Duration Of External Ventricular Drainage Research Articles

Modified ventriculoperitoneal shunt applied to temporary external ventricular drainage

External ventricular drainage (EVD) is a common procedure in neurosurgical practice. Presently, the three methods used most often include direct EVD (dEVD), long-tunneled external ventricular drains (LTEVDs), and EVD via the Ommaya reservoir (EVDvOR). But they possess drawbacks such as limited duration of retention, vulnerability to iatrogenic secondary infections, and challenges in regulating drainage flow. This study aimed to explore the use of a modified ventriculoperitoneal shunt (mVPS)—the abdominal end of the VPS device was placed externally—as a means of temporary EVD to address the aforementioned limitations. This retrospective cohort study, included 120 cases requiring EVD. dEVD was performed for 31 cases, EVDvOR for 54 cases (including 8 cases with previously performed dEVD), and mVPS for 35 cases (including 6 cases with previously performed EVDvOR). The one-time success rate (no need for further other EVD intervention) for dEVD, EVDvOR, and mVPS were 70.97%, 88.89%, and 91.42%, dEVD vs EVDvOR (P < 0.05), dEVD vs mVPS (P < 0.05), EVDvOR vs mVPS (P > 0.05). Puncture needle displacement or detachment was observed in nearly all cases of EVDvOR, while no such complications have been observed with mVPS. Apart from this complication, the incidence of postoperative complications was 35.48%, 14.81%, and 8.5%, dEVD vs EVDvOR (P < 0.05), dEVD vs mVPS (P < 0.05), EVDvOR vs mVPS (P > 0.05). Mean postoperative retention for EVD was 14.68 ± 9.50 days, 25.96 ± 15.14 days, and 82.43 ± 64.45 days, respectively (P < 0.001). In conclusion, mVPS significantly extends the duration of EVD, which is particularly beneficial for patients requiring long-term EVD.

Tunneled antibiotic-impregnated vs. bolt-connected, non-coated external ventricular drainage: a comparison of complications.

External ventricular drainage (EVD) is a common emergency neurosurgical procedure, but it is not free of adverse events. The aim of this study is to compare the complication rate of two frequently used EVD types, namely, tunneled antibiotic-impregnated catheters (Bactiseal©) and bolt-connected non-coated devices (Camino©). All EVDs placed between 1 March 2015 and 31 December 2017 were registered. Procedures performed with any catheter different from Bactiseal© or Camino© EVD with incomplete follow-up and those EVDs placed due to infectious disease were excluded. Demographic and clinical variables, as well as the overall complication rate (infection, hemorrhage, obstruction, malposition of the catheter, and involuntary pull-out of the device) and the need for replacement of the EVD, were collected. A total of 77 EVDs were finally considered for analysis (40 Bactiseal® and 37 Camino®). There was a statistically significant difference in diagnosis and also in the location of the procedure, as more bolt-connected EVD was placed outside the operating room (97.3 vs. 23.5%, p < 0.001) due to emergent pathologies such as vascular diseases and spontaneous hemorrhages. In the univariate analysis, a statistically significantly higher rate of catheter involuntary pull-out (29.7 vs. 7.5%, p = 0.012) and the need for EVD replacement (32.4 vs. 12.5%, p = 0.035) was found in the Camino cohort. However, those differences could not be confirmed with multivariable analysis, which showed no association between the type of catheter and any of the studied complications. Ventriculostomy duration was identified as a risk factor for infection (OR 1.09, 95% CI 1.02-1.18). No significant differences were observed regarding infection, hemorrhage, obstruction, malposition, involuntary catheter pull-out, and the need for EVD replacement when comparing non-impregnated bolt-connected EVDs (Camino®) with tunneled antibiotic-impregnated catheters (Bactiseal®). The duration of EVD was associated with an increased risk of infection.

