External Ventricular Drain Placement Research Articles

Seizures, periodic and rhythmic patterns in primary intraventricular hemorrhage.

ObjectivePrimary intraventricular hemorrhage (pIVH) uncommonly presents with seizures. There are no prior data regarding the frequency of seizures, periodic and rhythmic patterns on continuous electroencephalography (EEG), (cEEG) in these patients.MethodsWe retrospectively assessed frequency of seizures, periodic discharges, and rhythmic patterns in pIVH patients undergoing cEEG monitoring. We reviewed indications for cEEG, demographics, GCS at presentation and during cEEG, modified Graeb score (mGS), presence of hydrocephalus, cEEG duration, findings and use of antiseizure medications (ASM). cEEG patterns were classified according to location and morphology. All patterns were considered “hyperexcitable” except GRDA. The ictal‐interictal continuum (IIC) was defined as LRDA, PDs, and/or SW >1 Hz but <2.5 Hz, not meeting criteria for definite electrographic seizures.ResultsEleven patients had pIVH with median age of 81 (46–87) years and median mGS of 15 (9–23). Hydrocephalus was present in 7 (63.6%) and all underwent external ventricular drain (EVD) placement. Median cEEG recording was 19 (12–156) hours. Periodic or rhythmic EEG patterns were seen in 7 of 11 (64%), 5 of which were “hyperexcitable”. For the 5 patients with pIVH, EVDs, and hyperexcitable patterns, 4 (80%) were lateralized contralateral to the EVD and 1 (20%) was generalized to the EVD. The only significant difference between the hyperexcitable and non‐hyperexcitable group was duration of cEEG monitoring (P = 0.007).InterpretationHyperexcitable patterns were common in our cases. Further research is warranted to assess prevalence of hyperexcitable patterns, their risk factors, underlying pathophysiology, and association with neuronal injury in pIVH.

Aneurysmal Subarachnoid Hemorrhage and Vasospasm.

Aneurysmal subarachnoid hemorrhage is potentially fatal and is associated with poor outcomes in many patients. Advances in neurosurgical and medical management of ruptured aneurysms have improved mortality rates in patients with aneurysmal subarachnoid hemorrhage. Surgical and endovascular interventions, such as external ventricular drain placement, aneurysm clipping, and endovascular coiling, have been developed over the past few decades. Patients with aneurysmal subarachnoid hemorrhage are also at risk for cerebral vasospasm and delayed cerebral ischemia. This article describes the diagnosis and treatment of aneurysmal subarachnoid hemorrhage, vasospasm, and cerebral ischemia. Concurrent medical considerations and ideas for future neuroinflammatory vasospasm research are also discussed.

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.

Very Large Metastases to the Brain: Retrospective Study on Outcomes of Surgical Management

The incidence of brain metastases is rising. To our knowledge, no published study focuses exclusively on brain metastases larger than 4 cm. We present our surgical outcomes for patients with brain metastases larger than 4 cm. This is a retrospective chart review of inpatient data at our institution from January 2006 to September 2015. Primary end points included overall survival, progression-free survival, and local recurrence rate. Sixty-one patients had a total of 67 brain metastases larger than 4 cm: 52 were supratentorial and 15 were infratentorial. Forty-three patients underwent surgical resection. Average duration of disease freedom after resection was 4.79 months (range, 0-30 months). Excluding patients with residual on immediate postoperative magnetic resonance imaging, the average rate of local recurrence was 7 months (range, 1-14 months). Overall survival after surgery excluding patients who chose palliation in the immediate postoperative period averaged 8.76 months (range, 1-37 months). Thirty-five of 43 patients (81.4%) had stable or improved neurologic examinations postoperatively. Six patients (13.95%) developed surgical complications. There were 3 major complications (6.98%): 2 pseudomeningoceles required intervention and 1 postoperative hematoma required external ventricular drain placement. There were 3 minor complications (6.98%): 1 self-limited pseudomeningocele, 1 subgaleal fluid collection, and 1 postoperative seizure. Surgery resulted in stable or improved neurologic examination in 81.4% of cases. On statistical analysis, significantly increased overall survival was noted in patients undergoing surgical resection, and those with higher Karnofsky Performance Scale and lower number of brain metastases at presentation. There is a need for further studies to evaluate management of brain metastases larger than 4 cm.

