Risk Factors for Infections Related to Lumbar Drainage in Spontaneous Subarachnoid Hemorrhage

Impact of the Lumbar Catheter on the Incidence of Postsurgical Meningitis in the Endoscopic Endonasal Approach

Objectives  Endoscopic endonasal approach (EEA) procedures are inherently contaminated due to direct access through the nasopharyngeal mucosa. The reported rate of postoperative meningitis in EEA procedures is between 0.7 and 10%. Lumbar catheters are used in EEA surgeries to prevent cerebrospinal fluid (CSF) fistulae, but their use is associated with increased infection rates. This study investigated whether there is a difference in rates of postoperative meningitis based on lumbar catheter (LC) utilization. Methods  We performed a retrospective review of consecutive patients who underwent EEA surgeries between January 2016 and March 2023 at a single institution (Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia). Main Outcome  Incidence of meningitis following EEA surgery with lumbar catheter. Results  Seventy-two patients were enrolled, median age was 44 years, and 53% were female. The most frequent surgery performed was craniopharyngioma 46% (26 patients). A LC was used in 28 patients. Meningitis was diagnosed in 11 of 72 patients (15.2%), being higher in the LC group (10 patients). The odds ratio for the development of meningitis in the presence of an LC was 23.38 (95% confidence interval, 2.77-123.78; p  < 0.004). There was no statistical difference in the reported incidence of meningitis when CSF leak was present. Conclusion  This study demonstrates an extremely high incidence of meningitis (36%) following EEA procedures when an LC is used. The incidence of meningitis was not significantly associated with CSF leak in our cohort.

Advancements in Cerebrospinal Fluid Biosensors: Bridging the Gap from Early Diagnosis to the Detection of Rare Diseases

Cerebrospinal fluid (CSF) is a body fluid that can be used for the diagnosis of various diseases. However, CSF collection requires an invasive and painful procedure called a lumbar puncture (LP). This procedure is applied to any patient with a known risk of central nervous system (CNS) damage or neurodegenerative disease, regardless of their age range. Hence, this can be a very painful procedure, especially in infants and elderly patients. On the other hand, the detection of disease biomarkers in CSF makes diagnoses as accurate as possible. This review aims to explore novel electrochemical biosensing platforms that have impacted biomedical science. Biosensors have emerged as techniques to accelerate the detection of known biomarkers in body fluids such as CSF. Biosensors can be designed and modified in various ways and shapes according to their ultimate applications to detect and quantify biomarkers of interest. This process can also significantly influence the detection and diagnosis of CSF. Hence, it is important to understand the role of this technology in the rapidly progressing field of biomedical science.

Efficacy and Safety of Lumbar Drainage before Endovascular Treatment for Ruptured Intracranial Aneurysms

Objective

Intraoperative rebleeding during endovascular treatment for ruptured intracranial aneurysms is associated with poor prognosis. Lumbar drainage is performed preoperatively to control intracranial pressure; however, it is associated with a risk of brain herniation or rebleeding because intracranial pressure may change rapidly. Therefore, this study aimed to examine the efficacy and safety of preoperative lumbar drainage.

Methods

This retrospective study enrolled 375 patients who underwent endovascular treatment of ruptured intracranial aneurysms at our institution between April 2013 and March 2018. The incidence of rebleeding and clinical outcomes were compared between patients who did and did not undergo preoperative lumbar drainage.

Results

Among the 375 patients with ruptured intracranial aneurysms, 324 (86.0%) and 51 (14.0%) patients did and did not undergo lumbar drainage, respectively. The incidence of rebleeding was 11/324 (3.4%) and 2/51 (3.9%) in lumbar drainage and nonlumbar drainage groups, respectively, with no statistical differences (p = 0.98). Of the rebleeding cases, 9/11 (81%) and 2/2 (100%) in lumbar drainage and nonlumbar drainage groups, respectively, were due to intraoperative bleeding, and 2/11 (19%) in the lumbar drainage group, the causes of the rebleeding were undetermined. The incidence of symptomatic vasospasm did not differ significantly between the groups (13.2% vs. 11.8%, P = 0.776), while the incidence of hydrocephalus (24.6% vs. 11.8%, P = 0.043) and meningitis (15.2% vs. 5.9%, P = 0.075) were slightly higher in the lumbar drainage group. Favorable clinical outcomes (modified Rankin Scale score <2) at discharge were less frequent in the lumbar drainage group (55.3% vs. 70.0%, P = 0.051). No significant differences were observed in the propensity score-matched analysis.

