Lumbar drainage for communicating hydrocephalus after ICH with ventricular hemorrhage

Our objective was to investigate the feasibility of lumbar drainage (LD) as a new therapeutic approach for the treatment of communicating hydrocephalus in patients with supratentorial intracerebral hemorrhage (ICH) and ventricular extension (IVH) who initially required an external ventricular drain (EVD).

Three consecutive patients with ICH and severe IVH were treated with EVD immediately after admission due to acute obstructive hydrocephalus. Each patient received intraventricular fibrinolysis (IVF) starting 12 hours after admission (4 mg rtPA every 12 hours up to a maximum cumulative dose of 20 mg). Although complete clearing from blood of the third and fourth ventricles was achieved in all patients after IVF, branching off the EVD failed because of increasing intracranial pressure (ICP). Assuming a communicating, malresorptive hydrocephalus was present, a lumbar drain was placed (to allow extracorporal CSF drainage through outer CSF space).

In all patients, the EVD could be branched off without raising ICP (while the LD remained open), resulting in the opportunity to remove the EVD in all patients after another 24 hours (mean duration of EVD was 115 +/- 4 hours). Clamping the LD was performed every second day and development of hydrocephalus was monitored by CT. After a mean duration of 6 (5-7) days after placement, the LD could be removed. None of the patients required a VP-Shunt.

Our preliminary data suggest that LD is a simple and reasonable alternative for treating communicating hydrocephalus after ICH and IVH. The combination of IVF to enhance clot resolution and to clear the third and fourth ventricle followed by LD may represent a new and promising approach in the therapy of hydrocephalus following severe ventricular hemorrhage.