16. Optimizing Neurosurgical Drill Placement using the Microsoft HoloLens

Purpose: Tracked navigation systems require large carts of equipment, specialized technicians, and are impractical in bedside neurosurgical procedures. For bedside procedures like an opening of the skull for removing pressure caused by internal bleeding, navigation could improve the accuracy of the drill placement. We use the Microsoft HoloLens to display a hologram floating in the patient’s head to mark a drilling location on the skull. The accuracy of this placement is assessed to determine the feasibility of using the HoloLens to mark a drilling location within a clinically acceptable range.&#x0D; Methods: A 3D model of the head is created from CT scans and imported to the HoloLens. The hologram is interactively registered to the patient and the drilling location is marked on the skull (Figure 1). 3DSlicer, Unity, and Visual Studio were used for implementing the software. The system was tested by 7 users. They each performed 6 registrations on phantoms with markers placed at 3 plausible drilling locations. Registration accuracy was determined by measuring the distance between the holographic and physical markers. &#x0D; Results: Users placed 98% of the markers within the clinically acceptable range of 10 mm in an average time of 4:46 min. &#x0D; Conclusion: It is feasible to mark a neurosurgical drilling location with clinically acceptable accuracy using the Microsoft HoloLens, within an acceptable length of time. This technology may also prove useful for procedures that require higher accuracy of location and drain trajectory such as the placement of external ventricular drains.

Flat Panel Detector Computed Tomography−Guided Placement of External Ventricular Drains Using the BrainLAB Headband and Precalibrated Disposable Stylet Instrument: A Cadaveric Feasibility Study

The standard freehand method for the insertion of external ventricular drains (EVDs) is associated with high rates of incorrect placement. Use of neuronavigation has been shown to reduce the rates of inaccurately positioned EVDs. We present a novel neuronavigation-based approach for EVD placement using flat panel detector computed tomography (FDCT) imaging. Four cadaveric heads were used for neuronavigated placement of EVDs using the BrainLAB reference headband in combination with laser surface registration and the precalibrated disposable stylet. In 2 cases, conventional multislice CT imaging was performed to reference neuronavigation. In the other 2 cases, preprocedural imaging was performed with FDCT. After inserting the EVDs, all heads were examined again with the identical imaging method as used before the procedure, followed by evaluation of catheter position. Our data demonstrate that FDCT imaging provides adequate image quality for referencing neuronavigation and performing navigated neurosurgery. All EVDs showed an optimal position in the ipsilateral frontal horn. Use of a BrainLAB reference headband combined with laser surface registration and the precalibrated disposable stylet affords the advantage of not requiring rigid fixation in a clamp. Our presented method is fast, accurate, and easy to use. Furthermore, this study is the first to demonstrate that navigated neurosurgery can be performed on the basis of FDCT imaging.

Effectiveness of a Chlorhexidine Dressing on Silver-coated External Ventricular Drain-associated Colonization and Infection: A Prospective Single-blinded Randomized Controlled Clinical Trial.

Observational studies have shown that dressings containing chlorhexidine gluconate (CHX) lower the incidence external ventricular drain (EVD)-associated infections (EVDAIs). This prospective, randomized controlled trial (RCT) studies the efficacy of CHX-containing dressings in reducing bacterial colonization. In this RCT, patients aged ≥18 years undergoing emergency EVD placement were randomly given either a CHX-containing or an otherwise identical control dressing at the skin exit wound. The primary end-point was bacterial regrowth in cultured skin swab samples of the EVD exit wound. The secondary end-points were catheters processed by sonication, clinically diagnosed EVDAI and surgical treatment of hydrocephalus. From October 2013 to January 2016, a total of 57 patients were randomized to receive either a CHX or a control dressing (29 and 28 patients, respectively). Cutaneous bacterial regrowth at the EVD exit wound was significantly reduced over time (geometric mean ratio, 0.18; 95% confidence interval, .08-.42; P < .001). The incidence of colonized catheters was lower in the CHX group (5 of 28; 18%) than in the control group (10 of 27; 33%), with less microbial colonization on the subcutaneous portion. The infection rate was 4 of 28 (14%) in the CHX group, compared with 7 of 27 (26%) in the control group, with a substantially lower hydrocephalus treatment rate (7 of 28 [25%] vs 14 of 27 [52%], respectively). Our data support the use of CHX dressings to reduce EVD exit site contamination, potentially reducing EVDAIs and permanent cerebrospinal fluid diversion procedures for hydrocephalus. NCT02078830.