Conclusion

Lumbar drainage before endovascular treatment for ruptured intracranial aneurysms is a safe procedure that does not increase the incidence of rebleeding.

Management of Cerebrospinal Fluid Leakage after Microvascular Decompression Surgery: Clinical Strategy

(1) Background: Cerebrospinal fluid (CSF) leakage is one of the most common complications of microvascular decompression (MVD) surgery. Before fatal complications, such as intracranial infection, occur, early recognition and prompt treatment are essential. (2) Methods: The clinical data of 475 patients who underwent MVD surgery from September 2020 to March 2023 were retrospectively analyzed. In these patients, if there were any symptoms of CSF leakage, and if CSF leakage was evident, a lumbar drainage catheter was inserted immediately. (3) Results: CSF leakage was suspected in 18 (3.8%) patients. Five of these patients (1.1%) showed signs of CSF leakage during conservative management and subsequently underwent catheter insertion for lumbar drainage. The lumbar drain was removed after an average of 5.2 days, resulting in an average hospitalization of 14.8 days. In all 5 patients, CSF leakage was resolved without reoperation. (4) Conclusions: Our treatment strategy prevented the development of fatal complications. Close observation of the symptoms and postoperative temporal bone computed tomography and audiometry are considered to be good evaluation methods for all patients. If CSF leakage is certain, it is important to perform lumbar drainage immediately.

Causative Pathogens in Surgical Drain Infections and Antibiotic Resistance Profiles of These Pathogens: Growing Frequency of Resistance Among the Enterobacteriaceae Family

Introduction Surgical drain infections (SDIs) and antibiotic resistance profiles of these infectious pathogens are the issues that need to be emphasized. This study aimed to identify microorganisms isolated from drain cultures and determine antibiotic resistance rates among these microorganisms. Materials and methods The drain culture results of patients analyzed between January 2008 and January 2020 were included in the study. Data such as microorganisms grown in drain cultures, antibiotic resistance rates, and demographic information of patients were evaluated. Results Three hundred forty-six isolates were analyzed from the drain cultures of 279 patients. The mean age of the patients was 62.82 ± 17.77 years. Polymicrobial growth was detected in samples from 49 (18%) patients. The most frequently isolated microorganisms were pathogens belonging to the Enterobacteriaceae family (44%) and to Staphylococcus species (spp.) (20%). As shown by our results, the frequency of Staphylococcus spp. decreased in the last four years, whereas the frequency of Enterococcus increased. In terms of drug resistance, the highest rate of resistance among the isolates was to ampicillin (Enterobacteriaceae family), followed by gentamicin (Acinetobacter species.), cefepime (Pseudomonas spp.), penicillin (Staphylococcus spp.), and ciprofloxacin (Enterococcus spp.). In the Enterobacteriaceae family, 49% of the isolates were resistant to extended-spectrum beta-lactamases, and 17% were resistant to carbapenems. Methicillin resistance was detected in 55% of Staphylococcus aureus, and vancomycin resistance was found in 11% of Enterococcus. Conclusions In drain cultures for SDIs, information on the causative pathogens, in addition to the antibiotic resistance rates of these pathogens, is needed to initiate appropriate empirical treatment.

The HeMoVal study protocol: a prospective international multicenter cohort study to validate cerebrospinal fluid hemoglobin as a monitoring biomarker for aneurysmal subarachnoid hemorrhage related secondary brain injury

INTRODUCTION

Preclinical studies provided a strong rationale for a pathophysiological link between cell-free hemoglobin in the cerebrospinal fluid (CSF-Hb) and secondary brain injury after subarachnoid hemorrhage (SAH-SBI). In a single-center prospective observational clinical study, external ventricular drain (EVD) based CSF-Hb proved to be a promising biomarker to monitor for SAH-SBI. The primary objective of the HeMoVal study is to prospectively validate the association between EVD based CSF-Hb and SAH-SBI during the first 14 days post-SAH. Secondary objectives include the assessment of the discrimination ability of EVD based CSF-Hb for SAH-SBI and the definition of a clinically relevant range of EVD based CSF-Hb toxicity. In addition, lumbar drain (LD) based CSF-Hb will be assessed for its association with and discrimination ability for SAH-SBI.

