External lumbar drainage in progressive pediatric idiopathic intracranial hypertension

OBJECTIVE

Pediatric idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure despite normal cerebrospinal fluid and neuroimaging findings. Initial management is typically medical; however, nearly 10% of children will eventually require surgery for persistent headache and/or vision loss. External lumbar drainage, which is a considerably safer treatment option, has not been adequately analyzed in children with medically refractory IIH.

METHODS

The authors conducted a single-institution retrospective analysis of children with medically refractory IIH who had undergone external lumbar drain (ELD) placement because of worsening papilledema, reflected as increased retinal nerve fiber layer (RNFL) thickness on optical coherence tomography (OCT) testing. The main outcome measures were effects of external lumbar drainage on papilledema resolution, symptoms, and vision.

RESULTS

The authors analyzed the medical records of 13 children with IIH (11 girls, mean age 15.0 ± 2.3 years) whose mean CSF opening pressure was 45.5 ± 6.8 cm H2O. In all children, the average global RNFL thickness in both eyes significantly increased at ELD placement (right eye 371.8 ± 150.2 μm, left eye 400.3 ± 96.9 μm) compared with presentation thickness (right eye 301.6 ± 110.40 μm, left eye 350.2 ± 107.7 μm) despite acetazolamide medical therapy (20-30 mg/kg/day), leading to ELD placement after 9.5 ± 6.9 days (range 3-29 days). After ELD insertion, there was headache resolution, gradual and continuous improvement in optic disc thickness, and preservation of good vision.

CONCLUSIONS

ELD placement in children with medically refractory IIH who demonstrated worsening papilledema with increased RNFL thickening on OCT testing typically results in symptom relief and disc edema resolution with good visual outcome, often preventing the need for additional definitive surgeries that carry greater failure and morbidity risks.

Lumbar drain trial outcomes of normal pressure hydrocephalus: a single-center experience of 254 patients

OBJECTIVE

A short-term lumbar drain (LD) trial is commonly used to assess the response of normal pressure hydrocephalus (NPH) patients to CSF diversion. However, it remains unknown whether the predictors of passing an LD trial match the predictors of improvement after ventriculoperitoneal shunting. The aim of this study was to examine outcomes, complication rates, and associations between predictors and outcomes after an LD trial in patients with NPH.

METHODS

The authors retrospectively reviewed the records of 254 patients with probable NPH who underwent an LD trial between March 2008 and September 2017. Multivariate regression models were constructed to examine predictors of passing the LD trial. Complications associated with the LD trial procedure were recorded.

RESULTS

The mean patient age was 77 years and 56.7% were male. The mean durations of gait disturbance, cognitive decline, and urinary incontinence were 29 months, 32 months, and 28 months, respectively. Of the 254 patients, 30% and 16% reported objective and subjective improvement after the LD trial, respectively. Complications included a sheared LD catheter, meningitis, lumbar epidural abscess, CSF leak at insertion site, transient lower extremity numbness, slurred speech, refractory headaches, and hyponatremia. Multivariate analyses using MAX-R revealed that a prior history of stroke predicted worse outcomes, while disproportionate subarachnoid spaces (uneven enlargement of supratentorial spaces) predicted better outcomes after the LD trial (r2 = 0.12, p < 0.05).

CONCLUSIONS

The LD trial is generally safe and well tolerated. The best predictors of passing the LD trial include a negative history of stroke and having disproportionate subarachnoid spaces.

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).

An Automated, Gravity-driven CSF Drainage System Decreases Complications and Lowers Costs

BACKGROUND

FlowSafe^TM (BeckerSmith Medical, Irvine, CA, USA) is a novel, robotic, external lumbar drainage (ELD) system, which was designed to control cerebrospinal fluid (CSF) drainage, reduce complications, and decrease treatment costs.

METHODS

 Forty-seven consecutive neurosurgical patients requiring ELD were treated using the FlowSafe system.

RESULTS

In 39 of 40 patients with traumatic and surgical dural openings, potential CSF leaks were avoided. In seven patients with suspected normal pressure hydrocephalus, post-infectious ventriculomegaly, or pseudotumor cerebrum, we were able to assess the likelihood of improvement with shunting. The system, therefore, produced what we considered to be the "desired result" in 46 of 47 patients (98%). Our one treatment failure (2%) involved a patient with unrecognized hydrocephalus who, following a Chiari repair with a dural patch graft, was drained for six days. A persistent CSF leak eventually required a reoperation. Two patients (4%) described low-pressure headaches during treatment. Both responded to temporarily suspending or reducing the drainage rate. We saw no complications. Required nursing interventions were minimal.  Conclusions: The FlowSafe system was safe and effective. In our experience, there were fewer complications compared to currently available ELD systems. The FlowSafe was well tolerated by our patients. The near elimination of nursing interventions should allow lumbar drainage to be delivered in less costly, non-intensive care unit settings. Larger trials will be needed.

External lumbar drain: A pragmatic test for prediction of shunt outcomes in idiopathic normal pressure hydrocephalus

Background:

The consensus on most reliable supplemental test to predict the shunt responsiveness in patients with idiopathic normal pressure hydrocephalus (iNPH) is lacking. The aim of this study is to discuss the utility of external lumbar drain (ELD) in evaluation of shunt responsiveness for iNPH patients.

Methods:

A retrospective review of 66 patients with iNPH was conducted. All patients underwent 4-day ELD trial. ELD-positive patients were offered ventriculoperitoneal shunt (VPS) surgery. The primary outcome evaluation parameters were gait and mini mental status examination (MMSE) assessment. The family and patient perception of improvement was accounted for in the outcome evaluation.

Results:

There were 38 male and 28 female with mean age of 74 years (range 45-88 years). ELD trial was positive in 86% (57/66) of patients. No major complications were encountered with the ELD trial. A total of 60 patients (57 ELD-positive, 3 ELD-negative) underwent VPS insertion. The negative ELD trial (P = 0.006) was associated with poor outcomes following shunt insertion. The positive ELD trial predicted shunt responsiveness in 96% patients (P < 0.0001, OR = 96.2, CI = 11.6-795.3). A receiver operating characteristic (ROC) curve analysis revealed that the ELD trial is reasonably accurate in differentiating shunt responder from non-responder in iNPH patients (area under curve = 0.8 ± 0.14, P = 0.02, CI = 0.52-1.0). The mean follow-up period was 12-months (range 0.3-3 years). The significant overall improvement after VPS was seen in 92% (55/60). The improvement was sustained in 76% of patients at mean 3-year follow-up. The number of comorbid conditions (P = 0.034, OR = 4.15, CI = 1.2-9.04), and a history of cerebrovascular accident (CVA) (P = 0.035, OR = 4.4, CI = 1.9-14.6) were the predictors of poor outcome following shunt surgery.

Conclusion:

The positive ELD test predicted shunt responsiveness in 96% of patients. With adequate technique, maximal results with minimal complications can be anticipated. The number of comorbidities, history of CVA and negative ELD test were significantly associated with poor shunt outcomes.