Lumbar Cerebrospinal Fluid Drainage Research Articles

Cerebrospinal fluid lumbar drainage in reducing vasospasm following aneurysmal subarachnoid hemorrhage in Vietnam: A single-center prospective study

ObjectiveVasospasm after aneurysmal subarachnoid hemorrhage (aSAH) aggravates outcome of patients through a cascade of complications and harsh consequences. This study was conducted to evaluate the effect of cerebrospinal fluid (CSF) lumbar drainage in aSAH management and in the prevention of vasospasm at a university hospital in Vietnam. MethodsA single-center, prospective case series of aSAH treatment with CSF lumbar drainage was conducted from June 2018 to July 2019. Outcomes measured were clinical vasospasm, vasospasm-induced infarction, shunt-dependent rate, duration of treatment in hospital and Glasgow Outcome Scale (GOS) at 3 months and 1 year after discharge. ResultsAmong 43 patients with aSAH admitted to the clinic, thirty-two aSAH patients (71.8% female, mean age 58.8 ± 11.5 years) received lumbar drainage. The incidence of clinical vasospasm and vasospasm-induced infarction on CT scan/MRI (including asymptomatic cerebral infarction) was 21.9% and 56.3%, respectively. Four patients (12.5%) underwent another CSF shunting operation. The mean duration of hospital stay was 27.8 ± 16.9 days. Nearly 70% of aSAH patients were discharged and were able to return to normal life with no or minor neurological deficits (GOS 4–5) at 3-month and 1-year follow-ups. No serious complication of CSF lumbar drainage was observed, except for one major setback, which was meningitis during treatment (53.1%). ConclusionsCSF lumbar drainage may reduce the incidence of clinical vasospasm, shorten hospital stays, and possibly improve patient outcomes following aSAH. Our findings suggest that the selective use of CSF lumbar drainage, in addition to standard strategies, can be beneficial in preventing vasospasm and offers more choice in aSAH management.

Role of Lumbar Puncture In Traumatic Brain Injury

Background: Cerebrospinal fluid (CSF) drainage via ventricular puncture is an established therapy ofelevated intracranial pressure (ICP). In contrast, lumbar CSF removal is believed to be contraindicated withintracranial hypertension.Method: We investigated the safety and efficacy of lumbar CSF drainage to decrease refractory elevatedICP in a small cohort of patients with traumatic brain injury (TBI). A score (0–8 points) was used to assesscomputed tomography (CT) images for signs of herniation and for patency of the basal cisterns. All patientsreceived lumbar CSF drainage either as a continuous drainage or as a single lumbar puncture (LP). Type andmethod of CSF drainage, mean ICP 24 h prior and after CSF removal, and adverse events were documented.Outcome was assessed after 3 months (with dichotomized Glasgow outcome scale).Results: Eight patients were evaluated retrospectively. n = 5 suffered a moderate, n = 2 a severe TBI (oneGlasgow coma score not documented). The CT score was ?5 in all patients prior to LP and decreased afterpuncture without clinical consequences in two patients. The amount of CSF removal did not correlate withscore changes (P = 0.45). CSF drainage led to a significant reduction of mean ICP (from 22.3 to 13.9 mmHg,P = 0.002). Continuous drainage was more effective than a single LP. Three of eight patients reached afavorable outcome.Conclusions: Lumbar CSF removal for the treatment of intracranial hypertension is effective and safe,provided the basal cisterns are discernible, equivalent to ?5 points in the proposed new score. The scoreneeds further validation.

Acute spontaneous spinal cord infarction: Utilisation of hyperbaric oxygen treatment, cerebrospinal fluid drainage and pentoxifylline.