METHODS

HeMoVal is a prospective international multicenter observational cohort study. Adult patients admitted with aneurysmal subarachnoid hemorrhage (aSAH) are eligible. While all patients with aSAH are included, we target a sample size of 250 patients with EVD within the first 14 day after aSAH. Epidemiologic and disease-specific baseline measures are assessed at the time of study inclusion. In patients with EVD or LD, each day during the first 14 days post-SAH, 2 ml of CSF will be sampled in the morning, followed by assessment of the patients for SAH-SBI, co-interventions, and complications in the afternoon. After 3 months, a clinical follow-up will be performed. For statistical analysis, the cohort will be stratified into an EVD, LD and full cohort. The primary analysis will quantify the strength of association between EVD based CSF-Hb and SAH-SBI in the EVD cohort based on a generalized additive model. Secondary analyses include the strength of association between LD based CSF-Hb and SAH-SBI in the LD cohort based on a generalized additive model, as well as the discrimination ability of CSF-Hb for SAH-SBI based on receiver operating characteristic (ROC) analyses.

DISCUSSION

We hypothesize that this study will validate the value of CSF-Hb as a biomarker to monitor for SAH-SBI. In addition, the results of this study will provide the potential base to define an intervention threshold for future studies targeting CSF-Hb toxicity after aSAH.

STUDY REGISTRATION

ClinicalTrials.gov Identifier NCT04998370 . Date of registration: August 10, 2021.

Prediction of Lumbar Drainage-Related Meningitis Based on Supervised Machine Learning Algorithms

Background

Lumbar drainage is widely used in the clinic; however, forecasting lumbar drainage-related meningitis (LDRM) is limited. We aimed to establish prediction models using supervised machine learning (ML) algorithms.

Methods

We utilized a cohort of 273 eligible lumbar drainage cases. Data were preprocessed and split into training and testing sets. Optimal hyper-parameters were archived by 10-fold cross-validation and grid search. The support vector machine (SVM), random forest (RF), and artificial neural network (ANN) were adopted for model training. The area under the operating characteristic curve (AUROC) and precision-recall curve (AUPRC), true positive ratio (TPR), true negative ratio (TNR), specificity, sensitivity, accuracy, and kappa coefficient were used for model evaluation. All trained models were internally validated. The importance of features was also analyzed.

Results

In the training set, all the models had AUROC exceeding 0.8. SVM and the RF models had an AUPRC of more than 0.6, but the ANN model had an unexpectedly low AUPRC (0.380). The RF and ANN models revealed similar TPR, whereas the ANN model had a higher TNR and demonstrated better specificity, sensitivity, accuracy, and kappa efficiency. In the testing set, most performance indicators of established models decreased. However, the RF and AVM models maintained adequate AUROC (0.828 vs. 0.719) and AUPRC (0.413 vs. 0.520), and the RF model also had better TPR, specificity, sensitivity, accuracy, and kappa efficiency. Site leakage showed the most considerable mean decrease in accuracy.

Conclusions

The RF and SVM models could predict LDRM, in which the RF model owned the best performance, and site leakage was the most meaningful predictor.

Establishment of a Nomogram for Predicting Lumbar Drainage-Related Meningitis: A Simple Tool to Estimate the Infection Risk

BACKGROUND

Lumbar drainage (LD) is one of the common treatment techniques in neurosurgery. There is a risk of secondary meningitis when using this modality. We aim to predict the probability of the complication by designing a nomogram.

METHODS

A retrospective study was conducted in a teaching hospital. Data were collected and LD-related meningitis (LDRM) was identified, mainly based on clinical manifestations and cerebrospinal fluid analysis. Univariate analysis was used to screen the risk factors, and binary logistic analysis was performed to build the prediction model, which was furtherly transferred into a nomogram. The prediction performance was evaluated by receiver operating characteristic (ROC) curve, Hosmer-Lemeshow test, and nomogram calibration plot. Internal validation was processed by using ordinary bootstrapping.

