Lumbalpunktion oder externe Ventrikeldrainage als initiale Behandlung des akuten Hydrozephalus bei aneurysmatischer Subarachnoidalblutung - Eine bizentrische Kohortenstudie

Acute hydrocephalus after aneurysmal subarachnoid haemorrhage (SAH) is typically treated by external ventricular drainage (EVD), which carries a risk for complications, including long-term shunt dependency. Lumbar puncture (LP) may be an effective and less invasive alternative. We compared efficacy and safety of LP versus EVD as initial treatment.

We performed a two-centre cohort study comparing two different institutional approaches, with either LP or EVD as initial treatment. SAH patients treated within 72 hours after ictus for acute hydrocephalus, with Glasgow Coma Scale ≥7 and no contraindications for LP were included. We determined the proportion of patients in the LP cohort in which EVD could be avoided and calculated odds ratios (OR) with adjustment for baseline predictors to compare the rates of permanent ventriculoperitoneal shunts, clinical and radiological complications, and poor functional outcome (Glasgow Outcome Scale of 1-3 at 3 months) between the two strategies.

In one institution, from 2013 admitted SAH patients between 2007 and 2021, 84 with acute hydrocephalus were initially treated with LP, whereas at the other institution, from 367 admitted SAH patients between 2015 and 2021, 77 similar patients were initially treated with EVD. Both groups were well comparable in terms of initial clinical condition and extent of hydrocephalus. In the LP group, 69 patients (82%) showed clinical improvement, and in 65 patients (77%) EVD could be avoided. A permanent ventriculoperitoneal shunt was placed in 8 patients (10%) of the LP group and 52 patients (68%) of the EVD group. Complications occurred less often in the LP-group and there was no significant difference in clinical outcome (detailed results in Table 1).

LP is associated with a reduced proportion of patients with chronic hydrocephalus and need for ventriculoperitoneal shunt, a smaller proportion of complications and comparable clinical outcomes as EVD and should therefore be considered as initial treatment for acute hydrocephalus after SAH. Further research should elucidate the effects of both treatments on cognitive functioning.

Table 1: Outcome measurements of patients with lumbar puncture (LP) and with external ventricular drain (EVD); VP = ventriculoperitoneal; OR = odds ratio; CI = confidence interval; Adjustment was made for age, GCS, rBCI, Hijdra score and modality of aneurysm occlusion.