Spinal cord infarction (SCI) is a potentially devastating disorder presenting with an acute anterior spinal artery syndrome, accounting for an estimated 1% of stroke presentations. Aetiologies include aortic surgical complications, systemic hypotension, fibrocartilaginous embolism and vascular malformations. Diagnosis is clinical combined with restriction on diffusion-weighted magnetic resonance imaging (MRI). There are no treatment guidelines for non-perioperative cases although there is limited literature regarding potential therapies, including hyperbaric oxygen treatment (HBOT) and cerebrospinal fluid (CSF) drainage. We describe 13 cases of acute SCI, five receiving HBOT, and three also receiving pentoxifylline and drainage of lumbar CSF. Data for all patients with MRI-proven SCI at Fiona Stanley Hospital from 2014-2019 were reviewed. Thirteen patients, median age 57 years (31-74), 54% female, were identified. Aetiologies: two fibrocartilaginous emboli; seven likely atherosclerotic; two thromboembolic; two cryptogenic. All presented with flaccid paraplegia except one with Brown-Sequard syndrome. Levels ranged from C4 to T11. Five patients received HBOT within a median time of 40 hours from symptom onset, with an average 15 treatments (10-20). Three of these received triple therapy (HBOT, pentoxifylline, CSF drainage) and had median Medical Research Council manual muscle testing power of 5, median modified Rankin Score (mRS) of 1 and American Spinal Injury Association (ASIA) score of D on discharge, compared with 2 power, mRS 3.5 and ASIA B in those who did not. SCI can be severely disabling. Triple therapy with pentoxifylline, CSF drainage and HBOT may reduce disability and further prospective trials are required.

Impact of Comorbidities and Frailty on Early Shunt Failure in Geriatric Patients With Normal Pressure Hydrocephalus.

Background/Aim: Older patients are considered to bear a higher perioperative risk. Since idiopathic normal pressure hydrocephalus (NPH) predominantly concerns older patients, identifying risk factors for early shunt failure for preoperative risk/benefit assessment is indispensable for indication and/or consultation of patients for ventriculoperitoneal shunting (VPS).Methods: We performed a retrospective study design, including data acquired from two university hospital neurosurgical institutions between 2012 and 2019. Overall, 211 consecutive patients with clinical/radiological signs for NPH who additionally showed alleviation of symptoms after lumbar cerebrospinal fluid (CSF) drainage, received VPS and were included for further analysis. Frailty was measured using the Clinical Frailty Scale (CFS). Main outcome was early shunt failure or post-operative complications within 30 days after initial VPS surgery.Results: The overall complication rate was 14%. Patient-related complications were observed in 13 patients (6%) and procedure-related complications in 16 patients (8%). Early post-operative complications resulted in a significantly prolonged length of hospital stay 6.9 ± 6.8 vs. 10.8 ± 11.8 days (p = 0.03). Diabetes mellitus with end-organ damage (OR 35.4, 95% CI 6.6 – 189.4, p < 0.0001) as well as preexisting Parkinson's disease were associated with early patient-related post-surgical complications after VPS for NPH.Conclusions: Patients comorbidities but not frailty were associated with early post-operative patient-related complications in patients suffering NPH. While frailty may deter patients from other (neurosurgical) procedures, VPS surgery might contribute to treating NPH in these patients at a tolerable risk.

Prevention of Intra-Operative Cerebrospinal Fluid Leaks by Lumbar Cerebrospinal Fluid Drainage during Endoscopic Endonasal Trans- Sphenoidal Surgery for Pituitary Macroadenomas