RESULTS

A total of 273 patients who match the research criteria were enrolled, in which 37 cases (13.6%) were confirmed to have LDRM. Univariate analysis showed the risk factors included diabetes (p = 0.003), admission on surgical intensive care unit (p = 0.012), duration time (p < 0.001), site leakage (p < 0.001), and craniotomy (p < 0.001). In multivariate analysis, four of the variables were identified as independent risk factors to establish a prediction model, and a graphical nomogram was designed. The area under the ROC curve was 0.837, and the p value in the Hosmer-Lemeshow test was 0.610, with a mean absolute error in the calibration plot calculated as 0.022. The indices in the testing set were in good accordance with the original set when internal validation was performed.

CONCLUSIONS

This is the first study to transform the prediction model of LDRM into a nomogram, which can be considered as a tool for clinicians to assess infection risk.

Fulminant Idiopathic Intracranial Hypertension

PURPOSE OF REVIEW

The goal of this review is to describe the presenting features of fulminant idiopathic intracranial hypertension (IIH) and outline the multimodal approach to its treatment.

RECENT FINDINGS

Venous sinus stenting may be an appropriate alternative to optic nerve sheath fenestration or cerebrospinal fluid shunting in select patients with fulminant IIH. Prompt surgical intervention maximizes the chance of visual recovery in patients with fulminant IIH. "Fulminant IIH" is defined as intracranial hypertension with no secondary cause, severe vision loss within 4 weeks of symptom onset, and progressive vision loss over days. Rapid recognition of the fulminant phenotype of IIH by emergency department physicians, neurologists, and ophthalmologists is critical. Without appropriate triage and rapid medical and surgical intervention, patients with fulminant IIH are at high risk for profound, permanent vision loss. Prompt surgical intervention with optic nerve sheath fenestration, cerebrospinal fluid shunting, or venous sinus stenting minimizes the chance of poor visual outcome. If a delay is anticipated, serial lumbar punctures or temporary cerebrospinal fluid drainage and medical therapy may forestall irreversible vision loss.

Logistic Regression Analysis of Risk Factors for Intracranial Infection After Multiple Traumatic Craniotomy and Preventive Measures

BACKGROUND AND OBJECTIVE

The aim of this study was to study the risk factors of intracranial infection after traumatic craniotomy in multiple trauma to provide references for clinical prevention and control of intracranial infection.

METHODS

A total of 34 multiple trauma patients treated with craniotomy and complicated with intracranial infection from February 2012 to December 2016 in the department of neurosurgery of our hospital were selected as infection group, and 60 multiple trauma patients who had not been infected after craniotomy during the same period were selected as control group. Related risk factors were screened by univariate analysis at first and analyzed by Logistic regression.

RESULTS

Of the 34 patients in the infection group, 13 cases were cured, 21 cases improved, whereas in the control group, 15 cases were cured and 45 cases improved. There was no significant difference in prognosis between the 2 groups (P > 0.05). Univariate analysis showed that surgical approach, surgical duration, postoperative cerebrospinal fluid leakage, and external drainage were important factors for intracranial infection after craniotomy (P < 0.05). Further Logistic regression analysis showed that postoperative external drainage, cerebrospinal fluid leakage, surgical time, and posterior fossa approaches were independent risk factors for intracranial infection after craniotomy.

CONCLUSION

High attention should be paid to the risk factors of intracranial infection after craniotomy such as postoperative cerebrospinal fluid leakage, external drainage, surgical duration and approach, and taking effective preventive measures to reduce the incidence of intracranial infection after craniotomy in patients with multiple traumatic injuries.

The SiLuDrain Trial: a prospective randomized controlled trial comparing standard versus silver-impregnated lumbar drains

OBJECTIVE

Catheter-associated cerebrospinal fluid (CSF) infection remains a serious event, especially for patients in neurocritical care units. The use of external ventricular drain (EVD) catheters impregnated with antimicrobial substances has led to a significant reduction of infection rates. This study was undertaken to compare the use of antimicrobial, silver-impregnated external lumbar drains (si-ELDs) and conventional ELDs.

