Acta Neurochir (Wien) (2005) 147: 1157–1162

DOI 10.1007/s00701-005-0584-5

Clinical Article
The risk of rebleeding after external lumbar drainage
in patients with untreated ruptured cerebral aneurysms

A. C. J. Ruijs1 , C. M. F. Dirven1 , A. Algra2 , I. Beijer2, W. P. Vandertop1 , and G. Rinkel2

1
Department of Neurosurgery, VU University Medical Center, Amsterdam, The Netherlands
2
Department of Neurology, University Medical Center Utrecht, Utrecht, The Netherlands

Received February 24, 2005; accepted June 1, 2005; published online July 25, 2005
# Springer-Verlag 2005

Summary
Background. Does continuous external lumbar CSF drainage before
aneurysm repair in patients with aneurysmal subarachnoid hemorrhage
increase the risk of rebleeding?
Method. The study population, consisting of 18 patients treated by
External Lumbar Drainage (ELD) after SAH before aneurysm repair,
was compared with an independent control group of 324 SAH patients
treated in another clinic. Control patients were selected for not being
treated for the ruptured aneurysm yet and not having undergone any
form of CSF drainage during the exposure time in the case patients. We
calculated hazard ratios with the Cox regression model, adjusted for
age, and clinical condition on admission and hydrocephalus.
Findings. The cox regression analysis shows a non-adjusted hazard ra-
tio of 2.1 (95% CI 0.8 to 5.3) in the model with 5 rebleedings in 18 patients.
Adjustment for age, clinical condition on admission and hydrocephalus
did not alter the hazard ratio estimate importantly in either analyses.
Conclusions. An increased risk of rebleeding by external lumbar
drainage in the acute phase after aneurysmal SAH could not be con-
firmed, but the data are too imprecise to rule out an increased risk. The
potential benefits of early drainage should be weighed against the risks if
the aneurysm is not occluded before or early after the start of drainage.
Keywords: Continuous CSF drainage; external lumbar drainage;
SAH; ruptured aneurysm; rebleeding.
Introduction
Delayed cerebral ischemia (DCI) and hydrocephalus
are among the most important factors that determine out-
come after aneurysmal subarachnoid hemorrhage (SAH).
Commonly used methods to treat hydrocephalus in the
acute phase of SAH are lumbar punctures and in case of
ventricular or parenchymal hemorrhage continuous drain-
age of CSF by a ventricular drain. Continuous drainage of
CSF and blood and its products from the arachnoid cis-
terns after SAH may decrease the risk of vasospasm-
related DCI [8, 10, 17, 25]. Ventricular drainage may
cause decrease of flow of fresh CSF through the basal
cisterns [12, 23]. Therefore, drainage of CSF via a lumbar
external catheter would be a more efficient way to ‘‘wash
out’’ the blood products from the cisterns than via a ven-
tricular catheter. To reach the maximal beneficial effect of
prevention of DCI, lumbar CSF drainage should start as
early as possible after SAH. However, drainage before
repair of the ruptured aneurysm may cause an increase
of transmural pressure over the aneurysm wall and there-
fore a higher risk of a rebleed [18]. In some studies an
increased rebleed risk after CSF drainage before aneur-
ysm repair has been reported [4, 11, 22] whereas others
demonstrated an equal frequency of rebleed in groups
with and without CSF drainage [14, 15, 20]. In none of
these studies was the comparison between groups with
and without CSF drainage controlled for factors that
determine the risk of rebleeding. Important factors that
determine the risk of rebleeding are duration of exposure
to CSF drainage, time lapse since onset of SAH and the
neurological status of the patient after initial hemorrhage,
reflected in the WFNS score [1, 3, 7, 21]. In this study we
compared the risk of rebleeding in patients with and with-
out external lumbar drainage while taking into account all
known risk factors for rebleeding.
Methods and materials
Study population
Between 1995 and 1997, 107 patients with aneurysmal SAH were
admitted to the VU University Medical Center, Amsterdam, The
1158 A. C. J. Ruijs et al.