Effect of cerebrospinal fluid drainage on clinical outcomes following aneurysmal subarachnoid hemorrhage

ObjectivesWe study the relationship between external ventricular drainage (EVD) of cerebrospinal fluid output and functional outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). MethodsA retrospective chart review of patients presenting to a single center with aSAH was performed. The primary outcome was good functional outcomes assessed by a composite of the modified Rankin scale (mRS 0–2) at last follow-up. Secondary outcomes were clinical and radiographic vasospasm. For data analysis, multivariable generalized estimating equations adjusting for potential confounders were used. ResultsA total of 119 patients were included; 91 (75.6%) presented with a modified Fisher grade 4 and 76 (63.9%) had hydrocephalus. The median EVD duration was 13 days. On average, most EVDs were set at 15 cmH2O (50, 42%). Follow-up was available in 109 patients; median time was 10.7 months; 69 (63.3%) had good outcomes. Multivariable analysis showed that EVDs set at 10 cmH2O had increased odds of good outcomes for every ml increase in the EVD output (OR = 1.02; 95% CI 1.01–1.03; p = 0.001). Post estimation analyses show that EVDs at 10 cmH2O with output close to 200 ml predicted a 50% probability of good outcomes. ConclusionsIncreased EVD outputs were associated with favorable outcomes at the last follow-up.

Predictors of Ventriculostomy-Associated Infections: A Retrospective Study of 243 Patients

Risk factors of ventriculostomy-associated infection (VAI) reported in the literature are variable owing to heterogeneity of external ventricular drainage (EVD) procedures and management. This study aimed to assess the rate of VAI and its risk factors. The medical records of patients >18 years old who received EVD catheterizations between January 2015 and December 2020 were retrospectively reviewed. Among 243 patients with 355 catheters, 23 VAIs were identified, yielding VIA rates of 9.5% per patient and 6.5% per catheter. VAI was associated with a longer total EVD duration (29.2 days vs. 15.8 days, P < 0.001), a longer procedural time (72 minutes vs. 41 minutes, P < 0.001), intraoperative ventriculostomy (39.1% vs. 9.1%, P < 0.001), craniotomy (87.0% vs. 60.9%, P=0.014), and other systemic infections (30.4% vs. 8.2%, P= 0.004). On multivariate analysis, a longer total EVD duration (odds ratio 1.086, P < 0.001), intraoperative ventriculostomy (odds ratio 6.119, P= 0.001), and other systemic infections (odds ratio 4.620, P= 0.015) were associated with VAI. There was no statistical difference between the VAI rates of patients with and without prophylactic EVD exchanges at a mean 12.6 days (7.1% vs. 2.2%, P= 0.401). Intraoperative ventriculostomy was independently associated with VAI. Prophylactic EVD exchange at 12.6 days did not lower VAI rate.

Early permanent cerebrospinal fluid diversion in aneurysmal subarachnoid hemorrhage: does a lower rate of nosocomial meningitis outweigh the risk of delayed cerebral vasospasm related morbidity?

ABSTRACT Objective: Early permanent cerebrospinal fluid (CSF) diversion for hydrocephalus during the first 2 weeks after aneurysmal subarachnoid hemorrhage (aSAH) shortens the duration of external ventricular drainage (EVD) and reduces EVD-associated infections (EVDAI). The objective of this study was to detect any association with symptomatic delayed cerebral vasospasm (DCVS), or delayed cerebral ischemia (DCI) by the time of hospital discharge. Methods: We used a single-center dataset of aSAH patients who had received a permanent CSF diversion. We compared an ‘early group’ in which the procedure was performed up to 14 days after the ictus, to a ‘late group’ in which it was performed from the 15th day onward. Results: Among 274 consecutive aSAH patients, 39 (14%) had a permanent CSF diversion procedure with a silver-coated EVD. While the blood clot burden was similarly distributed, patients with early permanent CSF diversion (20 out of 39; 51%) had higher levels of consciousness on admission. Early permanent CSF diversion was associated with less colonized catheter, a shorter duration of extracorporeal CSF diversion (OR 0.73, 95%CI 0.58–0.92 per EVD day), and a lower rate of EVDAI (OR 0.08, 95%CI 0.01–0.80). The occurrence of CSF diversion device obstruction, the rate of symptomatic DCVS or detected DCI on computed tomography and the likelihood of a poor outcome at discharge did not differ between the two groups. Discussion: Early permanent CSF diversion lowers the occurrence of catheter colonization and infectious complication without affecting DCVS-related morbidity in good-grade aSAH patients. These findings need confirmation in larger prospective multicenter cohorts. Abbreviations: aSAH: aneurysmal subarachnoid hemorrhage; BNI: Barrow Neurological Institute Scale; CSF: Cerebrospinal fluid; DCVS: Delayed Cerebral Vasospasm; DCI: Delayed Cortical Ischemia; EKNZ: Ethik-Kommission Nordwest Schweiz; EVD: External ventricular drain; EVDAI: External ventricular drain-associated infections; GCS: Glasgow Coma Scale; IRB: Institutional Review Board; IVH: Inraventricular hemorrhage; mRS: Modified Rankin Scale; SOS: Swiss Study of Subarachnoid Hemorrhage Registry; WFNS: World Federation Neurological-Surgeon Scale

