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

Analysis of Cerebral Spinal Fluid Drainage and Intracranial Pressure Peaks in Patients with Subarachnoid Hemorrhage

BACKGROUND

After aneurysmal subarachnoid hemorrhage (aSAH), elevated intracranial pressure (ICP) due to disrupted cerebrospinal fluid (CSF) dynamics is a critical concern. An external ventricular drainage (EVD) is commonly employed for management; however, optimal strategies remain debated. The randomized controlled Earlydrain trial showed that an additional prophylactic lumbar drainage (LD) after aneurysm treatment improves neurological outcome. We performed a post hoc investigation on the impact of drainage volumes and critical ICP values on patient outcomes after aSAH.

METHODS

Using raw patient data from Earlydrain, we analyzed CSF drainage amounts and ICP measurements in the first 8 days after aSAH. Outcomes were the occurrence of secondary infarctions and the score on the modified Rankin scale after 6 months, dichotomized in values of 0-2 as favorable and 3-6 as unfavorable. Repeated measurements were considered with generalized estimation equations.

RESULTS

Earlydrain recruited 287 patients, of whom 221 received an EVD and 140 received an LD. Higher EVD volumes showed a trend to more secondary infarctions (p = 0.09), whereas higher LD volumes were associated with less secondary infarctions (p = 0.009). The mean total CSF drainage was 1052 ± 659 mL and did not differ concerning infarction and neurological outcome. Maximum ICP values were higher in patients with poor outcomes but not related to drainage volumes via EVD. After adjustment for aSAH severity and total CSF drainage, higher LD volume was linked to favorable outcome (per 100 mL: odds ratio 0.61 (95% confidence interval 0.39-0.95), p = 0.03), whereas higher EVD amounts were associated with unfavorable outcome (per 100 mL: odds ratio 1.63 (95% confidence interval 1.05-2.54), p = 0.03).

CONCLUSIONS

Findings indicate that effects of CSF drainage via EVD and LD differ. Higher amounts and higher proportions of LD volumes were associated with better outcomes, suggesting a potential quantity-dependent protective effect. Optimizing LD volume and mitigating ICP spikes may be a strategy to improve patient outcomes after aSAH.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01258257.

Rapid Versus Gradual Weaning of External Ventricular Drain: A Systematic Literature Review and Meta-analysis

The insertion of an external ventricular drain (EVD) is one of the most common neurosurgical procedures. Whether the weaning method (gradual or rapid) influences the ventriculoperitoneal shunt (VPS) insertion rate has not been conclusively established. The aim of this study is to provide a systematic literature review and conduct a meta-analysis of studies comparing gradual with rapid EVD weaning regarding VPS insertion rate. Articles were identified by searching the Pubmed/Medline, Embase, and Web of Science databases throughout October 2022. Two independent researchers assessed the studies for inclusion and quality. We included randomized trials, prospective cohort studies, and retrospective cohort studies, which compared gradual and rapid EVD weaning. The primary outcome was VPS insertion rate, whereas secondary outcomes were EVD-associated infection (EVDAI) rate and length of stay in the hospital and intensive care unit (ICU). Four studies directly comparing rapid versus gradual EVD weaning, with 1337 patients suffering from subarachnoid hemorrhage, were identified and included in the meta-analysis. VPS insertion rate was 28.1% and 32.1% in patients with gradual and rapid EVD weaning, respectively (relative risk 0.85, 95% confidence interval 0.49-1.46, p = 0.56). Further, the EVDAI rate was comparable between the groups (gradual group 11.2%, rapid group 11.5%, relative risk 0.67, 95% confidence interval 0.24-1.89, p = 0.45), whereas length of stay in the ICU and hospital were significantly shorter in the rapid weaning group (2.7 and 3.6 days, respectively; p < 0.01). Rapid EVD weaning seems comparable to gradual EVD weaning concerning VPS insertion rates and EVDAI, whereas hospital and ICU length of stay is significantly reduced.