Aim and Objective: Postoperative cerebrospinal fluid leak is a recognized complication of endoscopic endonasal trans- sphenoidal surgery for pituitary macroadenomas. In this study we assess the utility of prophylactic use of lumbar drain in preventing intra-operative cerebrospinal fluid leakage during endscopic endonasal transsphenoidal surgery for pituitary macroadenoma which will ultimately reduce the rate of persistent post-operative cerebrospinal fluid leakage.&#x0D; Materials and Methods: 34 patients who underwent endscopic endonasal transsphenoidal surgery for pituitary macroadenoma were dividedd into two groups by non-probability convenient sampling technique. In one group of which lumbar subarachnoid drain were given just before induction of anesthesia named LD Group and another group went through conventional method without giving lumbar drain named No LD Group. In all patients of LD Group 20-30 ml of CSF was drawn through lumbar drain before giving dural incision. Valsalva maneuver was used in each group to identify intraoperative CSF leaks at the end of definitive surgery before repairing the sellar floor.Zero degree rigid endoscope was used in all cases. Intraoperative CSF leak was categorized as ‘Yes’ or ‘No’ which was decided by surgeon.Lumbar drains were removed within 24 hours of operation in 16 patients of LD Group and in case 1,who developed intraoperative CSF leak, lumbar drain was removed later.&#x0D; Results: Thirty four patients were eligible for inclusion, of which 17 were assigned to the LD Group and 17 to the no LD Group. There were no statistically significant differences in patient demographics, tumor pathology, or radiology between the two groups. In LD Group intraoperative CSF leak occurred in 1(5.9%) patient and leak did not occur in 16(94.1%) patients, in No LD Group intraoperative CSF leak occurred in 14(82.4%) patients and leak did not occur in 3(17.6%) patients. Intraoperative CSF drainage significantly reduced the incidence of intraoperative CSF leaks from 82.4% in the No LD group to 5.9% in the LD group (P &lt; 0.001). There were no catheter related complications.&#x0D; Conclusion: Intraoperative CSF drainage significantly reduces the incidence of intraoperative CSF leakage in patients undergoing endoscopic endonasal transsphenoidal surgery for pituitary macroadenomas.&#x0D; Bang. J Neurosurgery 2020; 10(1): 52-56

Application effect of two modalities for placing lumbar drain catheters in patients with postcraniotomy aseptic meningitis

AimAseptic meningitis is an unfortunate complication after craniotomy. Continuous lumbar drainage is a safe and effective method for treating postcraniotomy aseptic meningitis. This study compared the incidence of cerebrospinal fluid (CSF) leakage around the tube at the skin exit site and infection associated with tubes placed in two different ways. Patients and MethodsThe study enrolled 140 consecutive patients with postoperative aseptic meningitis manifesting as headache and fever and managed by lumbar external drainage (LED) between June 2014 and July 2018. From June 2014 to Jan 2016, an LED catheter was set in a conventional fashion without a subcutaneous tunnel. From Feb 2016 to July 2018, we adopted a modified mode of placing the LED catheter with a subcutaneous tunnel. Drain-related CSF leakage and infection were analyzed between the two groups. ResultsPostoperative aseptic meningitis can be easily managed through lumbar CSF drainage. The incidences of drain-associated infection and CSF leakage were 20% and 7.14%, respectively, in group 1 (without subcutaneous tunnels) and 7.14% and 4.28%, respectively, in group 2 (with subcutaneous tunnels). CSF leakage was significantly reduced in group 2 compared to group 1 (P < 0.05). The incidence of complications increased with the length of time that the drain remained in place. ConclusionsThe use of a modified mode of lumbar catheter placement remarkably decreases the risk of CSF leakage and offers an ideal alternative to CSF drains. The duration of catheterization and placement method are risk factors for drain-associated infection and CSF leakage. Despite its potential benefits, the modified method still involves prolonged drainage.

Effect of Lumbar Drainage on Cortical Excitability in Normal Pressure Hydrocephalus.

