Active Cerebrospinal Fluid Exchange Versus External Ventricular Drainage in IVH and SAH: A Meta-Analysis

Intraventricular hemorrhage and subarachnoid hemorrhage are associated with neuroinflammation and increased morbidity and mortality. Rapid clearance of blood from the cerebrospinal fluid space may mitigate neuroinflammatory cascades and improve clinical outcomes. This systematic review and meta-analysis aimed to compare the clinical effectiveness of active cerebrospinal fluid exchange, including neuroendoscopic lavage and IRRAflow systems, versus external ventricular drainage in patients with intraventricular hemorrhage or subarachnoid hemorrhage.

The study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and thoroughly assessed databases, including PubMed, Embase, Scopus, Cochrane, and Web of Science, up to September 18, 2025. Statistical analysis, both fixed-effect and random-effect model analyses, was performed by the Comprehensive Meta-Analysis software. In addition, the Cochran Q test was conducted to determine the statistical heterogeneity. In terms of low heterogeneity, the fixed-effect model is reported.

This review included 7 studies with a total sample size of 834. Our analysis showed that active cerebrospinal fluid exchange was associated with significantly higher hematoma clearance (odds ratio, 2.72 [95% CI, 1.22-6.08]; P=0.015), better functional outcomes (odds ratio, 1.66 [95% CI, 1.12-2.48]; P=0.012), lower shunt dependency (odds ratio, 0.22 [95% CI, 0.10-0.50]; P<0.001), and reduced infection rates (odds ratio, 0.22 [95% CI, 0.12-0.42]; P<0.001). Subgroup analysis showed that neuroendoscopic lavage was most effective for hematoma clearance, while IRRAflow reduced infection rates. Also, younger patients had better neurological recovery.

Active cerebrospinal fluid exchange techniques demonstrated superior outcomes over external ventricular drainage in managing intraventricular hemorrhage and subarachnoid hemorrhage, particularly in clot resolution and neurological recovery. Large-scale trials are warranted.