Image guidance and improved accuracy of external ventricular drain tip position particularly in patients with small ventricles.

External ventricular drain (EVD) insertion is one of the most common emergency neurosurgical procedures. EVDs are traditionally inserted freehand (FH) in an emergency setting, but often result in suboptimal positioning. Image-guided surgery (IGS) is selectively used to assist placement. However, the accuracy and practicality of IGS use is yet to be reported. In this study, the authors set out to assess if IGS is practical and improves the accuracy of EVD placement. Case notes and images obtained in patients who underwent frontal EVD placement were retrospectively reviewed. Ventriculomegaly was determined by the measurement of the Evans index. EVD location was classified as optimal (ipsilateral frontal horn) or suboptimal (any other location). Propensity score matching of the two groups (IGS vs FH) for the Evans index was performed. Data were analyzed for patient age, diagnosis, number of EVDs, and complications. Those without postoperative CT scans were excluded. A total of 607 patients with 760 EVDs placed were identified; 331 met inclusion criteria. Of these, 287 were inserted FH, and 44 were placed with IGS; 60.6% of all unmatched FH EVDs were optimal compared with 75% of the IGS group (p = 0.067). The IGS group had a significantly smaller Evans index (p < 0.0001). Propensity score matching demonstrated improved optimal position in the IGS group when compared with the matched FH group (75% vs 43.2%, OR 4.6 [1.5-14.6]; p = 0.002). Patients with an Evans index of ≥ 0.36 derived less benefit (75% in IGS vs 66% in FH, p = 0.5), and those with an Evans index < 0.36 derived more benefit (75% in IGS vs 53% in FH, p = 0.024). The overall EVD complication rate was 36% in the FH group versus 18% in the IGS group (p = 0.056). Revision rates were higher in the FH group (p = 0.035), and the operative times were similar (p = 0.69). Long intracranial EVD catheters were associated with tip malposition irrespective of the group. Image guidance is practical and improves the accuracy of EVD placement in patients with small ventricles; thus, it should be considered for these patients.

Utilizing preprocedural CT scans to identify patients at risk for suboptimal external ventricular drain placement with the freehand insertion technique.

Freehand insertion of external ventricular drains (EVDs) using anatomical landmarks is considered the primary method for placement, although alternative techniques have shown improved accuracy in positioning. The purpose of this study was to retrospectively evaluate which features of the baseline clinical history and preprocedural CT scan predict EVD positioning into suboptimal and unsatisfactory locations when using the freehand insertion technique. A retrospective chart review was performed evaluating 189 consecutive adult patients who received an EVD via freehand technique through an anterior burr hole between January 1, 2014, and December 31, 2015, at a Level 1 trauma facility in Edmonton, Alberta, Canada. The primary outcome measures included features associated with suboptimal positioning (Kakarla grade 1 vs Kakarla grades 2 and 3). The secondary outcome measures were features associated with unsatisfactory positioning (Kakarla grades 1 and 2 vs Kakarla grade 3). Fifty-one EVDs (27%) were suboptimally positioned. Fifteen (8%) EVDs were placed into eloquent cortex or nontarget CSF spaces. Admitting diagnosis, head height-to-width ratio in axial plane, and side of predominant pathology were found to be significantly associated with suboptimal placement (p = 0.02, 0.012, and 0.02, respectively). A decreased height-to-width ratio was also associated with placement into only eloquent cortex and/or nontarget CSF spaces (p = 0.003). Freehand insertion of an EVD is associated with significant suboptimal positioning into parenchyma and nontarget CSF spaces. The likelihood of inaccurate EVD placement can be predicted with baseline clinical and radiographic features. The patient's height-to-width ratio represents a novel potential radiographic predictor for malpositioning.