Intracranial Pressure Monitoring and Management in Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage is a medical condition that can lead to intracranial hypertension, negatively impacting patients' outcomes. This review article explores the underlying pathophysiology that causes increased intracranial pressure (ICP) during hospitalization. Hydrocephalus, brain swelling, and intracranial hematoma could produce an ICP rise. Although cerebrospinal fluid withdrawal via an external ventricular drain is commonly used, ICP monitoring is not always consistently practiced. Indications for ICP monitoring include neurological deterioration, hydrocephalus, brain swelling, intracranial masses, and the need for cerebrospinal fluid drainage. This review emphasizes the importance of ICP monitoring and presents findings from the Synapse-ICU study, which supports a correlation between ICP monitoring and treatment with better patient outcomes. The review also discusses various therapeutic strategies for managing increased ICP and identifies potential areas for future research.

External Ventricular Drainage: A Practical Guide for Neuro-Anesthesiologists

External ventricular drainage is often considered a life-saving treatment in acute hydrocephalus. Given the large number of discussion points, the ideal management of EVD has not been completely clarified. The objective of this study was to review the most relevant scientific evidence about the management of EVD in its main clinical scenarios. We reviewed the most recent and relevant articles about indications, timing, management, and complications of EVD in neurocritical care, with particular interest in patients with subarachnoid hemorrhage (SAH), severe traumatic brain injury (TBI), and intraventricular hemorrhage (IVH) using the following keywords alone or matching with one another: intracranial pressure, subarachnoid hemorrhage, traumatic brain injury, intraventricular hemorrhage, external ventricular drainage, cerebrospinal shunt, intracranial pressure monitoring, and ventriculoperitoneal shunt. In the management of EVD in SAH, the intermittent drainage strategy is burdened with an elevated risk of complications (e.g., clogged catheter, hemorrhage, and need for replacement). There seems to be more ventriculoperitoneal shunt dependency in rapid weaning approach-managed patients than in those treated with the gradual weaning approach. Although there is no evidence in favor of either strategy, it is conventionally accepted to adopt a continuous drainage approach in TBI patients. Less scientific evidence is available in the literature regarding the management of EVD in patients with severe TBI and intraparenchymal/intraventricular hemorrhage. EVD placement is a necessary treatment in several clinical scenarios. However, further randomized clinical trials are needed to clarify precisely how EVD should be managed in different clinical scenarios.

Mechanical Complications of External Ventricular and Lumbar Drains

BACKGROUND

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.

METHODS

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.

RESULTS

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).

DISCUSSION

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.

External ventricular drain management in subarachnoid haemorrhage: a systematic review and meta-analysis

External ventricular drainage (EVD) is one of the most commonly performed neurosurgical procedures. Despite this, the optimal drainage and weaning strategies are still unknown. This PRISMA-compliant systematic review and meta-analysis analysed the outcomes of patients undergoing EVD procedures, comparing continuous versus intermittent drainage and rapid versus gradual weaning. Four databases were searched from inception to 01/10/2020. Articles reporting at least 10 patients treated for hydrocephalus secondary to subarachnoid haemorrhage were included. Other inclusion criteria were the description of the EVD drainage and weaning strategies used and a comparison of continuous versus intermittent drainage or rapid versus gradual weaning within the study. Random effect meta-analyses were used to compare functional outcomes, incidence of complications and hospital length of stay. Intermittent external CSF drainage was associated with lower incidence of EVD-related infections (RR = 0.20, 95% CI 0.05-0.72, I-squared = 0%) and EVD blockages compared to continuous CSF drainage (RR = 0.45, 95% CI 0.27-0.74, I-squared = 0%). There was no clear advantage in using gradual EVD weaning strategies compared to rapid EVD weaning; however, patients who underwent rapid EVD weaning had a shorter hospital length of stay (SMD = 0.34, 95% CI 0.22-0.47, I-squared = 0%). Intermittent external CSF drainage after SAH is associated with lower incidence of EVD-related infections and EVD blockages compared to continuous CSF drainage. Patients who underwent rapid EVD weaning had a shorter hospital length of stay and there was no clear clinical advantage in using gradual weaning.

