Role of controlled lumbar CSF drainage for ICP control in aneurysmal SAH

Abstract

Background: A prospective study of lumbar CSF drainage in the setting of raised intra-cranial pressure refractory to medical management and ventriculostomy placement is presented. There has been increasing data that this may be a effective and safe intervention for reduction of ICP. Method: An IRB approved prospective study was conducted. Six patients with increased intracranial pressure secondary to aneurysm rupture were initially managed with sedation, ventriculostomy placement, mild hyperventilation (pCO2 = 30-35), and hyperosmolar therapy (Na = 150-155). A lumbar drain was placed if ICP continued to be above 20 mmHg despite optimization of medical therapy. Findings: After lumbar drain placement, ICP was reduced from 30.2 mmHg ± 6.7 to 9.7 mmHg ± 7.4, an average decrease of 20.5 mm H2O (P < 0.001). There was no significant change in CPP. Requirements for hypertonic saline and/or mannitol boluses and sedation to control ICP were decreased. There was no incidence of CSF infection or cerebral herniation. Conclusions: We have shown that controlled lumbar drainage is a safe, efficacious and minimally invasive method for treatment of elevated ICP which refractory to medical management. Ventriculostomies are always placed before utilizing lumbar drains to minimize the risk of cerebral herniation. We would advocate making controlled lumbar drainage a standard part of ICP control protocols. © Springer-Verlag/Wien 2011.