Predictors of shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage: a pilot study in a single Egyptian institute

BackgroundAcute hydrocephalus can cause neurological deterioration after aneurysmal subarachnoid hemorrhage (aSAH). Predicting which patient would require shunting is challenging.MethodsThis prospective study was conducted upon twenty patients who suffered acute hydrocephalus due to subarachnoid hemorrhage of ruptured aneurysms. Surgical or non-surgical management of hydrocephalus was conducted. Glasgow Coma scale (GCS) was assessed, and hydrocephalus was graded by bicaudate index. Fisher grade was determined from CT scan. Aneurysm site was determined by conventional or CT angiography. Either surgical clipping or endovascular coiling of aneurysms was performed.ResultsInitially, 3 (15%) patients had emergency CSF diversion on admission due to poor GCS on arrival. Initially, the remaining 17 patients were managed conservatively. Five patients did not require any intervention. Twelve patients had external ventricular drainage placement, 4 were weaned, and 8 failed weaning. High bicaudate index (> 0.2) correlated with shunting. Aneurysm site correlated well with shunting (ACoA or PCoA).ConclusionsPatients with fair GCS can be managed conservatively. Any deterioration warrants shifting to CSF diversion. Higher bicaudate index will usually need CSF diversion. The value of Fisher carries no significant value. Aneurysm location (ACoA or PCoA) correlates with an increased incidence of ventriculoperitoneal shunt placement.

Preliminary Results of Emergency Computed Tomography–Guided Ventricular Drain Placement—Precision for the Most Difficult Cases

External ventricular drainage (EVD) catheter placement is one of the most commonly performed neurosurgical procedures. The study's objective was to compare a computed tomography (CT) bolt scan-guided approach for the placement of EVDs with conventional landmark-based insertion. In this retrospective case-control study, we analyzed patients undergoing bolt-kit EVD catheter placement, either CT-guided or landmark-based, between 2013 and 2016. The CT bolt scan-guided approach was based on a dose-reduced CT scan after bolt fixation with immediate image reconstruction along the axis of the bolt to evaluate the putative insertion axis. If needed, angulation of the bolt was corrected and the procedure repeated before the catheter was inserted. Primary endpoint was the accuracy of insertion. Secondary endpoints were the overall number of attempts, duration of intervention, complication rates, and cumulative radiation dose. In total, 34 patients were included in the final analysis. In the group undergoing CT-guided placement, the average ventricle width was significantly smaller (P=0.04) and average midline shift significantly more pronounced (P= 0.01). CT-guided placement resulted in correct positioning of the catheter in the ipsilateral frontal horn in all 100% of the cases compared with landmark-guided insertion (63%; P= 0.01). Application of the CT-guided approach increased the number of total CT scans (3.6 ± 1.9) and the overall radiation dose (3.34 ± 1.61 mSv) compared with the freehand insertion group (1.84 ± 2.0 mSv and 1.55 ± 1.66 mSv). No differences were found for the other secondary outcome parameters. CT-guided bolt-kit EVD catheter placement is feasible and accurate in the most difficult cases.

Impact of an External Ventricular Drain Placement and Handling Protocol on Infection Rates: A Meta-Analysis and Single Institution Experience

Numerous studies have examined the impact of initiating an external ventricular drain (EVD) placement and handling protocol on the infection rate dating back to the early 2000s. We report a quantitative systematic review of the published literature, described our own protocol (including a mandatory checklist), and present our single institution experience. Search terms "external ventricular drain protocol" or "external ventricular drain placement protocol" or "preventing infections in external ventricular drains" or "external ventricular drain infections" were entered into standard search engines in a systematic fashion. Articles were reviewed and graded independently for class of evidence. There were 10 relevant class IV articles and no discrepancies among article ratings (i.e., κ= 1). The published evidence was reviewed and evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. Our meta-analysis revealed a statistically significant drop in rates of EVD infection after initiation of the protocol, although the overall quality of the body of evidence according to the GRADE criteria was "very poor". Preimplementation and postimplementation infection rates were collected and analyzed in combination with the results from our literature review. The EVD infection rate in our institution was 12% in the 8 months before protocol initiation (January 2015 to August 2015), and dropped to 0% in the 7 months after initiation. Although the quality of the literature supporting EVD placement protocols is poor, all published studies show a consistent and substantial benefit, and this effect was recapitulated in our own meta-analysis-based prospective EVD protocol experience.

Tailored Strategies to Manage Cerebrospinal Fluid Leaks or Pseudomeningocele After Surgery for Tethered Cord Syndrome.