Older patients with Intraventricular Hemorrhage are Prone to Infection after External Ventricular Drainage

External ventricular drainage (EVD) is a life-saving and emergent procedure in neurosurgery. However, infection is the main problem in patients with EVD. The present study aims to analyze the infection rate of patients with EVD and to investigate the factors that contribute to infection and mortality rates. The data of patients who underwent emergent EVD procedure between 2018 and 2019 were retrospectively analyzed in this study. The demographic features of the patients were recorded. The correlation between age, gender, indication and duration of EVD, and the infection and mortality rate were investigated. In this study, 47 patients underwent emergent EVD in two years. Thirty (63.83%) patients were male, and 17 were female with a mean age of 28.02 years. The mean duration of drainage was 6.2 days. Fifty-eight cerebrospinal fluid (CSF) samples were analyzed during the drainage period and CSF culture was positive in 14 (24.14%) samples. The most common microorganism was Staphylococcus epidermidis. The infection rate was high in older and male patients with duration longer than six days. Nine (19.15%) patients died during the treatment period and six of them had IVH. The duration of EVD should be shorter in patients older than 65 years with the diagnosis of intraventricular hemorrhage, which is mostly related to dea.

Risk Factors of External Ventricular Drainage-Related Infections: A Retrospective Study of 147 Pediatric Post-tumor Resection Patients in a Single Center.

Background: External ventricular drainage (EVD) is common after brain surgery. However, the incidence of EVD-related infection (ERI) is still relatively high and can increase morbidity and mortality.Objective: The objective of this study was to analyze ERI factors in pediatric population post-brain tumor surgery.Methods: From January 2016 to December 2017, 147 patients <18 years old underwent tumor removal at Beijing Tiantan Hospital and had postoperative EVD. We recorded basic demographic data as well as several risk factors. We then analyzed whether these factors were related to ERI.Results: Patients with a preoperative ventriculo-peritoneal (V-P) shunt, those with longer operation time, those who received blood transfusion, those with more frequent cerebrospinal fluid (CSF) sampling, and those with longer indwelling time of EVD had higher risks of infection (p < 0.05). Logistic regression analysis confirmed that a preoperative V-P shunt, operative duration, intraoperative blood transfusion, frequency of CSF sampling, and EVD duration were correlated with postoperative ERI (p < 0.05).Conclusion: EVD should be removed as soon as possible and any unnecessary procedures should be avoided to reduce the infection rate. However, prophylactic treatment should be given in case patients do not meet the indication for EVD removal.

External ventricular drainage for intraventricular hemorrhage

Abstract Background: Intervention to reduce intracranial pressure using External Ventricular Drain (EVD) is a common life saving measure in a neurosurgery intensive care unit(ICU). Objective: The present study was undertaken to assess the outcome of patients who underwent external ventricular drainage for intraventricular hemorrhage(IVH). Methods: The available data of the patients who underwent placement of external ventricular drain from February 2012 to May 2016 for intraventricular hemorrhage (IVH) at Narayana Medical College and Hospital, Nellore, was retrieved from the hospital case records and analyzed. Results: Total of 69 patients were included in this study. Mean age was 53.7 ±11.6 years. Clinical presentation included altered sensorium in 66 patients (96%), hemiparesis in 62 patients (90%) , vomiting in 40 patients (58%) and seizures in 9 patients (13%). Fifty two patients (75%) were known hypertensives and 10 patients (15%) were diabetic. Past history of smoking was recorded in 16(23%) patients and alcohol intake in 17 patients (25%). GCS at the time of admission was 3-8 (low) in 39 patients (57%), 9-12 in 23 patients(33%) and 13-15 in 7 patients (10%). At the time of admission, 60 patients ( 87%) had diastolic blood pressure more than 90 mmHg, 63 patients (91%) had systolic blood pressure more than 140 mmHg. Major site of hemorrhage was basal ganglia in 24 (35%), thalamus in 13 (19%), cerebellum in 5 (7%), brain stem in 3, frontal/temporal in 2 patients. SAH with IVH was noted in 12 patients (17%) and only IVH was noted in 10 patients (14%). Mean duration of external ventricular drainage was 4.6+1.7 days (Range 1-9 days). Mean hospital stay was 11.3±7.5 days and mean ICU stay was 8+5.4 days. Thirty eight patients (55%) died during hospital stay. At the time of discharge, poor out come (Glagow out come score 1-3) was noted in 52 patients (75%) and good out come (Glagow out come score-4,5) was noted in 17 patients. Among various parameters analyzed , poor GCS (3-8) at admission, history of smoking and alcohol intake were found to correlate significantly with poor outcome. None of the other factors like old age, site of bleed, pupillary asymmetry at admission, high blood pressure at admission, past history of hypertension and diabetes were found to correlate with poor outcome. Conclusions: Majority of the patients with intracranial hematomas with intraventricular extension presented in poor neurological condition (GCS= 3-8). Poor neurological condition at the time of admission, past history of smoking and alcohol intake were associated with poor outcome.