Netherlands. The clinical diagnosis of SAH was confirmed by the pre-
sence of extravasated blood in the basal cisterns on a CT scan or, if the
CT was negative, on xanthochromia of cerebrospinal fluid. Conventional
angiography, CT- or MR angiography were performed to detect an
aneurysm. If angiography could not be performed, a patient was con-
sidered to have an aneurysmal SAH if the CT scan showed a typical
aneurysmal pattern of haemorrhage. To treat symptoms of increased
intracranial pressure, 18 patients received an external lumbar drain
(ELD) before surgical or endovascular aneurysm repair, in some cases
preceded or followed by external ventricular (EV) drainage. Nineteen
patients who received EV drainage only and 70 patients who did not
undergo CSF drainage before aneurysm repair, were excluded from this
study. The indication for ELD treatment in this cohort of patients was the
presence of severe headache or other symptoms of elevated intracranial
pressure, such as lowered consciousness, in combination with enlarged
ventricles on CT but without intraventricular extension of the haemor-
rhage. In cases of intraventricular extension of the haemorrhage an
external ventricular drain was inserted. Insertion of an external lumbar
drain was typically performed by an experienced neurosurgeon. Care was
taken to avoid outflow of large amounts of CSF by means of an initial
outflow level of 20 cm. above Monro, which would be lowered to 15 cm
after 24 hours and a draining volume of maximally 10 ml CSF=hour.
ventricular system measured on CT, moment and duration of ELD inser-
tion calculated from onset of SAH, occurrence of a rebleed, timing of
treatment of aneurysm, and death. Hydrocephalus was measured by means
of the relative bicaudate index [4]. We quantified the size of the frontal
horns of the lateral ventricles by means of the bicaudate index (BCI) on all
CT’s made within 72 hours after SAH. To calculate age-adjusted relative
sizes, the bicaudate indexes were divided by the corresponding upper limit
per age group (95th percentile for age). Hydrocephalus was defined as an
age-adjusted relative BCI above 1. Acute hydrocephalus was considered
to be present if any of the CT scans performed within the first 72 hours
after the hemorrhage met these criteria.
Evaluation of rebleeding
Rebleeding was defined as a sudden clinical deterioration with evi-
dence of new blood on a CT scan in comparison with a previous scan. To
assess the risk of rebleeding, the duration of ELD-drainage was re-
corded. The exposure time is the time period between insertion of the
ELD and the endpoint. The endpoint is defined as the moment when one
of the following events occurred: rebleeding, removal of ELD, insertion
of other CSF draining method (EVD, LP), repair of aneurysm (surgical
or endovascular) or death. Time is measured in 6 hour periods or
quarters of days, the day of SAH is defined as day 0 (Fig. 1).

Data collection
Characteristics and clinical data of the patients were collected, with
special attention to the time of initial SAH, clinical grade according to the
World Federation of Neurological Surgeons (WFNS) scale [2], size of
Control group
To acquire a control group, we used the database of a consecu-
tive series of 546 patients with aneurysmal SAH admitted from 1993

Fig. 1. Time lines of patients undergoing external lumbar drainage. This Fig. shows the data of the individual patients. Legend: # marks insertion of
the ELD. The time-period of lumbar drainage is measured until one of the following events occurred: " removal of the ELD,
Surgical or
endovascular definitive aneurysm treatment, r rebleeding from ruptured aneurysm or y Death.  Insertion and  removal of other CCSF drainage
method. The patients with a rebleed during lumbar drainage are marked with an  . @ Rebleed caused by unintended over drainage
Lumbar drainage after SAH and risk of rebleeding 1159