Cerebrospinal fluid (CSF) leaks are a dreaded complication after surgery for tethered cord and are associated with significant patient morbidity. Although many strategies for managing postoperative CSF leaks exist, this problem is still daunting, especially in very young patients. In this study, we compared different management techniques for CSF leaks or significant pseudomeningocele in patients with tethered cord syndrome (TCS). We analyzed a cohort of children who underwent surgery for TCS from January 2011 to March 2016 (n= 260) and postoperatively experienced either a CSF leak or significant pseudomeningocele. A subset of patients presented with CSF leak (n= 25). We analyzed patient age, sex, presentation, leak appearance, management, and outcome. The different techniques of management were compared for efficacy and morbidity. The diseases associated with leak formation included lipomyelomeningocele (n= 16), myelocystocele (n= 4), and myelomeningocele (n= 5). Three children also had hydrocephalus. Management techniques included cystoperitoneal shunt (CPS) (n= 15), primary resuturing with local rotation flap of muscle (n= 3), external ventricular drain placement (n= 1), ventriculoperitoneal shunt (n= 3), external ventricular drainage (n= 1), and a combination of techniques (rotation flap with external drain; n= 1). Five patients who underwent primary wound revision experienced a leak and required a secondary intervention, but none of the patients who underwent CPS had any complications. In carefully selected cases, CPS performed early after CSF leakage is highly successful with low morbidity. The primary closure can be attempted for low-pressure leaks without an associated pseudomeningocele.

Intracerebral hemorrhage after external ventricular drain placement: an evaluation of risk factors for post-procedural hemorrhagic complications

BackgroundThe objective of this study was to evaluate and identify the risk factors for developing a new or enlarged intracranial hemorrhage (ICH) after the placement of an external ventricular drain.MethodsA single center, nested case-control study of individuals who received an external ventricular drain from June 1, 2011 to June 30, 2014 was conducted at a large academic medical center. A bivariate analysis was conducted to compare those individuals who experienced a post-procedural intracranial hemorrhage to those who did not experience a new bleed. The variables identified as having a p-value less than 0.15 in the bivariate analysis were then evaluated using a multivariate logistic regression model.ResultsTwenty-seven of the eighty-one study participants experienced a new or enlarged intracranial hemorrhage after the placement of an external ventricular drain. Of these twenty-seven patients, 6 individuals received an antiplatelet within ninety-six hours of external ventricular drain placement (p = 0.024). The multivariate logistic regression model identified antiplatelet use within 96 h of external ventricular drain insertion as an independent risk factor for post-EVD ICH (OR 13.1; 95% CI 1.95–88.6; p = 0.008).ConclusionCompared to those study participants who did not receive an antiplatelet within 96 h of external ventricular drain placement, those participants who did receive an antiplatelet were 13.1 times more likely to exhibit a new or enlarged intracranial hemorrhage.

Endoscopic Transsphenoidal Salvage Surgery for Symptomatic Residual Cystic Craniopharyngioma after Radiotherapy.

Objectives Ideal treatment of craniopharyngiomas is still controversial. Radiotherapy (RT) is considered effective for recurrences or after subtotal tumor removal (STR). About 40 to 50% of patients may experience tumor cyst expansion soon after RT; in these cases, the role of salvage surgery is debated. Design Operative video. Setting Tertiary care center. Participants An 11-year-old boy diagnosed with persistent craniopharyngioma. In 2015, the patient underwent right frontotemporal craniotomy for STR at another center, complicated by panhypopituitarism. Two years later, fractionated 54-Gy RT was performed on growing residual tumor. After 3 months, he was admitted to our hospital due to persistent malaise, vomiting, pulsating headache, and epistaxis. Ophthalmologic evaluation evidenced left homonymous hemianopsia. Results A contrast-enhanced magnetic resonance imaging (MRI) showed a 27-mm cystic component enlarging from the cranial end of the persistent craniopharyngioma lesion, extending into the third ventricle. Biventricular hydrocephalus and brain midline shift to the right were present. Compared with the early post-RT MRI, the cystic component of the tumor demonstrated growth. The patient underwent external ventricular drainage placement for emergent treatment of hydrocephalus and endoscopic transsphenoidal surgery. After cystic content drainage, the lesion was completely removed with its capsule. A “gasket seal” technique was performed for skull base reconstruction, with autologous fascia lata, septal bone, and mucoperiosteum from inferior turbinate. Histologic examination confirmed the craniopharyngioma diagnosis. Postoperative MRI showed resolution of the hydrocephalus and complete tumor removal. Conclusion Although shrinkage of cystic components of craniopharyngioma residuals may occur within 5 to 6 months after RT, salvage surgery is indicated in symptomatic patients. The link to the video can be found at https://youtu.be/4x6Qe76bf60 .

Reinfection after treatment of first cerebrospinal fluid shunt infection: a prospective observational cohort study.