Idiopathic normal pressure hydrocephalus (iNPH) is characterized by the clinical triad of gait disturbance, urinary incontinence, and memory impairment with normal cerebrospinal fluid (CSF) pressure. Transcranial magnetic stimulation (TMS) has been used to assess the corticospinal motor pathways in patients with iNPH with conflicting results. Our study included 11 patients with iNPH and 13 healthy controls. All the subjects underwent TMS and resting motor threshold (RMT), central motor conduction time (CMCT), short-interval intracortical inhibition (SICI), intracortical facilitation, and silent period (SP) were recorded in the upper limb. Besides, RMT and CMCT in lower limb were also recorded. Cognitive assessments were done using mini-mental status examination, Montreal cognitive assessment (MoCA), and Addenbrooke's cognitive evaluation III (ACE III). Same parameters were recorded 24 h of CSF (lumbar puncture, LP) drainage. Mean age of the iNPH patients was 69.00±6.71 years with age at onset being 66.64±7.10 years. Duration of disease was 1.80±1.25 years. A significant difference was noted in CMCT for the lower limb (CMCT-LL), SICI, and ipsilateral SP between pre-LP NPH and controls. Also, there was a significant difference in MoCA and ACE III between pre-LP NPH and controls. A significant reduction was observed in lower limb RMT between pre- and post-LP NPH patients. Post LP, there was a reduction in the lower limb CMCT and improvement in SICI. A significant prolongation of CMCT-LL was observed in NPH patients. Lumbar CSF drainage in them resulted in a significant reduction in lower limb RMT thereby suggesting an increase in cortical excitability.

Neuroimage-Based Consciousness Evaluation of Patients with Secondary Doubtful Hydrocephalus Before and After Lumbar Drainage.

Hydrocephalus is often treated with a cerebrospinal fluid shunt (CFS) for excessive amounts of cerebrospinal fluid in the brain. However, it is very difficult to distinguish whether the ventricular enlargement is due to hydrocephalus or other causes, such as brain atrophy after brain damage and surgery. The non-trivial evaluation of the consciousness level, along with a continuous drainage test of the lumbar cistern is thus clinically important before the decision for CFS is made. We studied 32 secondary mild hydrocephalus patients with different consciousness levels, who received T1 and diffusion tensor imaging magnetic resonance scans before and after lumbar cerebrospinal fluid drainage. We applied a novel machine-learning method to find the most discriminative features from the multi-modal neuroimages. Then, we built a regression model to regress the JFK Coma Recovery Scale-Revised (CRS-R) scores to quantify the level of consciousness. The experimental results showed that our method not only approximated the CRS-R scores but also tracked the temporal changes in individual patients. The regression model has high potential for the evaluation of consciousness in clinical practice.

Safety and effectiveness of lumbar cerebrospinal fluid drainage to prevent delayed cerebral ischemia after Fisher grade 3 subarachnoid hemorrhage with minimal intraventricular hemorrhage

ObjectiveLumbar drainage (LD) of cerebrospinal fluid (CSF) is a simple way of clearing subarachnoid hemorrhage (SAH) and reducing the risk of delayed cerebral ischemia (DCI). We focused on Fisher grade 3 SAH with or without minimal intraventricular hemorrhage (IVH; Graeb score ≤5), which has a lower risk of cerebellar tonsillar herniation during LD. The aim of this study was to test the efficacy of LD with respect to reducing the risk of DCI in this patient group. MethodsThe authors retrospectively reviewed the medical records of 107 patients with Fisher grade 3 SAH with or without minimal IVH, admitted to two hospitals from 2013 to 2019. Patients were retrospectively divided into two groups: study group receiving standard therapy plus LD, or control group receiving standard therapy alone. Primary outcome measures were efficient in preventing DCI. ResultsOne hundred and seven subjects were allocated to the control (n=79) or study (n=28) groups. Incidence of DCI was 28% (n=22) and 18% (n=5), respectively (P=0.448). Subgroup analysis for HH grade 3+4 (n=68) showed incidence of DCI of 24% (n=19) in the control group (n=50) and 7% (n=2) in the study group (n=18) (P=0.040). There were no LD-related complications. ConclusionsThis study could not draw a meaningful conclusion about the overall efficacy of LD on DCI reduction due to small sample size. However, there was a significant reduction of DCI by LD in the HH 3+4 subpopulation. Larger-scale studies are required to confirm our results.

Reconstruction after endoscopic surgery for skull base malignancies.

