Lin Michelle, Dallas Jonathan, Ding Li, Nguyen Vincent N, Bageac Devin, Hopkins Benjamin, Attenello Frank J, Mack William J
Department of Neurological Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
Department of Neurological Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
J Clin Neurosci. 2025 Feb;132:111008. doi: 10.1016/j.jocn.2024.111008. Epub 2024 Dec 27.
Aneurysmal subarachnoid hemorrhage (aSAH) carries a high economic cost and clinical morbidity in the United States. Beyond prolonged admissions and poor post-injury functional status, there is an additional cost of chronic shunt-dependent hydrocephalus for many aSAH patients. Adjuvant lumbar drain (LD) placement has been hypothesized to promote clearance of subarachnoid blood from the cisternal space, with an ultimate effect of decreasing shunt placement rates. In this nationwide database study, we aim to evaluate outcomes associated with different forms of temporary bedside cerebrospinal fluid (CSF) diversion in the aSAH patient cohort.
Inpatient admissions were queried from the National Inpatient Sample (NIS; 2016-2020). Inclusion criteria included adult patients presenting with non-traumatic SAH that underwent treatment with either non-elective clip ligation or coil embolization of their underlying aneurysms and received either an external ventricular drain (EVD), lumbar drain (LD), or both (EVD + LD) for temporary CSF diversion during that admission. Outcome variables evaluated included inpatient mortality, bacterial meningitis, length of stay, discharge disposition, and need for shunt placement.
A total of 5505 admissions met inclusion criteria, of which 18.42 % required permanent CSF diversion. The majority of patients received EVD alone (4842, 87.96 %). The remaining patients were split between LD alone (366, 6.65 %) or EVD + LD placement (297, 5.4 %). Patients receiving LD alone tended to be healthier, with lower rates of extreme APR-DRG subclass, Elixhauser Comorbidity Index (ECI), and NIS SAH Severity Score (NIS-SSS). Patients in the EVD + LD cohort had higher rates of shunt placement (OR 1.624, p = 0.0009) and higher rates of bacterial meningitis (OR 8.715, p < 0.0001), even when controlling for APR-DRG illness severity and ECI.
Our study found higher rates of permanent CSF diversion, longer lengths of stay, and higher rates of bacterial meningitis in patients receiving both EVD and LD placement. Due to limitations inherent to nationwide database studies, these results should be interpreted cautiously. Further studies are needed to clarify whether adjuvant temporary CSF diversion with LD placement in the aSAH cohort for intent of minimizing chronic shunt-dependence is efficacious.
在美国，动脉瘤性蛛网膜下腔出血（aSAH）带来了高昂的经济成本和临床发病率。除了延长住院时间和受伤后功能状态不佳外，许多aSAH患者还需承担慢性分流依赖型脑积水的额外费用。辅助性腰大池引流（LD）的放置被认为可促进蛛网膜下腔血液从脑池间隙清除，最终降低分流放置率。在这项全国性数据库研究中，我们旨在评估aSAH患者队列中不同形式的临时床边脑脊液（CSF）分流相关的结局。
从国家住院样本（NIS；2016 - 2020年）中查询住院患者记录。纳入标准包括成年非创伤性SAH患者，这些患者接受了非选择性动脉瘤夹闭或弹簧圈栓塞治疗，并在此次住院期间接受了外部脑室引流（EVD）、腰大池引流（LD）或两者联合（EVD + LD）进行临时CSF分流。评估的结局变量包括住院死亡率、细菌性脑膜炎、住院时间、出院处置以及分流放置需求。
共有5505例入院患者符合纳入标准，其中18.42%需要永久性CSF分流。大多数患者仅接受EVD（4842例，87.96%）。其余患者分为仅接受LD（366例，6.65%）或接受EVD + LD放置（297例，5.4%）。仅接受LD的患者往往健康状况更好，极端APR - DRG亚类、埃利克斯豪泽合并症指数（ECI）和NIS SAH严重程度评分（NIS - SSS）的发生率较低。即使在控制了APR - DRG疾病严重程度和ECI后，EVD + LD队列中的患者分流放置率（OR 1.624，p = 0.0009）和细菌性脑膜炎发生率（OR 8.715，p < 0.0001）更高。
我们的研究发现，接受EVD和LD放置的患者永久性CSF分流率更高、住院时间更长且细菌性脑膜炎发生率更高。由于全国性数据库研究存在固有局限性，这些结果应谨慎解读。需要进一步研究以阐明在aSAH队列中为尽量减少慢性分流依赖而进行辅助性临时CSF分流（通过放置LD）是否有效。
