Index; p = 0.001, BVR at PC; p = 0.024). This was due to a significant decrease in ventricular measurement (p = 0.005) that correlated to independent 3D volumetry (p = 0.008).Conclusion. In the context of multimorbidity burden, frailty risks and overlay from neurodegenerative disease, 3d morphological indices demonstrated utility in distinguishing hydrocephalus vs. non-hydrocephalus and degree of CSF responsiveness. Further work may support the characterization of patients with Complex NPH who would best benefit from the risks of interventions.

External lumbar drainage in progressive pediatric idiopathic intracranial hypertension.

Pediatric idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure despite normal cerebrospinal fluid and neuroimaging findings. Initial management is typically medical; however, nearly 10% of children will eventually require surgery for persistent headache and/or vision loss. External lumbar drainage, which is a considerably safer treatment option, has not been adequately analyzed in children with medically refractory IIH. The authors conducted a single-institution retrospective analysis of children with medically refractory IIH who had undergone external lumbar drain (ELD) placement because of worsening papilledema, reflected as increased retinal nerve fiber layer (RNFL) thickness on optical coherence tomography (OCT) testing. The main outcome measures were effects of external lumbar drainage on papilledema resolution, symptoms, and vision. The authors analyzed the medical records of 13 children with IIH (11 girls, mean age 15.0 ± 2.3 years) whose mean CSF opening pressure was 45.5 ± 6.8 cm H2O. In all children, the average global RNFL thickness in both eyes significantly increased at ELD placement (right eye 371.8 ± 150.2 μm, left eye 400.3 ± 96.9 μm) compared with presentation thickness (right eye 301.6 ± 110.40 μm, left eye 350.2 ± 107.7 μm) despite acetazolamide medical therapy (20-30 mg/kg/day), leading to ELD placement after 9.5 ± 6.9 days (range 3-29 days). After ELD insertion, there was headache resolution, gradual and continuous improvement in optic disc thickness, and preservation of good vision. ELD placement in children with medically refractory IIH who demonstrated worsening papilledema with increased RNFL thickening on OCT testing typically results in symptom relief and disc edema resolution with good visual outcome, often preventing the need for additional definitive surgeries that carry greater failure and morbidity risks.

External Lumbar Drainage following Traumatic Intracranial Hypertension: A Systematic Review and Meta-Analysis.

Traumatic brain injury (TBI) often results in elevations in intracranial pressure (ICP) that are refractory to standard therapies. Several studies have investigated the utility of external lumbar drainage (ELD) in this setting. To evaluate the safety and efficacy of ELD or lumbar puncture with regard to immediate effect on ICP, durability of the effect on ICP, complications, and neurological outcomes in adults with refractory traumatic intracranial hypertension. A systematic review and meta-analysis were conducted beginning with a comprehensive search of PubMed/EMBASE. Two investigators reviewed studies for eligibility and extracted data. The strength of evidence was evaluated using GRADE methodology. Random-effects meta-analyses were performed to calculate pooled estimates. Nine articles detailing 6 studies (N=110) were included. There was moderate evidence that ELD has a significant immediate effect on ICP; the pooled effect size was -19.5mmHg (95% CI -21.0 to -17.9mmHg). There was low evidence to indicate a durable effect of ELD on ICP up to at least 24 h following ELD. There was low evidence to indicate that ELD was safe and associated with a low rate of clinical cerebral herniation or meningitis. There was very low evidence pertaining to neurological outcomes. Given preliminary data indicating potential safety and feasibility in highly selected cases, the use of ELD in adults with severe TBI and refractory intracranial hypertension in the presence of open basal cisterns and absence of large focal hematoma merits further high-quality investigation; the ideal conditions for potential application remain to be determined.