Intracranial Pressure Monitoring via External Ventricular Drain: Are We Waiting Long Enough Before Recording the Real Value?

BACKGROUND

External ventricular drain (EVD) is a standard approach for both monitoring intracranial pressure (ICP) and draining cerebrospinal fluid (CSF) for patients with subarachnoid hemorrhage. Documenting an accurate ICP value is important to assess the status of the brain, which would require the EVD system to be leveled properly and closed to CSF drainage for an adequate period. It is suggested that a minimum period of 5-minute EVD closure is needed before documenting a true ICP; however, there is no commonly agreed upon standard for documenting ICP. To obtain an insight into how well the intermittent EVD clamping procedure is performed for ICP documentation, we conducted a retrospective analysis of ICP recordings obtained through EVD from 107 patients with subarachnoid hemorrhage.

METHODS

The EVD was kept open for continuous CSF drainage and then intermittently closed for ICP documentation. For each EVD closure, mean ICP, standard deviation of ICP, duration of EVD closure, and time interval between 2 adjacent EVD closures were studied. The total number of EVD closures was calculated for each patient. We developed an algorithm to evaluate whether ICP reached a new equilibrium before the EVD was reopened to drainage. The percentage of EVD closures that reach the equilibrium was calculated.

RESULTS

The 107 patients had 32 755 EVD closures in total, among which 65.9% instances lasted less than 1 minute and only 16.3% of all the EVD closure episodes lasted longer than 5 minutes. The median duration of each EVD closure was 25 seconds (interquartile range, 10.2 seconds to 2.33 minutes). Only 22.9% of the EVD closures reached ICP equilibrium before EVD reopening.

CONCLUSION

A standard guideline and proper training are needed for bedside nurses, and a potential tool that can render ICP trend at a proper scale at bedside would help clinicians correctly document ICP.

Optimal Timing of External Ventricular Drainage after Severe Traumatic Brain Injury: A Systematic Review

External ventricular drainage (EVD) may be used for therapeutic cerebrospinal fluid (CSF) drainage to control intracranial pressure (ICP) after traumatic brain injury (TBI). However, there is currently uncertainty regarding the optimal timing for EVD insertion. This study aims to compare patient outcomes for patients with early and late EVD insertion. Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, MEDLINE/EMBASE/Scopus/Web of Science/Cochrane Central Register of Controlled Trials were searched for published literature involving at least 10 severe TBI (sTBI) patients from their inception date to December 2019. Outcomes assessed were mortality, functional outcome, ICP control, length of stay, therapy intensity level, and complications. Twenty-one studies comprising 4542 sTBI patients with an EVD were included; 19 of the studies included patients with an early EVD, and two studies had late EVD placements. The limited number of studies, small sample sizes, imbalance in baseline characteristics between the groups and poor methodological quality have limited the scope of our analysis. We present the descriptive statistics highlighting the current conflicting data and the overall lack of reliable research into the optimal timing of EVD. There is a clear need for high quality comparisons of early vs. late EVD insertion on patient outcomes in sTBI.

Evidence-Based Management of External Ventricular Drains

PURPOSE OF REVIEW

The optimal management of external ventricular drains (EVD) in the setting of acute brain injury remains controversial. Therefore, we sought to determine whether there are optimal management approaches based on the current evidence.

RECENT FINDINGS

We identified 2 recent retrospective studies on the management of EVDs after subarachnoid hemorrhage (SAH) which showed conflicting results. A multicenter survey revealed discordance between existing evidence from randomized trials and actual practice. A prospective study in a post-traumatic brain injury (TBI) population demonstrated the benefit of EVDs but did not determine the optimal management of the EVD itself. The recent CLEAR trials have suggested that specific positioning of the EVD in the setting of intracerebral hemorrhage with intraventricular hemorrhage may be a promising approach to improve blood clearance. Evidence on the optimal management of EVDs remains limited. Additional multicenter prospective studies are critically needed to guide approaches to the management of the EVD.