Strategies to reduce external ventricular drain-related infections: a multicenter retrospective study.

Various strategies have been proposed to reduce the incidence of external ventricular drain (EVD)-related infections. The authors retrospectively studied the impact of EVD care management on EVD-related infections at 3 French university hospital intensive care units. Between 2010 and 2014, 462 consecutive adult patients with no evidence of a preexisting CSF infection received EVDs as part of their care at one of the following sites: Grenoble (221 patients), Saint-Etienne (130 patients), and Marseille (111 patients). Written protocols describing the EVD placement procedure, management, and removal were implemented at the 3 sites. Daily CSF sampling and intraventricular administration of antibiotics prior to EVD removal were performed at the Grenoble site only. EVD-related infection was considered for any confirmed ventriculostomy-related infection (VRI) and ventriculitis. VRI was defined as one or more positive CSF cultures or Gram stain with CSF pleocytosis and biochemical abnormalities. Ventriculitis was defined as CSF pleocytosis and biochemical abnormalities with degradation of neurological status and fever. A total of 6945 EVD days were observed in the entire population. In the Grenoble cohort, the mean cumulative incidence of EVD-related infections was significantly lower than that in the 2 other cohorts: 1.4% (95% CI 0.0%-2.9%) versus 9.2% (95% CI 4.2%-14.2%) and 7.2% (95% CI 2.4%-12.0%) at Saint-Etienne and Marseille, respectively (p < 0.01). Accounting for the duration of external ventricular drainage at each site, the risk for EVD-related CSF infections was significantly higher at Saint-Etienne and Marseille than at Grenoble, with ORs of 15.9 (95% CI 3.6-71.4, p < 0.001) and 10.0 (95% CI 2.2-45.5, p = 0.003), respectively. These findings indicate that it is possible to attain a low incidence of EVD-related infections, provided that an EVD care bundle, which can include routine daily CSF sampling, is implemented and strongly adhered to.

Analysis on risk factors of catheter-related infections of external ventricular drainage

Objective To explore the risk factors of catheter-related infections of external ventricular drainage (EVD) , so as to provide evidence for effective prevention and control measures. Methods A total of 428 patients′ clinical data were collected by retrospective case analysis in cluster sampling, who underwent external ventricular drainage in Neurosurgery Department of a class Ⅲ grade A hospital in Shanghai from January 2014 to October 2016. The incidence of EVD infection was analyzed. At the same time, univariate analysis and multivariate Logistic regression analysis were adopted for risk factors of EVD related infection. Results The catheter-related ventricular infections occurred in 36 of 428 cases of patients, with the incidence rate 8.41%. The detection rate of pathogens in cerebrospinal fluid was 75.00%, and Gram-negative bacteria were the main pathogens (78.13%) , among which the most common was Acinetobacter baumannii (28.11%) . Univariate analysis showed that the incidence of catheter-related ventricular infection was related to gender, age, admission diagnosis, diabetes mellitus, preoperative pulmonary infection, Glasgow Coma Scale (GCS) score, American Society of Anesthesiologists (ASA) physical status classification, duration of EVD, type of EVD, number of catheters, frequency of replacing catheter, frequency of sampling cerebrospinal fluid (P<0.05) . Multivariate Logistic regression suggested that duration of EVD, number of catheters, pulmonary infection and frequency of sampling cerebrospinal fluid were independent risk factors causing catheter-related ventricular infection (OR=1.070, 13.236, 6.800, 6.248) . Conclusions The catheter-related ventricular infection can be caused by single factor or the synergistic action of multiple factors. The control of pulmonary infection and the management of blood glucose level are helpful to reduce the infection of EVD related infection. Key words: Risk factors; Neurosurgical procedures; External ventricular drainage; Catheter-related infection

Endoscopic third ventriculostomy as adjunctive therapy in the treatment of low-pressure hydrocephalus in adults.

