Simultaneous head rotation and lumboventricular lavage in patients after severe subarachnoid haemorrhage: an initial analysis of the influence on clot clearance rate and cerebral vasospasm

Background. Some recent publications from Japan suggested that head-shaking might attenuate cerebral vasospasm after subarachnoid haemorrhage (SAH) due to facilitated wash-out. It can also be assumed that the accepted beneficial effect of cisternal infusion of spasmolytics is partially related to the accompanying enhanced clearance of the clot. The Current clinical phase I study was initiated in order to investigate clot clearance rates and the development of cerebral vasospasm. Method. Ten patients with aneurysmal subarachnoid haemorrhage WFNS grades 2-5 (GCS 13-3) and Fisher grades 3 or 4 were included in this prospective phase I trial, which was approved by the local ethical committee, between May and October 2005. After ventriculostomy and early aneurysm elimination by microsurgery, 2 lumbar intrathecal catheters were inserted. Through one of the lumbar catheters, continuous lumboventricular irrigation with 500ml Ringer solution per day was instituted for five days. Intrathecal pressure was monitored by the second lumbar catheter. During the perfusion period, the patients were also treated in a rotational kinetic system (KCI (TM)). The patients were monitored by daily CT scans with determination of clot clearance rate. Vasospasm was identified by clinical evaluation, routine TCD, and DSA if indicated. The data were compared with a matched control group Of 10 patients and analyzed statistically. Findings. Lumboventricular lavage and the rotational kinetic system worked without any complications. The clot clearance rate was defined as the Course of haemorrhage volume in cm 3 as measured on CT scans from day I through days 5-8. Using the Wilcoxon rank sum test, the Study group had a significantly faster clot clearance (p = 0.033) than the control group. The pooled TCD monitoring data of anterior and middle cerebral and internal carotid artery over a period of 14 days showed lower mean flow velocities in the study group compared to the control group. The difference was statistically significant (p=0.011). Delayed ischaemic neurological deficits with evident vasospasm on angiogram and TCD occurred in one patient of the study group, as compared to two patients of the control group (n.s.). Conclusions. This first analysis of a treatment protocol combining moderate head rotation and lumboventricular lavage in patients after severe aneurysmal SAH supports the principal feasibility of the concept and suggests that clot clearance can be accelerated. A larger number of patients are necessary in order to define the beneficial effect with regard to vasospasm and long-term outcome.