External Ventricular Drains After Subarachnoid Hemorrhage: Is Less More?

External ventricular drains (EVD) are essential in the early management of hydrocephalus and elevated intracranial pressure after subarachnoid hemorrhage (SAH). Once in place, management of the EVD is thought to influence long-term patient outcomes, rates of ventriculitis, incidence of delayed cerebral ischemia, need for a ventriculoperitoneal shunt, and intensive care unit (ICU) and hospital length of stay. The available evidence supports adopting early clamp trials and intermittent cerebrospinal fluid (CSF) drainage. However, a recent survey demonstrated that most neurological ICUs employ the opposite approach of continuously open EVDs and gradual weaning. In this article, we review the literature and arguments for and against the different EVD approaches. We conclude that an early clamp trial and intermittent CSF drainage can be safe and result in fewer EVD complications and shorter length of stay. Given the discrepancy between the available evidence and current practice, more studies on the optimal management of EVDs are warranted with the greatest need for multicenter prospective studies.

The Evolution of the Role of External Ventricular Drainage in Traumatic Brain Injury

External ventricular drains (EVDs) are commonly used in neurosurgery in different conditions but frequently in the management of traumatic brain injury (TBI) to monitor and/or control intracranial pressure (ICP) by diverting cerebrospinal fluid (CSF). Their clinical effectiveness, when used as a therapeutic ICP-lowering procedure in contemporary practice, remains unclear. No consensus has been reached regarding the drainage strategy and optimal timing of insertion. We review the literature on EVDs in the setting of TBI, discussing its clinical indications, surgical technique, complications, clinical outcomes, and economic considerations.

ICP Monitoring by Open Extraventricular Drainage: Common Practice but Not Suitable for Advanced Neuromonitoring and Prone to False Negativity

OBJECTIVE

A drawback in the use of an external ventricular drain (EVD) originates in the fact that draining cerebrospinal fluid (CSF) (open system) and intracranial pressure (ICP) monitoring can be done at the same time but is considered to be unreliable regarding the ICP trace. Furthermore, with the more widespread use of autoregulation monitoring using blood pressure and ICP signals, the question arises of whether an ICP signal from an open EVD can be used for this purpose. Using an EVD system with an integrated parenchymal ICP probe we compared the different traces of an ICP signal and their derived parameters under opened and closed CSF drainage.

METHODS

Twenty patients with either subarachnoid or intraventricular hemorrhage and indication for ventriculostomy plus ICP monitoring received an EVD in combination with an air-pouch-based ICP probe. ICP was monitored via an open ventricular catheter (ICP_evd) and ICP probe (ICP_probe) simultaneously. Neuromonitoring data (ICP, arterial blood pressure, cerebral perfusion pressure, pressure reactivity index (PRx)) were recorded by ICM+ software for the time of ICU intensive care treatment. Routinely (at least every 4 h) ICP was recorded with a closed CSF drainage system for at least 15 min. ICP, ICP amplitude, and the autoregulation parameters (PRx_probe, PRx_evd) were evaluated for every episode with closed CSF drainage and during the 3 h prior with an open drainage system.

RESULTS

One hundred and forty-four episodes with open/closed drainage were evaluated. During open drainage, overall mean ICP_evd levels were nonsignificantly different from those of ICP_probe, with 9.8 + 3.3 versus 8.2 + 3.2 mmHg, respectively. Limits of agreement ranged between 5.2 and -8.3 mmHg. However, 51 increases of ICP >20 mmHg with a duration of 3-30 min were missed by ICP_evd, and in 101 episodes the difference between ICPs was greater than 10 mmHg. After closure of the EVD, ICP increased moderately using both methods. Mean PRx_evd was significantly higher (falsely indicating impaired autoregulation) and more subjected to fluctuations than PRx_probe.