The ability to resect malignancies of the ventral skull base using endoscopic endonasal approaches has created a need for effective endoscopic reconstructive techniques. The purpose of this review is to summarize current techniques for reconstruction of large skull base defects during endoscopic endonasal surgery. Recent medical literature was reviewed to identify techniques and best practices for repair of skull base defects during endoscopic endonasal surgery. Preference was given to evidence-based recommendations. Superior results are observed with multilayer inlay/onlay grafts supplemented with vascularized flaps. The nasoseptal flap is the primary reconstructive flap for most defects; secondary choices include the lateral nasal wall flap and extracranial pericranial flap. Clival defects are particularly challenging and are further augmented with adipose tissue to prevent pontine herniation. Perioperative management including the use of lumbar cerebrospinal fluid drainage minimizes the risk of a postoperative leak in high-risk patients. Postoperative cerebrospinal fluid leaks are managed similarly to primary leaks and may require use of a secondary vascularized flap. Complications of reconstructive flaps include flap necrosis and cosmetic nasal deformity. Large defects of the anterior, middle, and posterior cranial fossae can be managed similarly by adhering to basic principles of reconstruction. Future developments will improve stratification of patients into reconstructive groups and allow tailored reconstructive algorithms. New biomaterials may replace autologous tissue and facilitate endoscopic repair. Improved monitoring will allow for assessment of the reconstructive site with early detection and repair of postoperative cerebrospinal fluid leaks.

Incidental durotomy: intraoperative aid in ten steps

Management of the intradural structures safely, closure of the dura according to the tear, and minimizing the epidural dead space. Incidental durotomy (ID). None. 1.Bone removal until whole dural tear is visible (if necessary); 2.intradural inspection; 3.reposition the fibers; 4.perform an inside patch (if ID > 5 mm); 5.dural closure; 6.outside patch; 7.Valsalva maneuver; 8.epidural pedicled muscle flap; 9.multilayer wound closure; 10.lumbar drainage of cerebrospinal fluid (if necessary). Bed rest up to 48 h; analgesics. The intraspinal part of 4020 surgeries performed with the aid of amicroscope were evaluated. The overall prevalence of ID was 4.4%. The prevalence was lowest in virgin microdiscectomies (1.7%) and varied from 3.6% in decompression for spinal canal stenosis up to 14.5% in revision procedures. Of the overall 195 IDs, 127 occurred in primary surgeries and 68 in revision surgeries. In 107 primary surgeries, the individual surgical technique (InT) achieved asingle stage closure of the ID in 96procedures (89.7%). Among 20virgin surgeries, the ten-step technique (10ST) was successful in all cases (P = 0.21). Among 42 revision procedures following failed attempts to stop the CSF leakage, the InT achieved single-stage closure in 36procedures (85.7%), whereas after introduction of the 10ST, closure was successful in all 26cases (P = 0.03).

The effectiveness of lumbar cerebrospinal fluid drainage in aneurysmal subarachnoid hemorrhage with different bleeding amounts.

Continuous lumbar drainage (LD) of cerebrospinal fluid can reduce the risk of aneurysmal subarachnoid hemorrhage (aSAH)-related complications. We evaluated the effectiveness of LD in aSAH patients with aneurysmal clipping and the relative benefits of different bleeding amounts. We retrospectively reviewed all consecutive aSAH patients who underwent aneurysm clipping in our hospital between January 1, 2014 and December 31, 2014. Outcomes and incidence of post-operative complications were compared between the LD group and the non-LD group in all patients and further analyzed in patients with the low modified Fisher Scale (mFS) (0-2) and high mFS (3-4). In 193 aSAH patients who underwent clipping, LD reduced the risk of hydrocephalus and improved the Glasgow Outcome Scale (GOS) score at discharge and at 3months of follow-up. In the higher mFS group, patients who received LD had significantly lower risk of cerebral vasospasm, delayed cerebral infarction, and hydrocephalus; the GOS score was significantly higher in the LD group at discharge and at 3months of follow-up. However, LD showed no benefits in terms of post-operative complications and outcome in patients with low mFS. LD for aneurysm clipping surgery after aSAH can reduce the risk of post-operative complications and improve the clinical outcome in patients with mFS grades 3 and 4. It should be considered as an adjunctive but dispensable treatment for aneurysm clipping in aSAH patient with low mFS.

