Neurocritical Care

, Volume 14, Issue 1, pp 68–72

Continuous and Intermittent CSF Diversion after Subarachnoid Hemorrhage: a Pilot Study

  • G. S. Kim
  • A. Amato
  • M. L. James
  • G. W. Britz
  • A. Zomorodi
  • C. Graffagnino
  • M. Zomorodi
  • DaiWai M. Olson
Original Article

Abstract

Background

We examine two accepted methods of managing cerebrospinal fluid (CSF) drainage in patients following subarachnoid hemorrhage (SAH). The first is intermittent CSF drainage when intracranial pressure (ICP) reaches a pre-defined threshold (monitor-first) and the second is continuous CSF drainage (drain-first) at set pressure thresholds. This pilot study is designed to determine if there is a cause for a randomized study of comparing the two methods.

Methods

This prospective observational pilot study enrolled 37 patients with SAH and external ventricular drainage between October 2008 and August 2009. Patients were treated with one of two methods of ICP management (drain-first vs. monitor-first) according to the discretion of the admitting physician.

Results

There were no significant differences in baseline characteristics including age, gender, severity of neurological dysfunction, and radiographic findings between the two groups. The incidence of vasospasm was not different between the drain-first group (66.7%; 16 of 24 patients) and the monitor-first group (53.9%; 7 of 13 patients).

Conclusion

This pilot study was neither powered, nor expected to detect a difference between groups. The results of this study provide support for the design and conduct of a randomized study to assess the impact of two methods of CSF diversion for patients with SAH.

Keywords

Cerebral vasospasm Complication External ventricular drainage Intracranial pressure Subarachnoid hemorrhage 

