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

Different cerebrospinal fluid drainage methods and chronic hydrocephalus in patients with aneurysmal subarachnoid hemorrhage

Background

Chronic hydrocephalus represents a common complication following aneurysmal subarachnoid hemorrhage (aSAH); however, the underlying mechanisms driving its pathogenesis remain incompletely understood. Furthermore, current evidence regarding optimal preventive strategies to mitigate hydrocephalus development remains controversial within the neurosurgical community.

Objective

To investigate the efficacy of distinct cerebrospinal fluid (CSF) drainage modalities in mitigating the risk of developing chronic hydrocephalus among patients with aneurysmal subarachnoid hemorrhage (aSAH) through a comparative effectiveness study design.

Method

The patients with aSAH treated in our hospital from January 2021 to January 2024 were analyzed retrospectively. Firstly, the related factors of chronic hydrocephalus in patients with subarachnoid hemorrhage were compared between patients with cerebrospinal fluid drainage and patients without cerebrospinal fluid drainage. Then, the related factors of hydrocephalus in patients with aneurysm subarachnoid hemorrhage with different cerebrospinal fluid drainage were compared. Univariate and multivariate logical regression analysis was used to determine the risk factors associated with chronic hydrocephalus.

Result

Of the 246 hospitalized patients with aSAH, whether or not to receive cerebrospinal fluid drainage was associated with the formation of chronic hydrocephalus. A total of 67 patients (27.2%) developed hydrocephalus, of which 47 patients (34.8%) received cerebrospinal fluid drainage, while 20 (18%) patients developed chronic hydrocephalus. Of all IVH patients who received cerebrospinal fluid drainage, 34 (25.2%) received intermittent lumbar puncture drainage, 75 (55.5%) received continuous drainage in the lumbar cistern, and 26 (19.3%) received extraventricular drainage. Univariate analysis showed that different drainage methods had significant differences in postoperative chronic hydrocephalus in patients with aneurysmal subarachnoid hemorrhage (Purge 0.009). Multivariate Logistic regression analysis showed that different ways of cerebrospinal fluid drainage were independent risk factors for chronic hydrocephalus in patients with aneurysmal subarachnoid hemorrhage.

Conclusion

Patients with aneurysmal subarachnoid hemorrhage must perform cerebrospinal fluid drainage. Among the three different drainage methods: lumbar puncture intermittent drainage, lumbar cistern continuous drainage, and extraventricular drainage, continuous lumbar cistern drainage is more effective in reducing the formation of chronic hydrocephalus.

Prevention of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage-Summary of Existing Clinical Evidence

The 2023 International Subarachnoid Hemorrhage Conference identified a need to provide an up-to-date review on prevention methods for delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage and highlight areas for future research. A PubMed search was conducted for key factors contributing to development of delayed cerebral ischemia: anesthetics, antithrombotics, cerebrospinal fluid (CSF) diversion, hemodynamic, endovascular, and medical management. It was found that there is still a need for prospective studies analyzing the best methods for anesthetics and antithrombotics, though inhaled anesthetics and antiplatelets were found to have some advantages. Lumbar drains should increasingly be considered the first line of CSF diversion when applicable. Finally, maintaining euvolemia before and during vasospasm is recommended as there is no evidence supporting prophylactic spasmolysis or angioplasty. There is accumulating observational evidence, however, that intra-arterial spasmolysis with refractory DCI might be beneficial in patients not responding to induced hypertension. Nimodipine remains the medical therapy with the most support for prevention.

Construction and verification of risk predicting models to evaluate the possibility of hydrocephalus following aneurysmal subarachnoid hemorrhage

BACKGROUND

Hydrocephalus following a ruptured aneurysm portends a poor prognosis. The authors aimed to establish a nomogram to predict the risk of hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

A total of 421 patients with aSAH who were diagnosed by digital subtraction angiography in The General Hospital of Northern Theater Command center from January 2020 to June 2021 were screened to establish the training cohort. An additional 135 patients who enrolled between July 2021 and May 2022 were used for the validation cohort. Variate difference analysis and stepwise logistic regression (model A) and univariate and multivariate logistic regressions (model B) were respectively used to construct two models. Then, the net reclassification improvement (NRI), integrated discrimination improvement (IDI), and receiver operating characteristic (ROC) curve were used to compare the predictive abilities of the two models. Finally, two nomograms were constructed and externally validated.

RESULTS

After screening, 556 patients were included. The area under the ROC curve of models A and B in the training cohort were respectively 0.884 (95 % confidence interval [CI]: 0.847-0.921) and 0.834 (95 % CI: 0.787-0.881). The prediction ability of the model A was superior to model B (NRI > 0, IDI > 0, p < 0.05). The C-index of models A and B was 0.8835 and 0.8392, respectively. Regarding clinical usefulness, the two models offered a net benefit with a threshold probability of between 0.12 and 1 in the decision curve analysis, suggesting that the two models can accurately predict hydrocephalus events.

CONCLUSIONS

Both models have good prediction accuracy. Compared with model B, model A has better discrimination and calibration. Further, the easy-to-use nomogram can help neurosurgeons to make rapid clinical decisions and apply early treatment measures in high-risk groups, which ultimately benefits patients.

Cerebrospinal fluid drainage and chronic hydrocephalus in aneurysmal subarachnoid hemorrhage patients with intraventricular hemorrhage

Background

Patients with intraventricular hemorrhage (IVH) are at a higher risk of developing hydrocephalus and often require external ventricular drainage or long-term ventriculoperitoneal shunt surgery.

Objective

To investigate whether cerebrospinal fluid drainage in patients with IVH due to aneurysmal subarachnoid hemorrhage (aSAH) reduces the incidence of chronic hydrocephalus.

Method

A retrospective analysis was conducted on patients with aSAH treated at our hospital between January 2020 and December 2022. The first analysis compared patients with and without IVH, while the second analysis compared IVH patients with and without chronic hydrocephalus. The third analysis compared IVH patients who underwent in different drainage methods which is lumbar drainage (LD) or external ventricular drainage (EVD). The primary outcome measure was the incidence of chronic hydrocephalus.

Result

Of the 296 patients hospitalized with aSAH, 108 (36.5%) had IVH, which was associated with a significantly higher incidence of chronic hydrocephalus compared to patients without IVH (49.1% vs. 16.5%, p < 0.001). Multivariate logistic regression analysis showed that IVH was independently associated with the formation of chronic hydrocephalus (OR: 3.530, 95% CI: 1.958-6.362, p < 0.001). Among the 108 IVH patients, 53 (49.1%) developed chronic hydrocephalus. Multivariate logistic regression analysis revealed that the Hunt Hess grade at admission (OR: 3.362, 95% CI: 1.146-9.863, p = 0.027) and postoperative cerebrospinal fluid drainage (OR: 0.110, 95% CI: 0.036-0.336, p < 0.001) were independent risk factors for the development of chronic hydrocephalus in IVH patients. Among all IVH patients who underwent cerebrospinal fluid drainage, 45 (75%) received continuous lumbar puncture drainage, and 15 (25%) received external ventricular drainage. Univariate analysis did not show a statistically significant difference between the two groups in terms of postoperative chronic hydrocephalus (p = 0.283). However, multivariate logistic regression analysis suggested that the drainage methods of LD and EVD might be associated with the development of chronic hydrocephalus.

Conclusion

The presence of IVH increases the risk of chronic hydrocephalus in patients with aSAH, and postoperative cerebrospinal fluid drainage appears to reduce this risk. The specific effects of lumbar puncture drainage and ventricular drainage on the incidence of chronic hydrocephalus require further investigation.