Efficacy of three-dimensional rotational fluoroscopic unit guidance for lumbar cerebrospinal fluid drainage among patients with unsuccessful initial attempt at bedside.

Lumbar cerebrospinal fluid drainage has been widely performed in patients at the bedside; however, technical failure can occasionally occur as a result of blind maneuvering. Herein, we present the use of rotational fluoroscopic unit-guided lumbar drainage for patients with an unsuccessful initial attempt at bedside. In four of the 24 patients with aneurysmal subarachnoid hemorrhage, initial lumbar drainage could not be performed at bedside. Thus, a three-dimensional rotational technology guided by a high-quality fluoroscopic unit was used. After a cone-beam computed tomography scan was performed, an accurate puncture point and a target thecal sac were identified using the software. The fluoroscopic unit helped us to identify the puncture point and trajectory with a laser pointer on the patient. A needle was inserted along the tract until the cerebrospinal fluid was collected. The lumbar drainage tube was successfully inserted with a single puncture in all four patients. Rotational fluoroscopic technology helps to identify a suitable puncture point, trajectory and target site for lumbar spinal drainage. Our technique is considerably useful in an era wherein minimally invasive procedures are preferred.

Spinal cerebrospinal fluid drainage for prevention of vasospasm in aneurysmal subarachnoid hemorrhage: A prospective, randomized controlled study

Introduction:Cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is a major cause of mortality and morbidity. Despite various treatment modalities, the optimal management of vasospasm remains elusive. In this regard; we undertook a prospective, randomized controlled study to evaluate the effectiveness of lumbar cerebrospinal fluid drainage (LCSFD) for prevention of cerebral vasospasm and its sequelae.Materials and Methods:Patients with aneurysmal SAH who met the inclusion criteria were randomized into two groups – Group I (30 patients) underwent LCSFD whereas Group II (30 patients) did not undergo LCSFD. All patients underwent aneurysmal clipping. Both the groups received standard neurosurgical treatment except for LCSFD. The outcome was measured in terms of (1) clinically evident vasospasm; (2) vasospasm-related cerebral infarction; (3) condition of the patient at the time of discharge; and (4) Glasgow outcome score (GOS) at 1- and 3-month follow-up.Results:LCSFD conferred a statistically significant benefit reducing the incidence of clinical vasospasm from 63% (in non-LCSFD group) to 30% (in LCSFD group) (P = 0.01) and incidence of vasospasm-related cerebral infarction from 53% (in non-LCSFD group) to 20% (in LCSFD group) (P = 0.007). Incidence of vasospasm was quantitatively lower in LCSFD group across all Hunt and Hess grades; however, it was statistically significant in SAH Grade III (P = 0.008). Mean duration of hospital stay was slightly lower in LCSFD group compared to non-LCSFD group; however, it did not reach statistical significance. A higher incidence of meningitis in LCSFD group was not statistically significant. A higher GOS was observed in LCSFD group at 1- and 3-month follow-up as compared to non-LCSFD group.Conclusion:Drainage of CSF through a lumbar drain following aneurysmal SAH caused a statistically significant reduction in the incidence of clinical and radiological vasospasm and its sequelae. It also shortens the overall duration of hospital stay and improves the outcome as evidenced by a better GOS score at 1- and 3-month follow-up. The results of this prospective, randomized study establish the efficacy of LCSFD in prevention of vasospasm following aneurysmal SAH.

Drainage of Cerebrospinal Fluid and Blood Pressure Augmentation as Rescue Therapies for Ischemic Myelitis After Bronchial Embolization: A Case Report.