CONCLUSION

The general practice of draining CSF and monitoring ICP via a (usually open) EVD plus frequently performed catheter closure for ICP reading is feasible for assessment of overall ICP trends. However, it does have clinically relevant drawbacks, namely, a significant amount of undetected increases in ICP above thresholds, and continuous assessment of cerebrovascular autoregulation is less reliable. In conclusion, all patients who need CSF drainage plus ICP monitoring due to the severity of their brain insult need either an EVD with integrated ICP probe or an EVD line plus a separate ICP probe.

Refractory intracranial hypertension in traumatic brain injury: Proposal for a novel score to assess the safety of lumbar cerebrospinal fluid drainage

BACKGROUND

Cerebrospinal fluid (CSF) drainage via ventricular puncture is an established therapy of elevated intracranial pressure (ICP). In contrast, lumbar CSF removal is believed to be contraindicated with intracranial hypertension.

METHODS

We investigated the safety and efficacy of lumbar CSF drainage to decrease refractory elevated ICP in a small cohort of patients with traumatic brain injury (TBI). A score (0-8 points) was used to assess computed tomography (CT) images for signs of herniation and for patency of the basal cisterns. All patients received lumbar CSF drainage either as a continuous drainage or as a single lumbar puncture (LP). Type and method 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 (one Glasgow coma score not documented). The CT score was ≥5 in all patients prior to LP and decreased after puncture without clinical consequences in two patients. The amount of CSF removal did not correlate with score 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 a favorable 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 score needs further validation.

Observation of Autoregulation Indices During Ventricular CSF Drainage After Aneurysmal Subarachnoid Hemorrhage: A Pilot Study

BACKGROUND

Cerebral autoregulation is increasingly recognized as a factor that requires evaluation when managing poor grade aneurysmal subarachnoidal hemorrhage (aSAH) patients. In this single center pilot study, we investigated whether intraventricular intracranial pressure (ICP) derived when extraventricular drain (EVD) is open can be used to calculate dynamic autoregulation estimates in ICU aSAH patients.

METHODS

Ten patients with the diagnosis of aSAH as confirmed by computed tomography (CT) and CT-angiography were enrolled. ICP was monitored via a transducer connected to the most proximal side exit of the EVD catheter. From at least 30 min periods of brain monitoring before, during, and after temporarily EVD closure, commonly used indexes of dynamic cerebral autoregulation were calculated.

RESULTS

Preserved pulsatile ICP signals were seen with open EVD. There were no significant changes in parameters describing cerebral autoregulation between EVD open and closed conditions. Power spectra of ABP and ICP showed no significant changes for the selected frequency ranges. There was a small significant increase in absolute ICP [2.4 (3.8) mmHg, p < 0.001] upon short-term EVD closure. Cerebral spinal reserve capacity (RAP index) worsened significantly by short-term EVD closure.

CONCLUSIONS

Due to preserved slow fluctuations in the ICP signal, an open EVD system can be used to calculate dynamic autoregulation indices in aSAH patients requiring intensive care monitoring with the pressure measurement from the most proximal part of drain. If these results are confirmed in larger study, this technique can open the way for investigating the role of autoregulation disturbance in aSAH patients.

