Khawari, S., M. Kneizeh, M. E. Borady, L. Thorne, A. Toma, and L. Watkins, "The benefits of automated CSF drainage in normal pressure hydrocephalus.", Acta neurochirurgica, vol. 165, issue 6, pp. 1505-1509, 2023. Abstract

BACKGROUND: The commonly used cerebrospinal fluid (CSF) drainage system remains the manual drip-chamber drain. The LiquoGuard (Möller Medical GmbH, Germany) is an automated CSF management device with dual functionality, measuring intracranial pressure and automatic pressure- or volume-led CSF drainage. There is limited research for comparison of devices, particularly in the neurosurgical field, where it has potential to reshape care.

OBJECTIVE: This study aims to compare manual drip-chamber drain versus LiquoGuard system, by assessing accuracy of drainage, associated morbidity and impact on length of stay.

METHOD: Inclusion criteria consisted of suspected normal pressure hydrocephalus (NPH) patients undergoing extended lumbar drainage. Patients were divided into manual drain group versus automated group.

RESULTS: Data was analysed from 42 patients: 31 in the manual group versus 11 in the LiquoGuard group. Volumetric over-drainage was seen in 90.3% (n = 28) versus 0% (p < 0.05), and under-drainage in 38.7% (n = 12) versus 0% (p < 0.05), in the manual and automatic group, respectively. Symptoms of over-drainage were noted in 54.8% (n = 17) of the manual group, all of which had episodes of volumetric over-drainage, versus 18.2% (n = 2) in automated group, of which neither had actual over-drainage (p < 0.05). Higher over-drainage symptoms of manual drain is likely due to increased fluctuation of CSF drainage, instead of smooth CSF drainage seen with LiquoGuard system. An increased length of stay was seen in 38.7% (n = 12) versus 9% (n = 1) (p < 0.05) in the manual and LiquoGuard group, respectively.

CONCLUSION: The LiquoGuard device is a more superior way of CSF drainage in suspected NPH patients, with reduced morbidity and length of stay.

Tariq, K., A. Toma, S. Khawari, M. Amarouche, M. A. Elborady, L. Thorne, and L. Watkins, "Cerebrospinal fluid production rate in various pathological conditions: a preliminary study.", Acta neurochirurgica, 2023. Abstract

INTRODUCTION: The cerebrospinal fluid (CSF) production rate in humans is not clearly defined but is estimated to be 18-24 ml/h (Trevisi et al Croat Med J 55(4):377-387 (24); Casey and Vries Childs Nerv Syst 5(5):332-334 (8)). A frequent clinical observation is that patients often drain higher volumes of CSF than can be explained by the assumed 'normal' CSF production rate (PRcsf). In the National Hospital for Neurology and Neurosurgery PRcsf was recorded in a variety of common neurosurgical pathologies using LiquoGuard7, an automated peristaltic pump that accurately controls CSF drainage and maintains a pre-set CSF pressure.

METHODS: A prospective observational study was performed from September 2021 onwards, on all patients in the National Hospital for Neurology and Neurosurgery who required CSF drainage as part of their ongoing treatment. The external drain was connected to a LiquoGuard7 pump (Möller Medical GmbH, Fulda, Germany), and the internal software of LiquoGuard7 was used to measure PRcsf. Statistical analysis used SPSS (version 25.0, IBM) by paired t test, comparing measured rates to hypothetical 'normal' CSF production rates calculated and published by Ekstedt (16-34ml/h) (Ekstedt J Neurol Neurosurg Psychiatry 41(4):345-353 (14)), assuming a similar distribution.

RESULTS: PRcsf was calculated in 164 patients. Suspected normal pressure hydrocephalus (n=41): PRcsf of 79ml/h±20SD (p<0.0001). Post-surgical CSF leak (n=26): PRcsf of 90ml/h±20SD (p<0.0001). Subarachnoid haemorrhage (n=34): PRcsf of 143ml/h±9SD (p<0.0001). Intracerebral haemorrhage (n=22): PRcsf of 137ml/h±20SD (p<0.0001). Spinal lesions (n=7): PRcsf of 130ml/h±20SD (p<0.0032). Pituitary adenomas (n=10): PRcsf of 29 ml/h±9SD (p<0.049). Idiopathic intracranial hypertension (n=15): PRcsf of 86ml/h±10SD (p<0.0001). Decompensated long-standing overt ventriculomegaly (n=4): PRcsf of 65ml/h±10SD (p<0.0001). Cerebral infection (n=5): PRcsf of 90ml/h±20SD (p<0.0001).

CONCLUSION: Net CSF production rate may be higher than expected in many conditions, as measured with new device LiquoGuard7 through the study of net flow rate, which may have implications for clinical decisions on CSF diversion. The conventional understanding of CSF production and circulation does not explain the findings of this study. More extensive studies are needed to validate this technique.

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