Prophylactic Lumbar Drainage reduces secondary infarctions and adverse outcomes post aneurysmal subarachnoid hemorrhage

EARLYDRAIN trial revealed that the use of a prophylactic lumbar drain along with the standard of care has alleviated the infarctions at discharge and unfavorable outcomes at 6 months in patients with aneurysmal subarachnoid hemorrhage of any grade. The study results were published in the journal JAMA Neurology.

Subarachnoid hemorrhage that occurs due to a ruptured intracranial aneurysm leads to the development of stroke with increased mortality and morbidity. An aneurysm is generally managed by surgical clipping or endovascular coiling within 24 to 48 hours after hemorrhage. Literature has shown mixed results about the drainage of blood in the basal cisterns. Lumbar drainage was one of the methods which showed favorable outcomes. Hence researchers conducted the EARLYDRAIN trial, which is a pragmatic, multicenter, parallel-group, open-label randomized clinical trial to investigate the effect of a lumbar cerebrospinal fluid drainage among patients with a ruptured cerebral aneurysm between January 2011 and January 2016 and followed-up till July 2016.

The trial was carried out with a blinded endpoint evaluation conducted at 19 centers in Germany, Switzerland, and Canada. Out of the 307 randomizations, there were about 20 invalid randomizations due to a lack of informed consent. All the participants meeting all inclusion and exclusion criteria were included in the intention-to-treat analysis. The exclusion of patients was only performed in a per-protocol sensitivity analysis. A total of 287 adult patients with acute aneurysmal subarachnoid hemorrhage of all clinical grades were analyzable. Aneurysm treatment with clipping or coiling was performed within 48 hours. About 144 patients were randomized to receive an additional lumbar drain after aneurysm treatment and 143 patients to the standard of care only. Early lumbar drainage with 5 mL per hour was started within 72 hours of the subarachnoid hemorrhage. Measuring the rate of an unfavorable outcome, defined as a modified Rankin Scale score of 3 to 6 (range, 0 to 6), obtained by masked assessors 6 months after hemorrhage was the primary outcome.

Key findings:

• Of 287 included patients, 197 (68.6%) were female, and the median (IQR) age was 55 (48-63) years.
• Lumbar drainage started at a median (IQR) of day 2 (1-2) after aneurysmal subarachnoid hemorrhage.
• At 6 months, 47 patients (32.6%) in the lumbar drain group and 64 patients (44.8%) in the standard of care group had an unfavorable neurological outcome.
• Patients treated with a lumbar drain had fewer secondary infarctions at discharge (41 patients [28.5%] vs 57 patients [39.9%]; risk ratio, 0.71).

Thus, Prophylactic lumbar drainage following aneurysmal subarachnoid hemorrhage reduced the risk of poor outcome at 6 months and minimized the burden of subsequent infarction.

Further reading: 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. Published online June 18, 2023. doi:10.1001/jamaneurol.2023.1792