Lumbar drainage and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review

Lumbar drainage for cerebrospinal fluid (CSF) diversion in aneurysmal subarachnoid hemorrhage (aSAH) has been reported to be beneficial in small series. There is no consensus regarding the optimal candidates for lumbar drainage, timing of drain placement, or amount and duration of CSF drainage.We performed a comprehensive review of the English literature reporting series of patients with aSAH undergoing CSF diversion with lumbar drains. Favorable clinical outcome was defined as modified Rankin Scale of 0-2 or Glasgow Outcome Scale as 4-5.A total of 8 studies reporting on 841 patients were included. Of these, 446 patients were treated with lumbar drains. Two studies were prospective and five studies had comparison groups. Most patients undergoing lumbar drainage were in good clinical grade on presentation (394/446, 88%) and the majority had substantial clot burden on head CT. Among the five studies with a comparison group, lumbar drainage was associated with lower rates of symptomatic vasospasm or delayed cerebral ischemia (20% vs. 45%, P<0.001) and higher rates of favorable outcome (79.4% vs. 60.4% P<0.001). The complication rate was 3.5%.Lumbar drainage in aSAH appears to be safe and associated with reduced rates of symptomatic vasospasm and improved clinical outcomes in patients in good clinical grade with thick clot burden, but the quality of most available studies is weak. The optimal duration and rate of CSF diversion remains uncertain.