Marked reduction of cerebral vasospasm with lumbar drainage of cerebrospinal fluid after subarachnoid hemorrhage

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Object

Cerebral vasospasm after subarachnoid hemorrhage (SAH) continues to be a major source of morbidity in patients despite significant clinical and basic science research. Efforts to prevent vasospasm by removing spasmogens from the subarachnoid space have produced mixed results. The authors hypothesize that lumbar cisternal drainage can remove blood from the basal subarachnoid spaces more effectively than an external ventricular drain (EVD). This nonrandomized, controlled-cohort study was undertaken to evaluate the effectiveness of a lumbar drain in patients with SAH compared with those in whom an EVD or no form of cerebrospinal fluid (CSF) drainage was used to prevent the development of clinical vasospasm and its sequelae.

Methods

The authors collected data on 266 patients with nontraumatic SAH who were admitted to the University of Utah Health Sciences Center between January 1994 and January 2003. Of these, 167 met the study entry criteria. The treatment group consisted of 81 patients in whom a lumbar drain had been placed for CSF shunting, whereas the control group was composed of 86 patients who received no form of CSF drainage or who were treated solely with an EVD. Primary outcome measures were as follows: 1) clinically evident vasospasm; 2) the need for endovascular intervention; 3) vasospasm-induced infarction; 4) disposition at time of discharge; and 5) Glasgow Outcome Scale (GOS) score at 1 to 3 months postdischarge. Secondary outcomes included length of stay and the need for CSF shunting.

The presence of a lumbar drain conferred a statistically significant protective and beneficial effect across all outcome measures, reducing the incidence of clinical vasospasm from 51 to 17%, the need for angioplasty from 45 to 17%, and the occurrence of vasospastic infarction from 27 to 7% (all p ≤ 0.001–0.008). Patients in the treatment group were more likely to be discharged home (54% compared with 25%, p = 0.002) and to have a GOS score of 5 at follow up (71% compared with 35%, p < 0.001). The mean number of days spent in the intensive care unit and in the hospital overall was also fewer in the treatment group. A similar degree of benefit was found in patients with different Fisher grades and regardless of whether an EVD was needed on presentation, both by subgroup analysis and multivariate logistic regression modeling. There was no statistical difference between the groups in terms of patients requiring a shunt. Complications with lumbar drains were rare and yielded no permanent sequelae.

Conclusions

Shunting of CSF through a lumbar drain after an SAH markedly reduces the risk of clinically evident vasospasm and its sequelae, shortens hospital stay, and improves outcome. Its beneficial effects are probably mediated through the removal of spasmogens that exist in the CSF. The results of this study warrant a randomized clinical trial, which is currently under way.

Article Information

Address reprint requests to: Richard H. Schmidt, M.D., Ph.D., Department of Neurosurgery, University of Utah, 3B-409 SOM, 30 North 1900 East, Salt Lake City, Utah 84132–2303. email: rhs@suzy.med.utah.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Upper: Noncontrast axial CT scans demonstrating a Fisher Grade 3+4 SAH. There is dense blood within the basal cisterns (left) as well as significant intraventricular hemorrhage and a perisylvian intraparenchymal hemorrhage (right). Lower: Bar graph showing the risk of suffering clinical vasospasm based on our modified Fisher grading scheme. Patients with Fisher Grade 3+4 are at greatest risk (59%).

  • View in gallery

    Photograph showing CSF collected in one patient with a Fisher Grade 3 SAH in whom both an EVD and a lumbar drain were placed. Our hypothesis for this study is exemplified in this picture: the CSF from the lumbar drain is markedly bloody compared with the CSF obtained from the EVD.

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