Intracranial pressure and cerebral perfusion pressure monitoring in non-TBI patients: special considerations

The effect of intracranial pressure (ICP) and the role of ICP monitoring are best studied in traumatic brain injury (TBI). However, a variety of acute neurologic illnesses e.g., subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, meningitis/encephalitis, and select metabolic disorders, e.g., liver failure and malignant, brain tumors can affect ICP. The purpose of this paper is to review the literature about ICP monitoring in conditions other than TBI and to provide recommendations how the technique may be used in patient management. A PubMed search between 1980 and September 2013 identified 989 articles; 225 of which were reviewed in detail. The technique used to monitor ICP in non-TBI conditions is similar to that used in TBI; however, indications for ICP monitoring often are intertwined with the presence of obstructive hydrocephalus and hence the use of ventricular catheters is more frequent. Increased ICP can adversely affect outcome, particularly when it fails to respond to treatment. However, patients with elevated ICP can still have favorable outcomes. Although the influence of ICP-based care on outcome in non-TBI conditions appears less robust than in TBI, monitoring ICP and cerebral perfusion pressure can play a role in guiding therapy in select patients.

Predictors of extraventricular drain-associated bacterial ventriculitis

PURPOSE

Bacterial ventriculitis (BV) may develop in patients requiring external ventricular drains (EVDs). The purpose of this study was to determine predictors of EVD-associated BV onset.

MATERIALS AND METHODS

A retrospective review of Duke University Hospital patients with EVD device placement between January 2005 and May 2010 was conducted. Subject data were captured for predefined variables. Outcomes included in-hospital mortality, length of stay, and neurologic status at discharge.

RESULTS

In 410 subjects with 420 EVDs, the BV rate was 10.2%. Univariate analysis indicated that age, sex, positive blood culture, duration of EVD placement, and the number of cerebrospinal fluid (CSF) samples taken were associated with BV. Of these, the number of CSF samples and sex retained significance in multivariable modeling (female: odds ratio, 0.47 [confidence interval, 0.23-0.97]; CSF samples: odds ratio, 1.08 [confidence interval 1.01-1.17]; P = .04; c index = 0.69). In this model, each CSF sample taken expanded the likelihood of BV by 8.3%. The most common pathogens were Staphylococcus or proprioniobacter (n = 26). Bacterial ventriculitis was associated with an increase in hospital length of stay (33 ± 22.9 days vs 24.6 ± 20.4 days; P = .04) but not mortality.

CONCLUSION

An association exists between CSF sampling frequency and the development of EVD-associated BV. Larger prospective studies should be aimed at identifying causal relationships between these variables.

Continuous cerebral spinal fluid drainage associated with complications in patients admitted with subarachnoid hemorrhage

Object

Cerebral artery vasospasm is a major cause of death and disability in patients recovering from subarachnoid hemorrhage (SAH). Although the exact cause of vasospasm is unknown, one body of research suggests that clearing blood products by CSF drainage is associated with a lower frequency and severity of vasospasm. There are multiple approaches to facilitating CSF drainage, but there is inadequate evidence to determine the best practice. The purpose of this study was to explore whether continuous or intermittent CSF drainage was superior for reducing vasospasm.

Methods

The authors performed a randomized clinical trial. Within 72 hours of admission for SAH, patients with an external ventricular drain (EVD) were randomized to undergo continuous CSF drainage with intermittent intracranial pressure (ICP) monitoring (open-EVD group) or continuous ICP monitoring with intermittent CSF drainage (monitor-ICP group).

Results

After 60 patients completed the study, an interim analysis was performed. The complication rate of 52.9% for the open-EVD group was significantly higher than the 23.1% complication rate for the monitor-ICP group (OR 3.75, 95% CI 1.21–11.66, p = 0.022). These results were reported to the Data Safety and Monitoring Board and enrollment was terminated. The odds ratio of vasospasm for the open-EVD versus monitor-ICP group was not significant (OR 0.44, 95% CI 0.13–1.45, p = 0.177).

Conclusions

Continuous CSF drainage with intermittent ICP monitoring is associated with a higher rate of complications than continuous ICP monitoring with intermittent CSF drainage, but there is no difference between the two types of monitoring in vasospasm. Clinical trial registration no.: NCT01169454 (clinicaltrials.gov).