Radiologically defined acute hydrocephalus in aneurysmal subarachnoid haemorrhage

Background Ventriculomegaly is common in aneurysmal subarachnoid haemorrhage (aSAH). An imaging measure to predict the need for cerebrospinal fluid (CSF) diversion may be useful. The bicaudate index (BCI) has been previously applied to aSAH. Our aim was to derive and test a threshold BCI above which CSF diversion may be required. Methods Review of prospective registry. The derivation group (2009–2015) included WFNS grade 1–2 aSAH patients who deteriorated clinically, had a repeat CT brain and underwent CSF diversion. BCI was measured on post-deterioration CTs and the lower limit of the 95% confidence interval (95%CI) was the hydrocephalus threshold. In a separate test group (2016), in WFNS ≥ 2 patients, we compared BCI on diagnostic CTs with CSF diversion within 24 hours. Results The derivation group (n = 62) received an external ventricular (n = 57, 92%) or lumbar drain (n = 5, 8%). Mean post-deterioration BCI was 0.19 (95%CI 0.17–0.22) for age ≤49 years, 0.22 (95%CI 0.20–0.23) for age 50–64 years and 0.24 (95%CI 0.22–0.27) for age ≥65 years. Hydrocephalus thresholds were therefore 0.17, 0.20 and 0.22, respectively. In the test group (n = 105), there was no significant difference in BCI on the diagnostic CT between good and poor grade patients aged ≤49 years (p = 0.31) and ≥65 years (p = 0.96). 30/66 WFNS ≥ 2 patients underwent CSF diversion, although only 15/30 (50%) exceeded BCI thresholds for hydrocephalus. Conclusion A significant proportion of aSAH patients may undergo CSF diversion without objective evidence of hydrocephalus. Our threshold values require further testing but may provide an objective measure to aid clinical decision making in aSAH.

Quantitative Evaluation of Gait Changes Using APDM Inertial Sensors After the External Lumbar Drain in Patients With Idiopathic Normal Pressure Hydrocephalus.

Objectives: Gait and balance disturbances are common symptoms of idiopathic normal pressure hydrocephalus (iNPH). This study aimed to quantitatively evaluate gait and balance parameters after external lumbar drainage (ELD) using APDM inertial sensors.Methods: Two-minute walkway tests were performed in 36 patients with suspected iNPH and 20 healthy controls. A total of 36 patients underwent ELD. According to clinical outcomes, 20 patients were defined as responders, and the other 16 as non-responders. The gait parameters were documented, and the corresponding differences between responders and non-responders were calculated.Results: When compared with healthy controls, patients with suspected iNPH exhibited decreased cadence, reduced gait speed, a higher percentage of double support, decreased elevation at mid-swing, reduced foot strike angle, shorter stride length, difficulty in turning, and impaired balance functions. After the ELD, all these manifestations, except elevation at mid-swing and balance functions, were significantly improved in responders. The change of Z-score absolute value in the six parameters, except for foot strike angle, was >1. No significant improvement was observed in non-responders.Conclusion: APDM inertial sensors are useful for the quantitative assessment of gait impairment in patients with iNPH, which may be a valuable tool for identifying candidates that are suitable for shunting operations.

Implementation of an Automated Cerebrospinal Fluid Drainage System for Early Mobilization in Neurosurgical Patients.

Background: Automated cerebrospinal fluid (CSF) drainage systems allow for the mobilization of patients with an external CSF drain. The aim of this study is to describe the implementation of an automated CSF drainage system in neurosurgical patients with external CSF drains. Methods: A feasibility study was performed using an automated CSF drainage system (LiquoGuard®7, Möller Medical GmbH, Fulda, Germany) in adult neurosurgical patients treated with external lumbar or external ventricular drains between December 2017 and June 2020. Limited mobilization was allowed—patients were allowed to adjust their inclined beds, sit in chairs and walk under the supervision of a nurse or physical therapist. The primary outcome was the number of prematurely terminated drainage sessions. Results: Twenty-three patients were included. Drainage was terminated prematurely in eight (35%) patients. In three (13%) of these patients, drainage was terminated due to signs of hydrocephalus. Pressure-controlled drainage in patients with external lumbar drains (ELD) showed inaccurate pressure curves, which was solved by using volume-controlled drainage in ELD patients. Conclusion: The implementation of an automated CSF drainage system (LiquoGuard®7) for CSF drainage allows for early mobilization in a subset of patients with external CSF drains. External lumbar drains require volume-based drainage rather than differential pressure-dependent drainage.