A 62-year-old man presented to the emergency department with massive hemoptysis. After bronchial artery embolization, he developed ischemic myelitis, a rare complication in this setting for which no specific therapy is currently recommended. The symptoms were managed with lumbar drainage of cerebrospinal fluid and blood pressure augmentation therapy. To our knowledge, this is the first report of using lumbar drainage of cerebrospinal fluid and blood pressure augmentation in the treatment of anterior medullary ischemia after bronchial artery embolization for massive hemoptysis. The treatment was associated with neurological recovery.

Acute Monocular Blindness Due to Orbital Compartment Syndrome Following Pterional Craniotomy

We present a case of orbital compartment syndrome (OCS) leading to monocular irreversible blindness following a pterional craniotomy for clipping of an anterior communicating artery aneurysm. OCS is an uncommon but vision-threatening entity requiring urgent decompression to reduce the risk of permanent visual loss. Iatrogenic orbital roof defects are a common finding following pterional craniotomies. However, complications related to these defects are rarely reported. A 65-year-old female who underwent an anterior communicating artery clipping via a pterional approach 4 days before developed proptosis, ocular movement paresis, and irreversible visual impairment following an orthopedic surgery. Computed tomography images revealed an intraorbital cerebrospinal fluid (CSF) collection, which was evacuated via an acute recraniotomy. The next day, proptosis and intraorbital CSF collection on computed tomography images reoccurred and an oral and maxillofacial surgeon evacuated the collection via a blepharoplasty incision and blunt dissection. In addition, the patient was treated with acetazolamide and an external lumbar CSF drainage during 12 days. Hereafter, the CSF collection did not reoccur. Unfortunately, monocular blindness was persistent. We hypothesize the CSF collection occurred due to the combination of a postoperative orbital roof defect and a temporarily increased intracranial pressure during the orthopedic surgery. We plead for more awareness of this severe complication after pterional surgeries and emphasize the importance of 1) strict ophthalmologic examination after pterional craniotomies in case of intracranial pressure increasing events, 2) immediate consultation of an oral and maxillofacial surgeon, and 3) consideration of CSF-draining interventions since symptoms are severely invalidating and irreversible within a couple of hours.

Serial lumbar puncture reduces cerebrospinal fluid (CSF) infection during removal of hemorrhagic CSF in aneurysmal subarachnoid hemorrhage after endovascular coiling

The present study aimed to compare the complications and clinical outcomes of serial lumbar puncture (LP) and lumbar cerebrospinal fluid (CSF) drainage (LD) of patients with aneurysmal subarachnoid hemorrhage and provide more evidence to guide clinical management. In this retrospective study, 41 and 39 aneurysmal subarachnoid hemorrhage patients were enrolled in the LP and LD group, respectively. Clinical outcomes, including CSF infection, intracerebral hemorrhage, vasospasm, hydrocephalus, death, length of stay, duration of drainage and the Glasgow Outcome Scale score were compared between the two groups. By comparing with the LP group, the LD group showed a significantly higher rate of CSF infection (P=0.029) and shorter duration of drainage (P<0.001). Both groups displayed similar rates of vasospasm, hydrocephalus, intracerebral hemorrhage, the Glasgow Outcome Scale score one month after endovascular coiling and length of stay (P>0.05, respectively). In conclusion, both LD and serial LP are effective methods in the treatment of aneurysmal subarachnoid hemorrhage; besides, serial LP can reduce the incidence of CSF infection in draining hemorrhagic CSF in aneurysmal subarachnoid hemorrhage after endovascular coiling.

A randomized controlled trial to determine the role of intraoperative lumbar cerebrospinal fluid drainage in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas.