OBJECTIVE CSF shunt infection requires both surgical and antibiotic treatment. Surgical treatment includes either total shunt removal with external ventricular drain (EVD) placement followed by new shunt insertion, or distal shunt externalization followed by new shunt insertion once the CSF is sterile. Antibiotic treatment includes the administration of intravenous antibiotics. The Hydrocephalus Clinical Research Network (HCRN) registry provides a unique opportunity to understand reinfection following treatment for CSF shunt infection. This study examines the association of surgical and antibiotic decisions in the treatment of first CSF shunt infection with reinfection. METHODS A prospective cohort study of children undergoing treatment for first CSF infection at 7 HCRN hospitals from April 2008 to December 2012 was performed. The HCRN consensus definition was used to define CSF shunt infection and reinfection. The key surgical predictor variable was surgical approach to treatment for CSF shunt infection, and the key antibiotic treatment predictor variable was intravenous antibiotic selection and duration. Cox proportional hazards models were constructed to address the time-varying nature of the characteristics associated with shunt surgeries. RESULTS Of 233 children in the HCRN registry with an initial CSF shunt infection during the study period, 38 patients (16%) developed reinfection over a median time of 44 days (interquartile range [IQR] 19-437). The majority of initial CSF shunt infections were treated with total shunt removal and EVD placement (175 patients; 75%). The median time between infection surgeries was 15 days (IQR 10-22). For the subset of 172 infections diagnosed by CSF culture, the mean ± SD duration of antibiotic treatment was 18.7 ± 12.8 days. In all Cox proportional hazards models, neither surgical approach to infection treatment nor overall intravenous antibiotic duration was independently associated with reinfection. The only treatment decision independently associated with decreased infection risk was the use of rifampin. While this finding did not achieve statistical significance, in all 5 Cox proportional hazards models both surgical approach (other than total shunt removal at initial CSF shunt infection) and nonventriculoperitoneal shunt location were consistently associated with a higher hazard of reinfection, while the use of ultrasound was consistently associated with a lower hazard of reinfection. CONCLUSIONS Neither surgical approach to treatment nor antibiotic duration was associated with reinfection risk. While these findings did not achieve statistical significance, surgical approach other than total removal at initial CSF shunt infection was consistently associated with a higher hazard of reinfection in this study and suggests the feasibility of controlling and standardizing the surgical approach (shunt removal with EVD placement). Considerably more variation and equipoise exists in the duration and selection of intravenous antibiotic treatment. Further consideration should be given to the use of rifampin in the treatment of CSF shunt infection. High-quality studies of the optimal duration of antibiotic treatment are critical to the creation of evidence-based guidelines for CSF shunt infection treatment.

Abstract WMP28: Hemorrhage Associated With External Ventricle Drain Placement in Aneurysmal Sub Arachnoid Hemorrhage Patients on Dual Anti Platelet Therapy: A Retrospective Analysis

Object: Stenting and flow diversion of ruptured intracranial aneurysms requires the use of dual antiplatelet therapy (DAPT). These patients may be at increased risk for post surgical hemorrhagic complication. In this study, we sought to investigate whether DAPT is a risk factor for hemorrhagic complication associated with placement of external ventricular drains (EVD) in patients with aneurysmal sub-arachnoid hemorrhage (aSAH). Methods: Patients at our institution with aSAH requiring placement of an EVD for obstructive hydrocephalus between July of 2009 and November of 2016 were included. Rates of radiographically identified hemorrhage associated with EVD placement were compared between patients who were on DAPT for use of a stent or flow diverter, and patients who underwent microsurgical clipping or coiling and were not on DAPT by way of a backward stepwise multivariate analysis. Hemorrhages were judged to be clinically significant if they were temporally associated with neurologic declines, required surgical intervention, or caused seizures. Results: 443 patients were admitted for management of aSAH. 298 Required placement of an EVD. 120 (40%) were treated with stent assisted coiling or flow diverters and required DAPT, while 178 (60%) were treated with coiling without stents or microsurgical clipping and were not on DAPT. 42 (14%) cases of new hemorrhage along the EVD catheter were identified radiographically. 32 of these hemorrhages occurred in patients on DAPT, while while 10 occurred in patients not on DAPT. After multivariate analysis, DAPT was significantly associated with radiographic hemorrhage [OR: 4.92, 95% CI: 2.45-9.91, p=.0001]. 5 hemorrhages (5 of 10 [50%]) were classified as symptomatic in those patients not receiving DAPT, while 10 hemorrhages (10 of 32 [31%]) were classified as symptomatic in those patients on DAPT (p=.4508). Conclusions: Our series confirms that patients with aSAH who receive stent assisted coiling or flow diversion are at higher risk for radiographic hemorrhage associated with EVD placement. This increased hemorrhage risk does not appear to be clinically significant. These data suggest that stent assisted coiling and flow diversion for aSAH are viable options in an era of evolving endovascular therapeutics.