Serial Tap Test of patients with idiopathic normal pressure hydrocephalus: impact on cognitive function and its meaning

BackgroundIdiopathic normal pressure hydrocephalus (INPH) is characterized by gait disturbance, urinary incontinence and cognitive decline. Symptoms are potentially reversible and treatment is based on cerebrospinal fluid shunting. The tap test (TT) is used to identify patients that will benefit from surgery. This procedure consists of the withdrawal of 20 to 50 mL of cerebrospinal fluid (CSF) through a lumbar puncture (LP) after which the symptoms of the triad are tested. Improvement in the quality and speed of gait are already recognized but cognitive improvement depends on several factors such as tests used, the time elapsed after LP for re-testing, and the number of punctures. Serial punctures may trigger similar conditions as external lumbar drainage (ELD) to the organism.ObjectiveThis study aimed to identify how serial punctures affect cognition to increase the sensitivity of the test and consequently the accuracy of surgical indication.MethodsSixty-one patients with INPH underwent baseline memory and executive tests repeatedly following the 2-Step Tap Test protocol (2-STT – two procedures of 30 mL lumbar CSF drainage separated by a 24-h interval). The baseline scores of INPH patients were compared with those of 55 healthy controls, and with intragroup post-puncture scores of the 2-STT.ResultsThe group with INPH had lower performance than the control group in all cognitive tests (RAVLT, Stroop, CFT, FAR-COWA, FAB, MMSE, orientation, mental control), except for the forward digit span test (p = 0.707). After conducting LP procedures, the Stroop test (words, colors and errors), RAVLT (stage A1, A6 and B1), and CFT (immediate and delayed R) scores were equal to those of the control group (p > 0.05). The INPH group presented significant improvement after the first puncture in MMSE (p = 0.031) and in the Stroop Test (points) (p < 0.001). After the second puncture, subjects improved in orientation, MMSE, RAVLT (B1), Stroop (points, words, errors) and CFT (IR).ConclusionProgressive cognitive improvement occurred over the 2-STT and changes were more significant after the second LP in all cognitive domains except for RAVLT (A7). Encephalic alert system ‘arousal’ seems to participate in early improvements observed during 2-STT. The second LP increased the sensitivity of the drainage test to detect changes in cognitive variables, and consequently improved the quality of the method.

Morphological Aspects of Acute Renal Injury in Cardiac Surgery

Summary. The use of endoscopic transsphenoidal access is an effective and safe method for the surgical treatment of pituitary adenomas (PA). In endoscopic transsphenoidal surgeries, there is a need to control intracranial pressure (ICP) for reposition and expansion of the tumor capsule. Currently, the main method for reducing ICP in transsphenoidal surgery is installation of an external lumbar drainage, which is associated with a number of complications.Aim of study. To improve the results of surgical treatment of patients with arterial hypertension using hypertonic saline solution.Material and methods. A clinical and anatomical analysis of material from 27 deceased patients who were treated in the cardiac surgery department of the Institute was carried out. Valve replacement was performed in 11 patients, aortic replacement - 2, valves and aorta - 7, combined operations - 7. The patient’s records, autopsy protocols, results of histological examination of surgical and autopsy material were studied. Already on the next day after surgery, an increase in serum creatinine by more than 25% was noted under the conditions of CBR. Morphological examination of the kidneys revealed acute pathological processes - necrosis of nephrocytes of the convoluted tubules in 59.3% of cases and dystrophic changes in 40.7% of cases against the background of chronic pathology (nephrosclerosis, vascular atherosclerosis, glomerulosclerosis, pyelonephritis, secondary contracted kidney). After coronary angiography with a radiopaque contrast agent (RCA), signs of excretory nephrosis were noted, often with fixation of the RCA in the loop of Henle, with tubulorexis and the formation of cell casts.

Hydrocephalus after aneurysmal subarachnoid hemorrhage: Epidemiology, Pathogenesis, Diagnosis, and Management

Hydrocephalus is one of the most common complications of aneurysmal subarachnoid hemorrhage (aSAH), which seriously affects the quality of life and shortens the survival time of affected patients. By reviewing the recent studies on the risk factors of aSAH-associated hydrocephalus, we aimed to explicitly present the pathogenesis of acute and chronic hydrocephalus after aSAH and make a comprehensive list of the associated risk factors of aSAH-associated hydrocephalus and shunt-dependent hydrocephalus. It would help us to better explain the occurrence of hydrocephalus after aSAH, especially hydrocephalus caused by inflammation after bleeding. Many studies have recently suggested that high mobility group box 1 may be an early upstream promoter of inflammatory response after aSAH, which also provides important ideas for us to look for potential drug treatments. The surgery, such as external ventricular drain and lumbar drainage, is the most common and effective treatment. Yet, there are often complications, such as rebleeding and intracranial infection, and the optimal timing of intervention is controversial. Besides, this is also a systematic review of the recent advances in epidemiology, pathogenesis, diagnosis, and management of aSAH-associated hydrocephalus.