METHODS

Patients with an indication for ELD placement were randomized to receive either a conventional or an si-ELD catheter. Regular assessment for CSF infections and device-related complications was performed. Neurosurgeons placing the ELD rated the usability and handling of the catheter on a 6-item ordinal performance scale (range: 1, very bad, to 5, very good). All microorganisms isolated in this study were tested for silver-susceptibility via a catheter-roll method.

RESULTS

A total of 48 patients were enrolled in the trial. The si-ELD catheters showed a nonsignificantly lower infection rate compared to conventional ones (4.2% vs 16.7%, p = 0.16). The majority of infections were caused by Staphylococcus species. Device-related complications occurred significantly less often with silver-impregnated-catheters than with conventional ones (8.3% vs 37.5%, p = 0.02). The usability was rated significantly better for si-ELDs (p = 0.003). Antimicrobial susceptibility was shown for si-ELDs against various Staphylococcus spp., but Candida parapsilosis and Escherichia coli were not affected by this antimicrobial agent.

CONCLUSIONS

Silver-impregnated ELD catheters, which could potentially reduce the number of CSF infections, show significantly better properties in regard to handling and fewer device-related complications. Whether they are superior to antibiotic-impregnated catheters or a clinical regimen involving antibiotic prophylaxis remains to be proven.Clinical trial registration no.: DRKS00013513 (Deutsches Register Klinischer Studien).

Risk factors for meningitis in neurosurgical patients with cerebrospinal fluid drains: prospective observational cohort study

BACKGROUND

Cerebrospinal fluid (CSF) drainage or intracranial pressure (ICP) monitoring devices are life-saving devices. We examined the risk factors for infections related to them and assessed the effect of an infection control (IC) intervention.

METHODS

A prospective observational study was conducted in the Neurosurgical Department of our hospital between 2014 and 2017. We included all consecutive patients undergoing CSF catheter insertions, including external ventricular drainage (EVD), lumbar drainage (LD), and ICP catheters. An IC intervention was implemented between March and August 2016. We examined risk factors for meningitis or ventriculitis, defined according to Healthcare-associated infections surveillance definitions, on univariate and multivariate analysis.

RESULTS

A total of 232 patients with 437 drains (212 EVDs, 92 LDs, and 133 ICPs) were included. On univariate and multivariate analysis, the infection incidence was 13.7 per 1000 drain days (17.3/1000 before IC intervention, 7.9/1000 during, and 9.2/1000 after the intervention). Most episodes were caused by Gram-negative bacteria, and the most common pathogen was Acinetobacter baumanii. Risk factors for infection per patient included diabetes mellitus (p = 0.017), CSF leak (p = 0.032), drain opening (p = 0.027), and the duration of the drain in days (p = 0.035). Risk factors per catheter included drain opening (p < 0.001), drain days (p = 0.001), and the IC intervention period compared to before the intervention period (p = 0.037). When restricting the analysis to EVDs, drain days (p = 0.001) was the only significant risk factor.

CONCLUSIONS

Strict adherence to IC, shortening drain duration, and avoiding unnecessary opening and manipulation of the drains are crucial to preventing neurosurgical drain infections.

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.

Increased rate of ventriculostomy-related hemorrhage following endovascular treatment of ruptured aneurysms compared to clipping

OBJECTIVE

Acutely ruptured aneurysms can be treated by endovascular intervention or via surgery (clipping). After endovascular treatment, the risk of thromboembolic complications is reduced by the use of anticoagulative agents, which is not required after clipping. The aim of the study is to investigate the rate of ventriculostomy-related hemorrhage after endovascular treatment and clipping.

METHODS

A consecutive series of 99 patients treated for a ruptured aneurysm which required an external ventricular drainage between 2010 and 2015 were included. Their CT scans were investigated retrospectively for ventriculostomy-related hemorrhage. Furthermore, the extent of bleeding, the rate of revision surgery, and the rate of bacterial ventriculitis have been analyzed.

