Cisterno-Ventricular Lavage After Aneurysm Clipping for the Prevention of Delayed Infarction in Patients With Subarachnoid Hemorrhage.

Background and objectives: Cerebral infarction due to delayed cerebral ischemia (DCI) is an important source of morbidity after aneurysmal subarachnoid hemorrhage (aSAH). Breakdown products of cisternal and ventricular blood are putative triggers of cerebral vasospasm, which may progress to cerebral infarction. Therefore, intracranial blood clearance is a promising treatment approach. Surgical clipping of aneurysms of the anterior circulation grants access to the basal cisterns of the brain, allowing placement of cisterno-ventricular catheters (CVCs) for postoperative irrigation therapy. Here, we report on the implementation of this simple technique to enable clearance of subarachnoid and ventricular blood.

Methods: Twenty patients with aSAH were selected for intraoperative placement of a CVC through the fenestrated lamina terminalis after aneurysm clipping. Continuous irrigation was performed using the fibrinolytic urokinase and, on detection of vasospasm, nimodipine. All consecutive patients with aSAH with aneurysm clipping admitted between 2008 and 2015 served as controls. The primary end point was occurrence of cerebral infarction due to DCI.

Results: Placement of the CVC and application of lavage therapy were feasible and safe in all patients because no adverse events were observed. Cerebral infarction due to DCI occurred in 0/20 patients (0%) selected for lavage therapy vs 46/223 patients (20.6%) in the control cohort (P = .017). Shunt-dependent hydrocephalus occurred in 2/17 survivors (12%) from the CVC group vs 44/187 (23.5%) in the control group (P = .37).

Conclusion: Clipping of ruptured aneurysms of the anterior circulation allows placement of a CVC through the fenestrated lamina terminalis and postoperative lavage therapy. The risks of infarction due to DCI can be mitigated using this simple intraoperative approach.