Discussion
pneumonia, fever, traumatic brain injury, brain edema, obstructive hydrocephalus, vasospasm, infarctions, Infarct, aneurysmal subarachnoid hemorrhage, Vasospasm
DELAYED CEREBRAL ISCHEMIA, PNEUMONIA, BRAIN EDEMA, OBSTRUCTIVE HYDROCEPHALUS, DEPOLARIZATION, CNS INFECTIONS, VASOSPASM, DISEASE, SECONDARY, INFARCT, VASOSPASM
In the EARLYDRAIN trial involving patients with aneurysmal subarachnoid hemorrhage of all grades, the use of a lumbar drain in addition to standard of care resulted in less infarctions at discharge and decreased the rate of unfavorable outcome at 6 months. The amount of cerebrospinal fluid drained in the first week was similar in the lumbar drain and standard of care groups. The color difference in fluid from a ventricular and a lumbar drain when both are used simultaneously is visually striking (eFigure 1 in Patients in the lumbar drain group were noted to have significantly lower ICP (eFigures 4 and 5 in Vasospasm, regardless of its definition, was associated with the development of secondary infarctions. The lumbar drain and standard of care groups differed in the rate of secondary infarctions but showed similar vasospasm frequency and severity. This suggests additional mechanisms being necessary for the development of secondary infarctions beyond vasospasm of the large brain supplying vessels. Microcirculation disturbances are a factor difficult to assess at bedside. Techniques like local brain tissue oxygenation monitoring, detection of cortical spreading depolarizations, or continuous surface electroencephalography recording may provide further insight but were too infrequently used in the EARLYDRAIN trial for a sophisticated explanation.Assumed contraindications to a lumbar drainage are obstructive hydrocephalus and compressed basal cisterns. However, both lack a definition commonly agreed on. Data from traumatic brain injury show that cautious lumbar drainage may be used for treatment of refractory ICP.The rate of infections in the EARLYDRAIN trail reflects a mixed-grade aneurysmal subarachnoid hemorrhage population. More than half of affected patients develop fever, and roughly 20% develop pneumonia.Infarct detection at discharge was mainly performed using CT. Magnetic resonance imaging is likely to be a more sensitive measure but was not routinely used in the EARLYDRAIN trial. We did not use the current composite definition for delayed cerebral ischemia,The EARLYDRAIN trial was a randomized trial planned to closely reflect clinical routine. At the trial planning stage, the investigators had no agreement which specific group of patients would benefit from lumbar drainage with negligible risks. While cautious centers proposed to include only patients with good grades for safety reasons, others considered a lumbar drain as mandatory to ease surgery, especially in patients with poor grades with brain edema. Consequently, disease severity varied between centers, and patient inclusions reflect clinical equipoise of the local investigators. Therefore, despite that more than half of the patients were recruited in 2 centers only, we think the results of the EARLYDRAIN trial are generalizable for treatment after aneurysmal subarachnoid hemorrhage.