Background:Treatment of low-pressure hydrocephalus (LPH) may require prolonged external ventricular drainage (EVD) at sub-zero pressures to reverse ventriculomegaly. Endoscopic third ventriculostomy (ETV) has been used in the treatment of noncommunicating hydrocephalus; however, indications for ETV are expanding.Methods:Patients with the diagnosis of LPH as defined by the Pang and Altschuler criteria who underwent sub-zero drainage treatment over an 8-year period were included. Patients were divided into two cohorts based on whether or not ETV was employed during their treatment. Time from EVD placement to internalization of shunt was recorded for both groups; time from ETV to placement of shunt was recorded for the patients undergoing ETV.Results:Sixteen adult patients with LPH were managed with sub-zero drainage method. Ten (62.5%) patients did not undergo ETV and the average time from first ventriculostomy to shunting was 73 days (range 14–257 days). Six (37.5%) patients underwent ETV during the course of their treatment; average time from initial ventriculostomy to shunt was 114 days (range 0–236 days) (P = 0.16). Time from development of LPH to ETV ranged from 28 days to 6.5 months. In the ETV group, of the 4 patients who underwent shunting, the average time to shunting following ETV was 15.25 days.Conclusions:ETV can be used successfully in the management of refractory LPH to decrease the duration of EVD.

Application of the Ommaya Reservoir in Managing Ventricular Hemorrhage

Intraventricular hemorrhage (IVH) is associated with high morbidity and mortality. This study evaluated the safety and efficacy of the combined treatment of an Ommaya reservoir and conventional external ventricular drainage (EVD) using urokinase in the management of IVH. We performed a prospective controlled study. Sixty eligible patients with IVH received conventional EVD alone (group A) or combined EVD and Ommaya reservoir (group B) between January 2010 and January 2015. Clinical, cerebrospinal fluid, and radiographic data were used to assess clot clearance, clinical outcomes, and complications between the groups. There were no significant differences in gender, age, blood pressure, Glasgow Coma Scale, Graeb score, intracerebral hemorrhage volume on admission, and IVH volume before surgery between groups A and B (P > 0.05). The number of injections of urokinase (20,000 IU/dose) were significantly different in group B compared with group A (P < 0.05). Repeated computed tomography scans 3 days, 6 days, and 10 days after surgery revealed that clot clearance rates at each time point were significantly increased in group B compared with group A (P < 0.05). The conventional catheter-based EVD duration time was shortened to 5 (4-6) days in group B compared with 7 (5-9) days in group A (P < 0.05). The total drainage time was prolonged to 9 (8-11) days in group B compared with 7 (5-9) days in group A (P < 0.05). Ventriculitis was not significantly different between the 2 groups (P > 0.05). The hydrocephalus incidence and mortality revealed significant differences between the 2 groups (P < 0.05). The 30-day Glasgow Outcome Scale score was significantly increased in group B compared with group A (P < 0.05). The combined treatment approach of an Ommaya reservoir and EVD with intraventricular urokinase is safe and effective in patients with IVH. It increased clot clearance, shortened conventional catheter-based EVD duration, prolonged total drainage time, reduced the hydrocephalus incidence and mortality, and contributed to good clinical outcomes. The Ommaya reservoir provides a safe way to increase the injection times of urokinase, which accelerated clot resolution and did not increase the risk for ventriculitis infection.