References

  1. 1.
    Bederson JB, Connolly ES, Batjer HH, Dacey RG, Dion JE, Diringer MN, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage. Stroke. 2009;40:994–1025.CrossRefPubMedGoogle Scholar
  2. 2.
    Greenberg MS. Handbook of neurosurgery. 5th ed. Lakeland, FL: Thieme; 2001.Google Scholar
  3. 3.
    Mack WJ, King RG, Ducruet AF, Kreiter K, Mocco J, Maghoub A, et al. Intracranial pressure following aneurismal subarachnoid hemorrhage: monitoring practices and outcome data. Neurosurg Focus. 2003;14:1–5.CrossRefGoogle Scholar
  4. 4.
    Harrod CG, Bendok BR, Batjer HH. Prediction of cerebral vasospasm in patients presenting with aneurismal subarachnoid hemorrhage: a review. Neurosurgery. 2005;56:633–54.CrossRefPubMedGoogle Scholar
  5. 5.
    Claassen J, Bernardini GL, Kreiter K, Bates J, Du YE, Copeland D, et al. Effect of cisternal and ventricular blood on risk of delayed cerebral ischemia after subarachnoid hemorrhage: the Fisher scale revisited. Stroke. 2001;32:2012–20.CrossRefPubMedGoogle Scholar
  6. 6.
    Hirashima Y, Kurimoto I, Hayashi N, Umemura K, Hori E, Origasa H, et al. Duration of cerebrospinal fluid drainage in patients with aneurismal subarachnoid hemorrhage for prevention of symptomatic vasospasm and late hydrocephalus. Neurol Med Chir (Tokyo). 2005;45:177–83.CrossRefGoogle Scholar
  7. 7.
    Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1980;6:1–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Auer LM, Schneider GH, Auer T. Computerized tomography and prognosis in early aneurysm surgery. J Neurosurg. 1986;65:217–21.CrossRefPubMedGoogle Scholar
  9. 9.
    Auer LM, Mokry M. Disturbed cerebrospinal fluid circulation after subarachnoid hemorrhage and acute aneurysm surgery. Neurosurgery. 1990;26:804–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Kasuya H, Shimizu T, Kagawa M. The effect of continuous drainage of cerebrospinal fluid in patients with subarachnoid hemorrhage: a retrospective analysis 108 patients. Neurosurgery. 1991;28:56–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Otawara Y, Ogasawara K, Kubo Y, Sasoh M, Ogawa A. Effect of continuous cisternal cerebrospinal fluid drainage for patients with thin subarachnoid hemorrhage. Vasc Health Risk Manag. 2007;3(4):401–4.PubMedGoogle Scholar
  12. 12.
    Anderson GB, Ashforth R, Steinke DE, Findlay JM. CT angiography for the detection of cerebral vasospasm in patients with acute subarachnoid hemorrhage. Am J Neuroradiol. 2000;21:1011–5.PubMedGoogle Scholar
  13. 13.
    Klimo P Jr, Kestle JR, MacDonald JD, Schmidt RH. Marked reduction of cerebral vasospasm with lumbar drainage of cerebrospinal fluid after subarachnoid hemorrhage. J Neurosurg. 2004;100:215–24.CrossRefPubMedGoogle Scholar
  14. 14.
    Kwon OY, Kim Y-J, Kim YJ, Cho CS, Lee SK, Cho MK. The utility and benefits of external lumbar CSF drainage after endovascular coiling on aneurismal subarachnoid hemorrhage. J Korean Neurosurg Soc. 2008;43:281–7.CrossRefPubMedGoogle Scholar
  15. 15.
    Park IS, Meno JR, Witt CE, Chowdhary A, Nguyen TS, Winn HR, et al. Impairment of intracerebral arteriole dilation responses after subarachnoid hemorrhage. Laboratory investigation. J Neurosurg. 2009;111:1008–13.CrossRefPubMedGoogle Scholar
  16. 16.
    Britz GW, Meno JR, Park IS, Abel TJ, Chowdhary A, Nguyen TS, et al. Time-dependent alterations in functional and pharmacological arteriolar reactivity after subarachnoid hemorrhage. Stroke. 2007;38:1329–35.CrossRefPubMedGoogle Scholar
  17. 17.
    Deshaies EM, Boulos AS, Popp J. Peri-operative medical management of cerebral vasospasm. Neurol Res. 2009;31:644–50.CrossRefPubMedGoogle Scholar
  18. 18.
    Hoefnagel D, Dammers R, Ter Laak-Poort MP, Avezzat CJJ. Risk factors for infections related to external ventricular drainage. Acta Neurochir(Wien). 2008;150:209–14.CrossRefGoogle Scholar
  19. 19.
    Hirashima Y, Hamada H, Hayashi N, Kuwayama N, Origasa H, Endo S. Independent predictors of late hydrocephalus in patients with aneurismal subarachnoid hemorrhage- analysis by multivariate logistic regression model. Cerebrovasc Dis. 2003;16:205–10.CrossRefPubMedGoogle Scholar
  20. 20.
    Beer R, Lackner P, Pfausler B, Schmutzhard E. Nosocomial ventriculitis and meningitis in neurocritical care patients. J Neurol. 2008;255:1617–24.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • G. S. Kim
    • 1
  • A. Amato
    • 2
  • M. L. James
    • 2
    • 3
    • 5
  • G. W. Britz
    • 4
  • A. Zomorodi
    • 4
  • C. Graffagnino
    • 2
    • 5
  • M. Zomorodi
    • 2
    • 6
  • DaiWai M. Olson
    • 2
    • 5
  1. 1.Department of NeurologyNational Health Insurance Corporation Ilsan HospitalKoyangKorea
  2. 2.Neuroscience Critical Care UnitDuke University Medical CenterDurhamUSA
  3. 3.Department of AnesthesiologyDuke University Medical CenterDurhamUSA
  4. 4.Department of Surgery (Neurosurgery)Duke University Medical CenterDurhamUSA
  5. 5.Department of Medicine (Neurology)Duke University Medical CenterDurhamUSA
  6. 6.University of North Carolina at Chapel Hill School of NursingChapel HillUSA

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