Role of DESH, callosal angle and cingulate sulcus sign in prediction of gait responsiveness after shunting in iNPH patients

Primary endpoint of this single-centre, prospective consecutive cohort study was to evaluate DESH score, CA, CSS and Evans index of suspected iNPH patients against the reference standard of lumbar infusion test (LIT) and external lumbar drainage (ELD) in prediction of gait response after VP shunt implantation in patients with idiopathic normal pressure hydrocephalus (iNPH). Patients were assigned to NPH and non-NPH groups based on LIT and ELD results. Age-matched controls were added for group comparison. 32 NPH, 46 non-NPH and 15 control subjects were enrolled in the study. There were significant differences in mean preoperative DESH scores of NPH, non-NPH and control groups (6.3 ± 2.3 ([±SD]) (range 2–10) vs 4.5 ± 2.4 (range 0–10) vs 1.0 ± 1.2 (range 0–4)). Differences in mean CA and Evans index were not significant between NPH and non-NPH groups. CSS showed 62.5% sensitivity, 60.87% specificity, 52.63% PPV and 70% NPV for differentiation of NPH and non-NPH groups. A CA of 68 degrees had 48.49% sensitivity, 76.09% specificity, 59.26% PPV 67.31% NPV and DESH score of 4 had 93.75% sensitivity, 41.30% specificity, 52.63% PPV and 90.48% NPV for differentiation between NPH and non-NPH groups. The groups of probable iNPH patients with gait impairment diagnosed by high DESH score or positive functional testing did not overlap and DESH score did not correlate with gait improvement after ELD. DESH score should not be used as a simple diagnostic or prognostic marker of iNPH and we could not confirm the benefit of measurement of callosal angle and cingulate sulcus sign.

Metagenomic Next-Generation Sequencing of Cerebrospinal Fluid for the Diagnosis of External Ventricular and Lumbar Drainage-Associated Ventriculitis and Meningitis.

Metagenomic next-generation sequencing (mNGS) has become a widely used technology that can accurately detect individual pathogens. This prospective study was performed between February 2019 and September 2019 in one of the largest clinical neurosurgery centers in China. The study aimed to evaluate the performance of mNGS on cerebrospinal fluid (CSF) from neurosurgical patients for the diagnosis of external ventricular and lumbar drainage (EVD/LD)-associated ventriculitis and meningitis (VM). We collected CSF specimens from neurosurgical patients with EVD/LD for more than 24 h to perform conventional microbiological studies and mNGS analyses in a pairwise manner. We also investigated the usefulness of mNGS of CSF for the diagnosis of EVD/LD-associated VM. In total, 102 patients were enrolled in this study and divided into three groups, including confirmed VM (cVM) (39), suspected VM (sVM) (49), and non-VM (nVM) (14) groups. Of all the patients, mNGS detected 21 Gram-positive bacteria, 20 Gram-negative bacteria, and five fungi. The three primary bacteria detected were Staphylococcus epidermidis (9), Acinetobacter baumannii (5), and Staphylococcus aureus (3). The mNGS-positive coincidence rate of confirmed EVD/LD-associated VM was 61.54% (24/39), and the negative coincidence rate of the nVM group was 100% (14/14). Of 15 VM pathogens not identified by mNGS in the cVM group, eight were negative with mNGS and seven were inconsistent with the conventional microbiological identification results. In addition, mNGS identified pathogens in 22 cases that were negative using conventional methods; of them, 10 patients received a favorable clinical treatment; thus, showing the benefit of mNGS-guided therapy.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Drenaje lumbar externo en la unidad de cuidados intensivos

The placement of an external lumbar drainage (ELD), an invasive procedure to extract cerebrospinal fluid (CSF) from the spinal space, has gradually increased in practice in recent years within the context of neurocritical medicine. Despite it not being recommended by international guidelines or consensus, it is used for the handling of a few specific clinical situations in connection with different types of severe brain injury. The study consists of a non-systematic review of the literature, along with the authors’ experience, presenting the main current indications and details for its handling in the different clinical scenarios and describing side effects and complications of the procedure.