Refractory intracranial pressure elevation (ICP) treatment in acute aneurysmal subarachnoid hemorrhage via the novel neurapharesis CSF management system
Marc Alain Babi1, Spiros Blackburn2, Andrew Grande3, Omar Choudri3, Erick Hauck4, Christopher Kellner5
1Neurosurgery, Cleveland Clinic Foundation (Florida Region), 2Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, 3Neurosurgery, University of Minnesota Medical School, 4Neurosurgery, Duke University Hospital, 5Mt Sinai Health System
Objective:
We present the novel use of the CSF Neurapheresis™ CSF Management System as a safe, controlled CSF diversion system to manage ICP elevation in acute aneurysmal subarachnoid hemorrhage.
Background:
Aneurysmal Subarachnoid Hemorrhage (aSAH) often presents with elevated intracranial pressure (ICP) and communicating hydrocephalus, resulting in increased morbidity/mortality. The PILLAR-XT clinical trial of the Neurapheresis™ CSF Management System (NP) (an automated lumbar drain with an option to divert blood/waste products and return filtered CSF) highlighted its ability to filter and reduce blood/contaminants in the CSF of aSAH patients. We present the novel use of NP as a safe, controlled CSF diversion system to manage ICP elevation in these patients.
Design/Methods:
After enrollment, NP was successfully placed in a 58-year-old female presenting with a high grade ruptured saccular aneurysm (PCoA, Hunt/Hess grade 4), which was coiled. Two days post-admission, the patient experienced refractory ICP elevation (>22mmHg) due to acute communicating hydrocephalus and aSAH. The neuro-intensivist adjusted CSF filtration and waste rates using the NP system to successfully treat ICP elevation. The patient was discharged home without complications and did not require a shunt.
Results:
This case illustrates the novel use of NP to control and manage ICP in acute aSAH while filtering blood/contaminants from the CSF.
Conclusions:
Patients with acute aSAH face high risk complications due to ICP-elevation, and directly related to rupture grade. Current standard of care offers tiers-based approach therapies for ICP management with the use of external ventricular devices (EVDs) for CSF diversion. EVDs are manual, non-specific, and prevent real-time ICP monitoring during CSF diversion, often resulting in incorrect drainage. PILLAR-XT highlighted the potential of NP as a tool for CSF diversion and filtration of RBCs/inflammatory-mediators that are instrumental in common secondary complications. This is the first case of utilizing NP device to divert and filter CSF and also concurrently treat ICP elevation.