The Relationship Between Risk Factors and Prognostic Factors in Patients With Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage

We investigated the predictors and outcomes of aneurysmal subarachnoid hemorrhage in patients with shunt-dependent hydrocephalus and make a preliminary inquiry into the relationship between the two. A consecutive cohort of 202 patients was evaluated, which included 40 shunt-dependent hydrocephalus patients. The basic characteristics on admission, complications of hemorrhage, management before onset of chronic hydrocephalus, and outcomes of shunting were established. The Glasgow Outcome Scale score was used to evaluate the recovery of patients with a ventriculoperitoneal (V-P) shunt. Furthermore, relevant statistical analyses were presented to identify the significance of risk factors and prognostic factors associated with shunt-dependent hydrocephalus. From among 202 patients, 40 (19.8%) developed shunt-dependent hydrocephalus, and 26 (65.0%) of these 40 improved after undergoing a V-P shunt. In the univariate analysis, age, preexisting hypertension, Glasgow Coma Scale score, Hunt-Hess grade, modified Fisher grade, posterior circulation, rebleeding, acute hydrocephalus, intraventricular hemorrhage, vasospasm, nosocomial meningitis, neurosurgical clipping, decompressive craniectomy, external ventricular drainage (EVD), and duration of EVD were significantly related to shunt-dependent hydrocephalus; moreover, age, preexisting hypertension, posterior circulation, acute hydrocephalus, intraventricular hemorrhage, and decompressive craniectomy were independent predictors. Similarly, age, Hunt-Hess grade, Glasgow Coma Scale score, nosocomial meningitis, and duration of EVD could be the prognosticators of a V-P shunt. Patients who were older, with worse mental function status on admission, nosocomial meningitis, and longer duration of EVD, are susceptible to shunt-dependent hydrocephalus because of ruptured intracranial aneurysm and also have unfavorable outcomes after a V-P shunt. Timely and appropriate treatment can benefit such patients in recovery.

Comparative analysis of risk factors for ventriculostomy-related ventriculitis

Objective The aim of this study is to analyze the risk factors of ventriculostomy-related ventriculitis.Methods Total 71 patients were placed external ventricular drainage catheters and divided into ventriculitis group and control group.Clinical variables such as age,sex,prior clinical diagnosis,duration of external ventricular drainage,total numbers of catheters per person,and outcome were analyzed contrastively in theses cases.Results Total 96 catheters were placed in 71 patients.Among these patients,13 cases were noted presenting infection,indicating the incidence is 18％.And there were 8 males (11％) and 5 females (7％) in the 13 cases.The mean age of infected patients was 32.9 years.Each patient had 1.69 catheters.The mean of the duration of catheter was 18.5 days.The prior clinical diagnosis of the 13 patients was trauma (23％),tumor (23％),intraventricular hemorrhage (38％) and acute hydrocephalus after aneurysmal subarachnoid hemorrhage (15％) respectively.The results of statistical analysis showed the prior clinical diagnosis and the number of catheters were the risk factors of ventriculostomy-related ventriculitis.Conclusions The patient's underlying diagnosis and the number of catheters were associated with the risk of developing ventriculitis.Moreover,the longer the duration of external ventricular drainage catheter,the more likely the patient seemed to develop ventriculitis.But the age and gender of the patients are not related to ventriculostomy-related ventriculitis. Key words: Ventriculostomy; Ventriculitis; Risk factors

Prevention of Ventriculostomy-Related Infections With Prophylactic Antibiotics and Antibiotic-Coated External Ventricular Drains: A Systematic Review

Ventriculostomy-related infection (VRI) is a severe complication of external ventricular drain use, occurring in 5% to 23% of patients. Preventive measures for VRI include prolonged prophylactic systemic antibiotics (PSAs) and an antibiotic-coated external ventricular drains (ac-EVDs). We performed a systematic review of all studies evaluating PSAs and ac-EVD for VRI prevention through July 2010. Two reviewers independently assessed eligibility and evaluated study quality based on pre-established criteria. Observational studies and randomized clinical trials (RCTs) that fulfilled inclusion criteria were included in the meta-analysis. Three RCTs and 7 observational studies met our inclusion criteria and were included in the analysis. The type of antibiotics and VRI definitions varied among these studies. Pooled analysis showed a protective effect of PSAs and ac-EVDs for VRI (risk ratio: 0.32; 95% CI: 0.18-0.56). Results showed moderate heterogeneity (I(2) = 53%) explained by the difference in quality among the studies and the inclusion of 1 large positive cohort study. The effect of PSAs and ac-EVDs was unrelated to the type of study (RCT or observational, P for interaction = .55), the route of antibiotic administration (PSAs or ac-EVDs, P = .13), or the quality of the studies (suboptimal vs good/excellent, P = .55). RCTs and observational-derived evidence support the use of PSAs throughout the duration of external ventricular drainage; similarly, the use of ac-EVDs to prevent VRI seems to be beneficial. Available data are heterogeneous and of suboptimal quality. Further research is needed to confirm the findings of this meta-analysis. There are not sufficient data to compare the protective effect of ac-EVDs and PSAs.

