External Cerebrospinal Fluid Drainage in the Management of Nonaneurysmal Subarachnoid Hemorrhage

Abstract

Distinguishing the aneurysmal from nonaneurysmal subarachnoid hemorrhage (SAH) may be difficult as acute bleeding in the subarachnoid space is a common denominator. It is believed that toxic effects of breakdown products of acute bleed, including hemoglobin, contribute to the morbidity and mortality of this condition; and that early drainage will potentially reduce them. This series focuses on our local experience with the application of external cerebrospinal fluid (CSF) drainage in the management of a series of cases confirmed to be nonaneurysmal SAH and its effects on the outcome. The objective of this report is to observe the usefulness of external CSF drainage in the management of nonaneurysmal SAH. Five consecutive cases over four years were reviewed and reported as a case series. The main points we focused on were presentation, diagnostic findings on imaging, CSF drainage, and outcome up to six months. All the patients presented with headaches described as sudden, and only one had significant impairment of consciousness Glasgow Coma Scale (GCS) 10/15. Three out of the five patients had a premorbid hypertensive condition of unclear control status. We also observed that three out of the five had a low-pressure pretruncal/perimesencephalic pattern of bleed, whereas two had the typical high-pressure SAH pattern. CT angiography (CTA) was negative in all. Four had lumbar drainage, while one had external ventricular drainage. All were discharged within three weeks and functioned optimally at six months. CSF drainage in managing nonaneurysmal SAH is achievable with minimal access procedures, including lumbar drain (LD) and external ventricular drainage (EVD), which may have further reduced the low morbidity normally associated with this condition.

Keywords: cerebrospinal fluid; external ventricular drainage; hydrocephalus; lumbar drainage; non-aneurysmal sah.

Figure 1. Axial slides of plain CT brain showing nonaneurysmal SAH into the prepontine, perimesencephalic, and interpeduncular cisterns.

Figure 2. CT angiography showing no vascular abnormality in the posterior circulation.

Figure 3. (A) Axial slide of plain CT brain showing nonaneurysmal SAH into the anterior interhemispheric fissure and dilated both temporal horns of lateral ventricles. (B) CT angiography showing no vascular abnormality in the anterior circulation.

Figure 4. (A) Axial slide showing subarachnoid bleed with intra-ventricular extension and acute obstructive hydrocephalus. (B) CT angiography showing no vascular abnormality in the posterior circulation.