Effect of lumbar puncture in patients with aneurysmal subarachnoid hemorrhage treated microsurgically or endovascularly

OBJECTIVE

The aim of this study was to evaluate the effect of treatment modality (surgical clipping vs. endovascular coiling) and lumbar puncture (LP) in patients with aneurysmal subarachnoid hemorrhage (SAH) based on neurologic status on admission and clinical outcome.

PATIENTS AND METHODS

One hundred forty-eight consecutive patients with ruptured intracranial aneurysms treated via endovascular or surgical methods were included in our study. Patients who refused further therapy or received only supportive therapy because of bad neurologic status were excluded. Severity of SAH was evaluated using the Fisher score. World Federation of Neurosurgical Societies (WFNS) and Hunt and Hess (H&H) scores were used for evaluation of neurologic status. Glasgow Outcome Scale scores and modified Rankin scores were used for outcome evaluation.

RESULTS

We found that modified Rankin scores were significantly lower in the surgical clipping group (1.1 ± 1.4) than in the endovascular coiling group (1.7 ± 1.8) (p: 0.04). The positive lumbar puncture [LP(+)] group had similar outcome scores as the negative lumbar puncture [LP(-)] group, although the LP(+) group had worse initial SAH evaluation scores (WFNS 1.64 ± 0.95-1.23 ± 0.61, p: 0.0004 and H&H 2.18 ± 1.07-1.65 ± 0.88, p: 0.001).

CONCLUSION

Surgical clipping might improve clinical outcome better than endovascular coiling, although a more confident conclusion requires absolute randomization of patients for both treatments. LP could also improve clinical outcome in patients with high initial SAH evaluation scores.

Aggressive CSF diversion reverses delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a case report

BACKGROUND

External ventricular drain (EVD) placement temporarily provides cerebrospinal fluid (CSF) diversion and is indicated in patients with aneurysmal subarachnoid hemorrhage (aSAH) to relieve hydrocephalus.

METHODS

Case report.

RESULTS

A 56-year-old woman was admitted to our hospital with aSAH complicated by acute hydrocephalus. An EVD was placed and set to 15 mmHg. After nearly 72 h, she clinically deteriorated. A computed tomography (CT) perfusion scan showed hypoperfusion in the watershed regions in both hemispheres and CT angiogram showed mild segmental arterial narrowings. After the EVD was lowered to 5 mmHg, the radiologic perfusion abnormalities and clinical symptoms resolved.

CONCLUSIONS

We postulate a mechanism by which CSF diversion could decrease the risk of delayed cerebral ischemia after aSAH: CSF drainage at low levels of intracranial pressure (e.g., 5 mmHg) could improve blood flow in the microcirculation, and thus improve tissue perfusion.

An academic-health service partnership in nursing: lessons from the field

PURPOSE

To describe the development of an academic-health services partnership undertaken to improve use of evidence in clinical practice.

APPROACH

Academic health science schools and health service settings share common elements of their missions: to educate, participate in research, and excel in healthcare delivery, but differences in the business models, incentives, and approaches to problem solving can lead to differences in priorities. Thus, academic and health service settings do not naturally align their leadership structures or work processes. We established a common commitment to accelerate the appropriate use of evidence in clinical practice and created an organizational structure to optimize opportunities for partnering that would leverage shared resources to achieve our goal.

FINDINGS

A jointly governed and funded institute integrated existing activities from the academic and service sectors. Additional resources included clinical staff and student training and mentoring, a pilot research grant-funding program, and support to access existing data. Emergent developments include an appreciation for a wider range of investigative methodologies and cross-disciplinary teams with skills to integrate research in daily practice and improve patient outcomes.

CONCLUSIONS

By developing an integrated leadership structure and commitment to shared goals, we developed a framework for integrating academic and health service resources, leveraging additional resources, and forming a mutually beneficial partnership to improve clinical outcomes for patients.

CLINICAL RELEVANCE

Structurally integrated academic-health service partnerships result in improved evidence-based patient care delivery and in a stronger foundation for generating new clinical knowledge, thus improving patient outcomes.