From the Guidelines
Lumbar drains in subarachnoid hemorrhage (SAH) work by allowing expedited removal of blood products from the cerebrospinal fluid (CSF), which can help reduce the incidence of delayed cerebral ischemia (DCI) 1. The procedure involves inserting a small catheter into the lumbar subarachnoid space, typically between L3-L4 or L4-L5 vertebral interspaces, which is then connected to an external drainage system. Key benefits of lumbar drainage in SAH include:
- Reducing the amount of blood products in the CSF, which can help decrease the risk of DCI
- Potentially lowering intracranial pressure
- Clearing inflammatory mediators and spasmogens from the CSF According to the 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage, drainage through a lumbar drain has shown promise in reducing the incidence of DCI, despite trials being limited by population and center 1. Some important considerations for the use of lumbar drains in SAH include:
- The need for regular neurological assessments to monitor for potential complications
- Strict infection control measures to prevent meningitis and other infections
- Careful management of drainage rates to avoid overdrainage and intracranial hypotension
- Temporary clamping of the drain when mobilizing the patient to prevent excessive CSF drainage.
From the Research
Mechanism of Lumbar Drains in SAH
- Lumbar drains work by removing cerebrospinal fluid (CSF) from the lumbar cistern, which helps to reduce the amount of blood and spasmogens in the subarachnoid space 2, 3, 4, 5
- This reduction in blood and spasmogens can help to decrease the incidence of cerebral vasospasm, which is a major cause of morbidity and mortality in patients with subarachnoid hemorrhage (SAH) 2, 3, 4, 5
Benefits of Lumbar Drains in SAH
- Lumbar drains have been shown to reduce the incidence of symptomatic vasospasm, cerebral infarction, and subsequent endovascular treatment for vasospasm 2, 3, 4, 5
- They have also been shown to improve clinical outcomes, including reduced mortality and improved Glasgow Outcome Scale (GOS) scores 2, 3, 4, 5
- Lumbar drains may also shorten the duration of hospital stay and reduce the need for intensive care unit (ICU) admission 2, 3, 4, 5
Patient Selection and Timing of Lumbar Drain Placement
- The optimal candidates for lumbar drainage, timing of drain placement, and amount and duration of CSF drainage are not well established 5
- However, studies suggest that lumbar drainage may be beneficial in patients with good clinical grade on presentation and substantial clot burden on head CT 5
- Further studies are needed to determine the optimal patient selection and timing of lumbar drain placement 6, 5
Complications and Safety of Lumbar Drains
- The complication rate associated with lumbar drains is relatively low, ranging from 3.5% to 5% 2, 3, 4, 5
- Common complications include meningitis, CSF leakage, and spinal headache 2, 3, 4, 5
- However, the benefits of lumbar drainage in reducing cerebral vasospasm and improving clinical outcomes may outweigh the risks in selected patients 2, 3, 4, 5