RESULTS

Ventriculostomy-related hemorrhage was observed in 20 of 45 patients after endovascular treatment compared to 7 of 54 patients after clipping (chi-squared test, p < 0.001). Revision surgery was indicated in 75%. In 50% of these patients, revision surgery was required more than once and nearly 50% developed additional cerebral infections. Intraventricular or intracerebral extension of the bleeding was observed only in the endovascular treatment group (chi-squared test, p = 0.003). Glasgow outcome scale showed a significant better outcome in the surgical group (t test, p = 0.005).

CONCLUSIONS

Ventriculostomy-related hemorrhage is an underestimated complication after endovascular treatment leading to revision surgeries, bacterial infections, and may have a negative impact on long-term outcome. The probability of occurrence is increased when anticoagulation is performed by heparin in combination with antiplatelet drugs as compared to heparin alone. Lumbar drainage should be considered as an alternative for treatment of acute hydrocephalus in patients with Hunt and Hess grade 1-3.

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.

Management of infections associated with neurosurgical implanted devices

INTRODUCTION

Neurosurgical devices are increasingly used. With it, neurosurgical device-related infections gain relevance. As biofilms are involved in implant-associated infections the diagnosis and treatment is challenging and requires specific anti-biofilm concepts and management algorithms. Areas covered: The literature concerning the management of neurosurgical device-associated infections is scarce and heterogeneous treatment concepts are discussed, but no standardized diagnostic and treatment procedures exist. Therefore, we emphasize extrapolating management strategies predominantly from orthopedic device-associated infections, where the concept is better established and clinically validated. This review covers infections associated with craniotomy fixation devices, cranioplasties, external ventricular and lumbar drainages, internal shunts and neurostimulators. Expert commentary: Sonication of the removed implants significantly improves microbiological diagnosis. A combined surgical and antimicrobial management is crucial for successful treatment: appropriate surgical intervention is combined with prolonged anti-biofilm therapy of usually 12 weeks. In selected patients, new treatment algorithms enable cure of neurosurgical device-associated infections without implant removal or with a one-stage implant exchange, considerably improving the quality of patient lives.

Effect of the drainage of cerebrospinal fluid in patients with aneurismal subarachnoid hemorrhage: A meta-analysis

BACKGROUND AND OBJECTIVES

Vasospasm-related injury such as delayed ischemic neurological defect (DIND) or cerebral infarction is an important prognostic factor for aneurismal subarachnoid hemorrhage (SAH). Whether cerebrospinal fluid (CSF) drainage can achieve a better outcome in aneurismal SAH patients after coiling or clipping remains the subject of debate. Here, we report a meta-analysis of the related available literature to assess the effect of continuous CSF drainage on clinical outcomes in patients with aneurismal SAH.

METHODS

Case-control studies regarding the association between aneurismal SAH and CSF drainage were systematically identified through online databases (PubMed, Web of Science, Elsevier Science Direct, and Springer Link). Inclusion and exclusion criteria were defined for the eligible studies. The fixed-effects model was performed when homogeneity was indicated. Alternatively, the random-effects model was utilized.

RESULTS

This meta-analysis included 11 studies. Continuous CSF drainage obviously improved patients' long-term outcome (odds ratio [OR] of 2.86, 95% confidence interval [CI], 1.37-5.98, P < 0.01). CSF drainage also reduced angiographic vasospasm (OR of 0.35, 95% CI, 0.23-0.51, P < 0.01), symptomatic vasospasm (OR of 0.32, 95% CI, 0.32-0.43, P < 0.01), and DIND (OR of 0.48, 95% CI, 0.25-0.91, P = 0.03), but there was no significant difference between the CSF drainage group and the no CSF drainage group on shunt-dependent hydrocephalus (SDHC) prevention (OR of 1.04, 95% CI, 0.52-2.07, P = 0.91). Further analysis on lumbar drainage (LD) and external ventricular drainage (EVD) indicated that LD had a better outcome (OR of 3.11, 95% CI, 1.18-8.23, P = 0.02), whereas no significant difference in vasospasm-related injury was detected between the groups (OR of 1.13, 95% CI, 0.54-2.37, P = 0.75).

CONCLUSION

Continuous CSF drainage is an effective treatment for aneurismal SAH patients; lumbar drainage showed lower complications, but more well-designed studies are required to verify and consolidate this conclusion.