Lumbar Drainage in patients of Aneurysmal Subaarachnoid Hemorrhage improves Outcomes : EARLYDRAIN Trial

Recent research from Germany form the EARLYDRAIN trial, published in JAMA Neurology suggests that lumbar CSF drainage in patients of aneurysmal subarachnoid hemorrhage may improve overall outcomes in survivors.

Subarachnoid hemorrhage resulting from a ruptured intracranial aneurysm is a life-threatening event, often leading to death or irreversible disability. Historically, the presence of blood in the basal cisterns, which causes cerebral vasospasm, has been linked to the resultant delayed cerebral ischemia in these patients. While vasospasm is seen in about 70% of subarachnoid hemorrhage cases, up to 40% experience a secondary infarction, with some showing no signs of vasospasm. Traditional treatments aimed at addressing vasospasm have proven ineffective in enhancing mortality or functional outcomes.

The EARLYDRAIN trial has brought to light the potential benefits of lumbar drainage in these patients. As per this study, using a lumbar drain alongside standard care significantly reduced the instances of infarctions at discharge and decreased the unfavorable outcome rates at the six-month mark. Interestingly, the amount of cerebrospinal fluid (CSF) drained in the initial week post-onset was comparable in both the lumbar drain and standard of care groups.

One remarkable observation was the color disparity in the fluid from a ventricular vs. a lumbar drain. This is attributed to the sedimentation of erythrocytes in the CSF, making lumbar drainage more efficient than ventricular drainage.

Moreover, patients who underwent lumbar drainage demonstrated significantly lower intracranial pressures (ICP). High ICP is common in subarachnoid hemorrhage patients, with about 80% showcasing ICP elevation beyond 20 mm Hg. Prolonged and heightened ICP is directly correlated with unfavorable outcomes, with spikes potentially leading to spreading depolarizations, preluding infarctions. This trial's data suggests lumbar drains are superior in controlling ICP compared to other methods.

The rate of infections in the EARLYDRAIN trial is representative of a typical mixed-grade aneurysmal subarachnoid hemorrhage demographic. Over half of these patients develop fever, with about 20% progressing to pneumonia. Although device-associated meningitis was included in the infection definition, frequent CSF analyses, which could instigate infections, were not a standard procedure. Moreover, current diagnostics seem insufficient in pinpointing device-associated infections.

Infarct detection mainly utilized CT scans, even though MRI might offer better sensitivity. The EARLYDRAIN trial didn't adopt the latest definition of delayed cerebral ischemia. Instead, it focused on clinician-judged neurological worsening and imaging methods independently. Notably, the observed infarction rate was higher compared to other studies, potentially due to the inclusion of patients with poor grades in the EARLYDRAIN trial.

In summary, while the relationship between vasospasm and delayed cerebral ischemia remains complex, the EARLYDRAIN trial points towards the efficacy of lumbar drainage in improving outcomes and managing intracranial pressures for patients suffering from aneurysmal subarachnoid hemorrhage. Further studies are essential to delve deeper into the intricacies of the disease and refine treatment strategies.

Reference:

Wolf S, Mielke D, Barner C, et al. Effectiveness of Lumbar Cerebrospinal Fluid Drain Among Patients With Aneurysmal Subarachnoid Hemorrhage: A Randomized Clinical Trial. JAMA Neurol. 2023;80(8):833–842.

doi:10.1001/jamaneurol.2023.1792