Endoscopic ventricular irrigation for treatment of ventricular infection

Objective To study the effect of endoscopic ventricular irrigation for the treatment of ventricular infection. Methods 60 cases of ventricular infection were treated with endoscopic ventricular irrigation under flexible neuron-endoscope from Febrary, 2007 to November,2009. Among them, 41 cases were secondary to V-P shunt, 13 cases were secondary to external ventricular drainage due to intraventricular hemorrhage or traumatic hydrocephalus, 4 cases were secondary to other neurosurgical operations and 2 case was due to tuberculous meningitis. Results Of all the 60 patients, 25 (42%) were negative in CSF bacterial culture, 27(45%) were infected with general pyogenic bacteria such as staphylococci, streptococcus pneumoniae, Enterococcus faecalis, Klebsiella pneumoniae, Escherichia coli,Acinetobacter baumannii. 3(5%) were infected with Pseudomonas aeruginosa, 3(5%) were fungal infection, 2(3%) were infected with tubercle bacillus. 26(43%) cases of ventricular infection were cured with successful removal of shunt or external ventricular drainage (EVD) by single endoscopic ventricular irrigation. 34(57%) patients whose endoscopic ventricular irrigation were followed by EVD andintraventricular injection of antibiotics, the EVD duration was 4 to 76 d (mean 20.1 d). The second V-P shunt was not avoided due to intracranial hypertension after removal of EVD in 7 (12%) patients. The death rate was 8%. All dead cases were infected with Pseudomonas aeruginosa or fungus which were extensive drug -resistant. Conclusion Severe ventricular infection is troublesome in neurosurgery. Ventricular irrigation under flexible neuron-endoscope could shorten the course and improve the effect of the treatment of severe ventricular infection. Key words: Neuroendoscopy; Ventricular irrigation; Ventricular infection

Neuroendoscopic evacuation of intraventricular hematoma associated with thalamic hemorrhage to shorten the duration of external ventricular drainage

Background:We report neuroendoscopic evacuation of an intraventricular hematoma (IVH) in 13 patients with thalamic hemorrhage. We discuss strategies to improve the outcome and to shorten the management period by using external ventricular drainage (EVD).Methods:Patients were classified into fair (modified Rankin scale [mRS] grade 4 or less) and poor (mRS grade 5) outcome groups, and depending on the duration of EVD, into short (7 days or shorter) and long EVD (8 days or longer) groups.Results:The postoperative residual IVH, graded using the Graeb score, was better for the fair outcome group than for the poor outcome group (3.9 [1.2] vs. 5.7 [1.0], P < 0.05). The postoperative Graeb score was significantly better for the short EVD group than for the long EVD group (3.6 [0.8] vs. 6.0 [0.6], P < 0.01). The duration of EVD was not correlated with the IVH at the fourth ventricle, but it was correlated with the IVH at the foramen of Monro (P < 0.05) and the third ventricle (P < 0.01). Reduction in the volume of thalamic hemorrhage had no effect on the neurological outcome or duration of EVD.Conclusion:Neuroendoscopic evacuation of the IVH at the foramen of Monro and the third ventricle shortened the duration of EVD for hydrocephalus caused by thalamic hemorrhage with IVH involvement. Removal of the thalamic hemorrhage and IVH at the fourth ventricle was not necessary.

