Ventriculolumbar Irrigation Effects on Delayed Cerebral Infarction and Outcome After Aneurysmal Subarachnoid Hemorrhage: A Prospective Registry Study.

Abstract

Background and objectives: Aneurysmal subarachnoid hemorrhage (aSAH) remains associated with high morbidity and mortality, largely determined by delayed cerebral ischemia (DCI). Active blood clearance and vasodilation (ABCD) therapy targets key pathophysiological mechanisms of DCI by enhancing the clearance of blood from cerebrospinal fluid and counteracts vasospasm through continuous intrathecal fibrinolytic and spasmolytic irrigation. Although ABCD therapy has previously been implemented using technically demanding treatment approaches, this study introduces ventriculolumbar irrigation (VLI) as a simplified, bedside-applicable method. This study evaluates whether VLI-based ABCD therapy is associated with an improvement in DCI and morbidity.

Methods: In this prospective registry study, consecutive aSAH patients treated with the novel VLI-based ABCD therapy (pressure-controlled VLI with urokinase and on-demand nimodipine) between 2019 and 2025 were compared with matched controls receiving standard care. The primary outcome was the incidence of DCI and the secondary outcome was modified Rankin Scale (mRS) at 180 days.

Results: Seventy-two patients treated with VLI-based ABCD therapy were compared with 144 matched controls. VLI treatment was associated with significantly lower rates of DCI (9.7% vs 29.9%, P < .001), morbidity (mean mRS 2.33 vs 3.37, P < .001), and shunt-dependent hydrocephalus (9.7% vs 31.9%, P < .001). Compared with isolated, passive cerebrospinal fluid drainage, VLI was associated with lower DCI rates (9.7% vs 30.7%, P < .001) and reduced morbidity (mean mRS 2.33 vs 3.39, P < .001).

Conclusion: The novel and simplified VLI therapy was associated with considerably improved outcomes: lower DCI rates and shunt-dependent hydrocephalus. VLI offers a bedside technique to actively remove intrathecal blood and deliver intrathecal spasmolysis for the prevention of DCI. Randomized trials are needed to confirm these findings.