Intraoperative cerebrospinal fluid (CSF) leaks are a frequent cause of morbidity in patients undergoing transsphenoidal surgery. This prospective study was performed to examine the impact of intraoperative lumbar subarachnoid drainage (LSAD) on the incidence of this complication and on the extent of resection in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas. This prospective study was conducted in a single large academic medical center. All patients with pituitary adenomas who had not undergone prior transsphenoidal surgery were eligible for inclusion in the study. Patients were randomly assigned to undergo transsphenoidal surgery with intraoperative lumbar drain insertion (LSAD group) or no lumbar drain insertion (no LSAD group). An otolaryngologist independently determined the occurrence of an intraoperative CSF leak. Extent of tumor resection was determined by volumetric analysis of postoperative magnetic resonance images in patients with nonfunctional tumors or functional adenomas with a large suprasellar component. Sixty patients were eligible for inclusion, of which 30 were assigned to the LSAD group and 30 to the no LSAD group. There were no statistically significant differences in patient demographics, tumor pathology, or radiology between the two groups. The LSAD catheter was successfully inserted in all patients in the LSAD group. Intraoperative CSF drainage significantly reduced the incidence of CSF leak from 46.7% in the no LSAD group to 3.3% in the LSAD group (P < 0.001). However, there were no statistically significant differences in the incidence of postoperative CSF rhinorrhea between the two groups. There were no major catheter-related complications. There was no statistically significant difference in the extent of resection between the two groups. Controlled intraoperative CSF drainage significantly reduces the incidence of intraoperative CSF leakage in patients undergoing endoscopic transsphenoidal surgery for pituitary adenomas.

Contemporary Single-Center Experience With Prophylactic Cerebrospinal Fluid Drainage for Thoracic Endovascular Aortic Repair in Patients at High Risk for Ischemic Spinal Cord Injury

To review rates of permanent paraplegia and lumbar drain-related complications in patients undergoing thoracic endovascular aortic repair (TEVAR) surgery with prophylactic cerebrospinal fluid (CSF) drainage at the authors' institution. Retrospective cohort study. Tertiary care, academic medical center. Patients who underwent TEVAR with a high risk for ischemic spinal cord injury and prophylactic lumbar CSF drainage over a 5-year period. None. One hundred and two patients underwent TEVAR with lumbar CSF drainage. Thirty-day mortality was 5.9%, and the rate of permanent paraplegia was 2%. Drain complications occurred in 4 (3.9%) patients, but no patient experienced permanent injury related to CSF drainage. Two patients in the cohort had complete resolution of paraplegia with increased CSF drainage and mean arterial blood pressure increases aimed to increase spinal cord perfusion pressure by 25%. A third patient experienced improvement in lower extremity strength but remained paraplegic, and a fourth patient demonstrated no improvement in symptoms. The 6 patients taking clopidogrel experienced no bleeding complications, and there were no apparent risk factors for bleeding in the 5 patients who had bloody drain output or in 1 patient who developed an epidural hematoma. Prophylactic CSF drainage was associated with low paraplegia and drain-related complication rates. These data further support the safety of prophylactic CSF drainage in patients undergoing TEVAR with a high risk for ischemic spinal cord injury.

Aneurysmal Subarachnoid Hemorrhage: Strategies for Preventing Vasospasm in the Intensive Care Unit.

This article addresses the intensive care unit (ICU) management of patients with aneurysmal subarachnoid hemorrhage (SAH), with an emphasis on the prevention of cerebral vasospasm and delayed cerebral ischemia (DCI), which are major contributors to morbidity and mortality. Interventions addressing various steps in the development of vasospasm have been attempted, with variable success. Enteral nimodipine remains the only approved measure to potentially prevent DCI. Since oral and intravenous administrations are limited by hypotension, direct administration via sustained-release pellets and intraventricular administration of sustained-release microparticles are being investigated. Studies of other calcium channel blockers have been disappointing. Efforts to remove blood from the subarachnoid space via cisternal irrigation, cisternal or ventricular thrombolysis, and lumbar cerebrospinal fluid drainage have met with limited and variable success, and they remain an area of active investigation. Several interventions that had early promise have failed to show benefit when studied in large trials; these include tirilazad, magnesium, statins, clazosentan, transluminal angioplasty, and hypervolemia.