through 2000 within 72 hours after aneurysmal SAH to the Department Table 2. Characteristics of patients with rebleeding in ELD group
of Neurology of the University Medical Center Utrecht (UMCU). The
first criterion used to find controls in the UMCU database was the Number Age Gender Location WFNS Hypertension
moment and duration of exposure to CSF drainage, thus control patients
3 78 F A comm. 4 yes
who had not yet been treated for the ruptured aneurysm and had not
8@ 54 M A comm. 1 yes
undergone any form of CSF drainage (ventricular drainage, lumbar
10 51 F P comm. 4 no
puncture etc.) during the exposure time in the case patients. Secondly,
12 72 F P comm. 2 no
we selected those with a WFNS score as close as possible to the WFNS
13 76 F A comm. 4 no
score of the ELD patient.
This table shows the characteristics of the 5 patients in which rebleeding
occurred. Location describes the location of the ruptured aneurysm
Data analysis
(anterior communicating artery or posterior communicating artery).
To assess the relative risk of rebleeding in the patients treated with Patient number 3 and 8 had a medical history for hypertension. In
ELD as compared with the matched control group we first calculated the number 8 (@), a rebleed occurred after unintended drainage of a large
cumulative incidence ratio based on the tabular data. In order to account amount of CSF during induction of anesthesia for the clipping procedure.
for the time of follow-up for each patient, a hazard ratio was computed
with the Cox regression model. For that purpose exposure time was
taken as the time variable. Precision of the hazard ratio estimate was Table 3. Results of Cox regression analysis for risk of rebleeding (for 4
described with a 95% confidence interval, also derived from the Cox and 5 rebleeds respectively)
model. To address potential incomparability with regard to covariates
known to be related to the risk of rebleeding (age, clinical condition on Model 4 rebleeds 5 rebleeds
admission and hydrocephalus) between the ELD patients and their Exp (95% CI) Exp (95% CI)
matched controls adjusted hazard ratios were calculated. Non-adjusted 1.7 (0.6–4.7) 2.1 (0.8–5.3)
WFNS 1.5 (0.5–4.1) 1.9 (0.7–4.7)
Age 1.7 (0.6–4.9) 2.2 (0.9–5.5)
Results Hydrocephalus 1.7 (0.6–4.7) 2.1 (0.8–5.3)
WFNS þ Age þ HC 1.5 (0.5–4.4) 2.0 (0.8–5.0)
The characteristics of the patient group and the control WFNS þ Age 1.5 (0.5–4.4) 2.0 (0.8–5.0)
group are shown in Table 1. The study population consists
These are the results of the cox-regression analysis. The non-adjusted
of the 18 patients treated by external lumbar drainage. model has been adjusted for several variables: WFNS, age and the
There were 12 female (67%) and 6 (33%) male patients presence of hydrocephalus on the first CT-scan. The adjustments do
with an average age of 59 years (range 30–78). Six patients not have a strong influence on the significance of the results. Furthermore,
the first column shows the analysis with 4 rebleeds, assuming that one
were in poor neurological condition on arrival (WFNS
rebleeding could have been prevented using a strict protocol. In the second
grade IV and V). The time from aneurysmal bleeding un- column the results of the analysis are shown for all of the 5 rebleeds. The
til insertion of the ELD averaged 3.9 days (0.25–16 days). results do not differ significantly between these two groups.
The duration of lumbar drainage averaged 3.9 days (range
0.25–19 days). Four of 18 patients had a rebleed during the the basis of 5 patients with rebleeding in the ELD group,
period of external lumbar drainage (Table 2) and 44 of the which includes the patient with the adverse event, and a
324 control patients during the exposure time interval. A second on the basis of 4 patients with rebleeding in the
fifth patient had a rebleeding during induction of anesthe- ELD group. The Cox regression analysis shows a non-
sia for a clipping procedure, after unintended excessive adjusted hazard ratio of 2.1 (95% confidence interval
drainage of CSF due to an accidentally open drain with 0.8 to 5.3) in the first analysis (with 5 patients with ELD
the reservoir at a level of 60 cm below the head of the and rebleeding) and 1.7 (95% CI 0.6–4.7) in the sec-
patient. We performed two different analyses: a first on ond analysis (with 4 patients with ELD and rebleeding).
Adjustment for age, clinical condition on admission and
Table 1. Characteristics of the study population versus the control
hydrocephalus did not alter the hazard ratio estimate im-
group
portantly in either analyses (Table 3).
Variable ELD group Control group