Intraventricular Fibrinolysis and Lumbar Drainage for Ventricular Hemorrhage

Both intraventricular fibrinolysis (IVF) and lumbar drainage (LD) may reduce the need for exchange of external ventricular drainage (EVD) and shunt surgery in patients with intracerebral hemorrhage and severe intraventricular hemorrhage. We investigated the feasibility and safety of IVF followed by early LD for the treatment of posthemorrhagic hydrocephalus. This prospective study included patients with spontaneous ganglionic intracerebral hemorrhage and severe intraventricular hemorrhage with acute obstructive posthemorrhagic hydrocephalus who received an EVD (n=32). The treatment algorithm started with IVF (4 mg recombinant tissue plasminogen activator every 12 hours) until clearance of the third and fourth ventricles from blood. Thereupon, EVD was clamped and if clamping was unsuccessful, communicating posthemorrhagic hydrocephalus was assumed and LD placed. EVD was removed if there was neither an increase of intracranial pressure nor ventricle enlargement on CT. A ventriculoperitoneal shunt was indicated if "LD weaning" was unsuccessful for >10 days. Outcome was assessed at 90 and 180 days using the modified Rankin Scale. IVF resulted in fast clearance of the third and fourth ventricles (73+/-50 hours). However, early EVD removal was only possible in 4 patients. The remaining 28 patients developed communicating posthemorrhagic hydrocephalus. In all of these patients, early LD was capable to replace EVD. EVD exchange was not necessary and EVD duration was 105+/-59 hours. Only one patient required a ventriculoperitoneal shunt. At 180 days, 20 (62.5%) patients had a good (modified Rankin Scale 0 to 3) outcome and 5 (15.6%) patients had died. One patient had asymptomatic ventricular rebleeding. In patients with secondary intraventricular hemorrhage and posthemorrhagic hydrocephalus, the combined treatment approach of IVF and early LD is safe and feasible, avoids EVD exchange, and may markedly reduce the need for shunt surgery.

Predictive Value of Intrathecal Interleukin-6 for Ventriculostomy-related Infection

Early diagnosis of ventriculostomy-related infection (VRI) is crucial for the early treatment and course of this disease. In neurosurgical patients the diagnostic criteria are equivocal, mostly because of bloodstained cerebrospinal fluid (CSF). The predictive value, sensitivity and specificity of intrathecal interleukin-6 (IL-6 (CSF)) has been proven for VRI compared with classical diagnostic CSF parameters, i.e. cell countCSF (CC (CSF)) and total protein (CSF). We prospectively analyzed the daily clinical data and CSF samples of 75 neurosurgical patients with an external ventricular drainage (EVD), which had been inserted predominantly because of poor-grade subarachnoid hemorrhage (SAH). The intrathecal interleukin-6 concentrations (IL-6 (CSF)) were correlated with the clinical course and VRI incidence, as diagnosed by the classical VRI criteria (CC (CSF), total protein (CSF), clinical symptoms). Based on classical criteria, bacterial meningitis occurred in 26.7% of patients. Patients with VRI manifested significantly (p<0.001) higher median values of IL-6 (CSF) (up to 2,000-fold increase) the day before (day -1) infection was diagnosed by conventional parameters. Using a cut-off value of IL-6 (CSF)>or=2,700 pg/ml [4,050 pg/ml after WHO standardization] on day -1, the relative risk for VRI was 6.09 (95% CI: 2.62-14.18%). A predictive value of IL-6 (CSF)>or=2,700 pg/ml [4,050 pg/ml] for VRI was calculated of 89% (95% CI: 79.6-98.0%), a sensitivity of 73.7% and a specificity of 91.4%. The amount of intrathecal blood was an independent risk factor for VRI occurrence, whereas the mean duration of EVD in place showed no impact on the rate of infection. Our data indicate that IL-6 (CSF) is a reliable marker for predicting VRI prior to clinically manifest meningitis, one day earlier than the common diagnostic criteria of CSF infection (CC (CSF), total protein (CSF), clinical symptoms).

External Ventricular Drain Infection

Object The authors explored the relationship among the duration of external ventricular drainage, revision of external ventricular drains (EVDs), and cerebrospinal fluid (CSF) infection to shed light on the practice of electively revising these drains. Methods In a retrospective study of 199 patients with 269 EVDs in the intensive care unit at a major trauma center in Australasia, the authors found 21 CSF infections. Acinetobacter accounted for 10 (48%) of these infections. Whereas the duration of drainage was not an independent predictor of infection, multiple insertions of EVDs was a significant risk factor. Second and third EVDs in previously uninfected patients were more likely to become infected than first EVDs. An EVD infection was initially identified a mean of 5.5 ±0.7 days postinsertion (standard error of the mean); these data—that is, the number of days—were normally distributed. Conclusions This pattern of infection is best explained by EVD-associated CSF infections being acquired by the introduction of bacteria on insertion of the drain rather than by subsequent retrograde colonization. Elective EVD revision would be expected to increase infection rates in light of these results, and thus the practice has been abandoned by the authors' institution.