Active Cerebrospinal Fluid Exchange vs External Ventricular Drainage in the Neurocritical Care Unit: An International, Retrospective Cohort Study

BACKGROUND AND OBJECTIVES: Active cerebrospinal fluid exchange (ACE) through the dual-lumen IRRA flow catheter is a technique that has been used in the treatment of intraventricular hemorrhage and subarachnoid hemorrhage, ventriculitis, and others. Previous reports have consisted of small numbers of patients and focused on particular conditions. Our objective was to complete a multi-institutional retrospective cohort study to evaluate the safety and clinical outcomes of ACE therapy through the IRRA flow catheter. METHODS: Multiple academic neurocritical care units from the United States and Europe contributed patients treated with either ACE or external ventricular drainage to a retrospective database. Complications including failure to drain, inadvertent removal, infection, cerebrospinal fluid leak, insertional hemorrhage, and early replacement were compared. Shunt dependence and modified Rankin score were also compared. RESULTS: A total of 401 treated with external ventricular drainage and 118 treated with ACE were included. Diagnoses included were subarachnoid hemorrhage, intraventricular hemorrhage, and ventriculitis. ACE therapy showed fewer overall complications (odds ratio [OR] = 0.29, P < .0001), failures to drain (OR = 0.21, P = .0004), infections (OR = 0.2, P < .0001), cerebrospinal fluid leak (OR = 0.26, P = .017), and early replacements (OR = 0.4, P = .036). There was no difference in insertional hemorrhage or inadvertent removal. ACE therapy was associated with a lower rate of shunt dependence (OR = 0.28, P < .0001) and higher likelihood of discharge with an modified Rankin score of 0 to 2 (OR = 2.47, P = .001). CONCLUSION: ACE therapy with the IRRA flow catheter is associated with fewer complications and improvement in some clinical outcomes. These results need to be confirmed with prospective and randomized trials.