Number 18 324
Mean age (SD) 59 (14.2) 56 (13.7)
Discussion
Male (percentage) 6 (33%) 98 (30%)
Drainage of CSF in the acute phase after SAH is a
Hydrocephalus present 9 (50%) 164 (51%)
on first CT-scan well-accepted treatment for acute hydrocephalus and
WFNS Grade I & II 8 (45%) 188 (58%) increased intracranial pressure. However, continuous
– Grade III 4 (22%) 32 (10%) drainage of CSF in the acute phase after SAH, before
– Grade IV & V 6 (33%) 104 (32%)
aneurysm repair, is generally thought to be associated
Rebleed (percentage) 4 or 5 (22% or 28%) 44 (14%)
with an increased risk of aneurysm rebleeding. In this
1160 A. C. J. Ruijs et al.

Table 4. Studies on CSF drainage before treatment of the ruptured aneurysm

Author Study design Drainage group Control group Results

N (rebleeding %) N (rebleeding %)

Van Gijn 1985 [4] pre-op VD, Acute HC, TA 9 (44%) 25 (8%) 5.5X
Hasan 1989 [6] pre-op VD 32 (43%) 441 (15–20%) 2–3X
Kawai 1997 [11] pre-op VD, grade V WFNS 28 (54%) 39 (21%) 2.5X
Kusske 1973 [14] pre-op VD 11 (0%) 9 (0%) matched ¼
McIver 2002 [15] pre-op VD >24 h before repair 45 (4.4%) 259 (5.4%) ¼
Milhorat 1987 [16] pre-op EVD 35 (0%) 165 (0%) ¼
Ochiai 2001 [20] pre-op LD (þ15 cm Monro) 33 (9%) 17 (12%) ¼
Pare 1992 [22] pre-op VD 20 (30%) 108 (8%) 2.5X#
Raimondi 1973 [23] pre-op shunting (VP=VJ) 21 (52%) – 
Rajshekar 1992 [24] pre-op VD, 9x in OR or after repair 52 (14%) – 

In study design the setup of the research is explained. For example the first study administered Ventricular Drainage in patients with acute
Hydrocephalus. Their patients were also included into a clinical study for the effects of tranexamic acid. Results show the multiplication factor of
rebleeding in the drainage group compared to the control group. Footnotes: There was no difference in rebleeding rate between the two groups; # the
association of ventricular drainage with rebleeding was limited to patients with severe hydrocephalus and  significant improvement of clinical status
after drainage. Legend. LD Lumbar Drainage, VD Ventricular Drainage, EVD External Ventricular Drainage, TA Tranexamic acid trial, VP
Ventriculoperitoneal, VJ Ventriculojugular.