Abstract TP401: Dual Anti-platelet Therapy is Associated With Reduced Risk of Clinical Vasospasm and Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage

Introduction: Clinical vasospasm and delayed cerebral ischemia (DCI) are devastating complications of aneurysmal subarachnoid hemorrhage (aSAH). Several theories have been postulated as potential etiologies of clinical vasospasm and DCI, involving platelet activation. However, the effects of dual anti-platelet therapy (DAPT: aspirin and clopidogrel) on clinical vasospasm and DCI have not been previously investigated. The objective of this study was to evaluate the effects of DAPT on clinical vasospasm and DCI in aSAH patients. Methods: Analysis of patients treated for aSAH during the period from July 2009 to April 2014 was performed in a single-institution retrospective study. Patients were divided into two groups: patients who underwent stent-assisted coiling or placement of flow diverters requiring DAPT (DAPT group) and patients who underwent coiling only without DAPT (control group). The frequency of symptomatic clinical vasospasm and DCI and of hemorrhagic complications was compared between the two groups, utilizing univariate and multivariate logistic regression. Results: Of 312 aSAH patients considered for this study, 161 patients met the inclusion and exclusion criteria and were included in the analysis (85 patients in the DAPT group and 76 patients in the control group). The risk of clinical vasospasm (OR: 0.244; CI 95% [0.097 - 0.615]; p = 0.003) and DCI (OR: 0.056; CI 95% [0.01 - 0.318]; p = 0.001) were significantly lower in patients receiving DAPT. Hemorrhagic complications associated with placement of external ventricular drains and ventriculoperitoneal shunts were similar in both groups (4% versus 2%; p = 0.9). Conclusions: The use of DAPT was associated with a lower risk of clinical vasospasm and DCI in patients treated for aSAH without an increased risk of hemorrhagic complications.

Abstract TP331: Plasma IL-6 Levels are Independently Associated With Functional Outcome and Markers of Secondary Injury in Spontaneous Intracerebral Hemorrhage

Introduction: The impact of the inflammatory response after intracerebral hemorrhage (ICH) has not been well characterized in patients and little is known about the relationship between early markers of inflammation and functional outcome. It is hypothesized that cytokine levels may be associated with three-month functional outcome and radiologic markers of secondary injury. Methods: Fifty-four patients with spontaneous ICH were prospectively enrolled at Yale-New Haven Hospital. Blood samples were collected at 24 (n=44) and 72 (n = 33) hours post-ICH. Plasma cytokine levels were measured using commercially available multiplex ELISA kits (Millipore). Modified Rankin Scale (mRS) was collected at three months by telephone interview. Associations between cytokines and outcome were assessed using ordinal logistics regression. Linear regression was used to evaluate the association between cytokine levels and markers of secondary injury. Results: IL-6 was correlated with ICH volume (p = 0.003) and PHE volume (p = 0.009) in univariable analysis. In multivariable analysis, IL-6 was associated with midline shift after adjustment for ICH volume (p=0.027). 24h IL-6 (p &lt; 0.001), IL-10 (p &lt; 0.001), IL-15 (p = 0.001), admission Glasgow Coma Score (GCS), ICH volume, ICH Score, and external ventricular drain (EVD) placement were associated with higher (worse) mRS in univariable ordinal regression. After adjustment for the ICH score, 24h IL-6 (OR 2.00, 95% CI 1.2-3.3, p = 0.003) and IL-15 (OR 2.7, 95% CI 1.4-5.0, p = 0.007) were significantly associated with worse mRS. Conclusions: Plasma IL-6 is independently associated with 24h midline shift, a measure of global hemispheric swelling, and with functional outcome after spontaneous ICH. These data are consistent with the early robust increase in brain IL-6 in experimental models of ICH. These data warrant further investigation of IL-6 levels as a biomarker for secondary injury and poor outcome in ICH.