Effectiveness of Cerebrospinal Fluid Drain Among Patients with Aneurysmal Subarachnoid Hemorrhage: A Bayesian Network Meta-analysis

Introduction: Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating neurological condition often complicated by hydrocephalus, leading to increased intracranial pressure (ICP). Cerebrospinal fluid (CSF) drainage is a common intervention to manage ICP, but its efficacy remains uncertain.

Methods: A Bayesian network meta-analysis (NMA) was performed according to PRISMA guidelines, using data from randomized controlled trials (RCTs) comparing CSF drainage methods. Treatment arms included early placement of an External Ventricular Drain (EVD) or lumbar drain (LD) during the same hospitalization, and a “no early drainage” group where drainage was delayed until after acute inpatient risks of rebleeding and vasospasm were managed. The outcomes analyzed included mortality, delayed cerebral ischemia (DCI), and future shunt need.

Results: The NMA included 23 RCTs with 4324 patients. No differences in bleeding risk were observed with EVD (OR 0.38, 95% CrI 0.01–4.04) or LD (OR 1.579, 95% CrI 0.26–11.65) compared to no drainage. LD was associated with a reduced likelihood of DCI versus no drainage (OR 0.468, 95% CrI 0.219–0.968), indicating a potential benefit. No significant differences in DCI were found between EVD and no drainage or between EVD and LD. Mortality rates were similar: no drainage vs. EVD (OR 1.23, 95% CrI 0.34–3.83) and no drainage vs. LD (OR 2.06, 95% CrI 0.87–6.44). Shunt rates showed no differences: no drainage vs. EVD (OR 0.86, 95% CrI 0.38–1.8) and no drainage vs. LD (OR 1.12, 95% CrI 0.66–1.86).

Conclusion : This Bayesian NMA suggests that lumbar drainage may reduce the likelihood of DCI in patients with aSAH. However, no significant differences were observed in mortality, shunt rates, or bleeding complications among the interventions. Lumbar drainage could offer a specific benefit in managing DCI, though its impact on other outcomes remains comparable to conservative approaches from the CSF diversion standpoint.