study we could not confirm an increased risk of rebleed-
ing from continuous drainage by ELD in patients with
unrepaired aneurysms.
Several studies have addressed the effects of contin-
uous CSF drainage after SAH on the risk of rebleeding
(Table 4). Some studies claim a higher rate of rebleeding
after continuous ventricular or lumbar drainage [4, 6, 11,
22] whereas other studies provide no evidence of a
higher rebleeding risk [14–16, 20, 24]. Assessment of
the rebleeding risk in groups of patients with or without
drainage of CSF requires careful control for factors that
determine the rebleeding risk in both groups. Time lapse
since onset of the SAH is a very important factor in the
risk of rebleeding. The rebleeding rate is highest on the
day of the initial hemorrhage, then diminishes, and
increases slightly again during the second week [1].
Four studies found no increased risk of rebleeding from
continuous CSF drainage. In 2 of these studies aneur-
ysms were repaired acutely [14, 16], in a third the mean
time interval between ventriculostomy and repair of
aneurysm was 3.8 days [15]. In the fourth rebleeding
after lumbar drainage occurred in 3 of 33 patients, in 1
patient 7 hrs after drain insertion and in the other 2 after
4 and 5 days respectively [20]. Other factors that deter-
mine the rebleeding risk are clinical condition on admis-
sion, amount of extravasated blood, and hydrocephalus.
In one study the observation of increased rebleeding risk
in patients with ventricular drains was limited to patients
with severe hydrocephalus, defined by radiological cri-
teria with a cerebral-ventricular index greater than the
95th percentile [22].
The significance strength of our study is that it eval-
uates rebleeding risks after continuous drainage while
taking into account the timing since SAH and the dura-
tion of the drainage, and also the clinical condition on
admission, amount of extravasated blood, and ventricu-
lar size. Furthermore, in this study the case group and
control group are derived from two different treating
centers in which other treatment strategies for SAH
patients are similar. Although the numbers of patients
treated by continuous drainage before aneurysm occlu-
sion is relatively large, in an absolute sense the numbers
are too small to provide very precise estimates. Although
in this study an increased risk for rebleeding after con-
tinuous CSF drainage with ELD before aneurysm repair
could not be confirmed, an increased risk could not be
ruled out either.
Continuous CSF drainage after SAH has recently
gained new interest as a means of removal of cisternal
blood, thus decreasing the occurrence of DCI [12]. Also
the use of continuous cisternal drainage in the post-
operative period, often combined with fibrinolytic local
therapy has been reported to decrease the risk of DCI
[13]. Furthermore, it has been shown in animal models
that removal of blood clots from the basal cisterns in
order to reduce the risk of DCI needs to be performed at
a very early stage after SAH [5, 19]. These observations
support a possible role for early continuous CSF drain-
age by ELD before aneurysm repair. The results of our
study indicate that the potential benefits of early drain-
age should be weighed against the risks if the aneurysm
is not occluded before or early after the start of drainage.
Lumbar drainage after SAH and risk of rebleeding
In one patient a rebleed occurred under circumstances
of unintended over drainage. During induction of an-
esthesia the external drain reservoir was accidentally
lowered to a very low level below the patients head
and had drained a large amount of CSF within an hour
time. This serious adverse event shows the necessity of
caution in handling patients with an external CSF drain.
Extreme care must be taken to prohibit over drainage
and drainage of large amounts of CSF. Critical levels for
drainage level or amount of drained CSF have not been
established. One earlier study showed that drainage
above the level of 25 mm Mercury caused no increased
risk for aneurysm rupture [26].
In conclusion, an increased risk of rebleeding by
external lumbar drainage in the acute phase after aneur-
ysmal SAH could not be confirmed, but the data are too
imprecise to rule out an increased risk. The potential
benefits of early drainage should be weighed against
the risks if the aneurysm is not occluded before or
early after the start of drainage. Moreover if drainage
is used before the aneurysm is occluded it needs to
be performed according to a strict protocol in which
over drainage or drainage of large amounts of CSF is
prevented.
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Comments
This is a well written and interesting paper. The authors are correct
to emphasise that the results do not exclude the possibility of either
an increase or decrease in rebleeding with an external lumbar drain
before aneurysm repair. However, this is most probably due to the small
numbers.
Gillian Taylor
Edinburgh
This is a very interesting study that evaluated rebleeding risks after
continuous drainage while taking into account its timing since aneurysm
1162
rupture, the duration of the lumbar drainage, the clinical condition on
admission, the amount of extravasated blood, and the ventricular size. It
would also enforce the conclusion of the authors that the group having
undergone lumbar drainage and the control group were derived from two
different treating departments in which other treatment strategies for
SAH patients were similar.
Unfortunately, the number of patients treated with continuous drain-
age before aneurysm occlusion was relatively small to provide very
precise prognostic estimates. (Drainage was started in the acute stage
of SAH only in 10 out of 18; there were more severe patients in the
A. C. J. Ruijs et al.: Lumbar drainage after SAH and risk of rebleeding
‘‘drained’’ group =WFNS Grade III, IV, V= – rebleeding is common in
the acute stage, and in severe conditions!).
An increased risk of rebleeding due to insertion of lumbar drainage
before aneurysm closure could not be confirmed or excluded.
T. Doczi
Pecs
Correspondence: Clemens M. F. Dirven, VU University Medical
Center, Department of Neurosurgery, P.O. Box 7057, 1007 MB
Amsterdam, The Netherlands. e-mail: C.Dirven@vumc.nl