Ventricular Drainage Research Articles

External Ventricular Drain Misadministration Events: Systematic Literature Review and Report of a Case.

External ventricular drain (EVD) is a common neurosurgical procedure with potential complications, including catheter misplacement, infection, mechanical obstruction, and inadvertent catheter pull-out. A less discussed but critical complication is the misadministration of medications into EVD. This project aimed to review the literature on EVD misadministration and discuss preventative measures, emphasizing the new International Organization for Standardization (ISO) standard for neuraxial connectors. A systematic review of PubMed, Embase, and SCOPUS databases was conducted to identify studies reporting misadministration in EVD systems. We also present a case of misadministration of a blood product into an EVD. Factors contributing to these events were researched, relevant guidelines from professional organizations were reviewed, and preventive strategies, including the novel NRFit® connector designed to prevent such errors, were discussed. The literature review identified 7 reports of 8 cases of misadministration involving substances such as gadolinium-based contrast agents, anesthetic agents, and antiepileptic drugs. In addition, we report a case of an 87-year-old man with multiple traumatic brain injuries, where a blood transfusion line was mistakenly connected to the EVD. This incident is the first reported case of blood misadministration through EVD. Despite immediate drainage and flushing of the EVD system with saline, the patient's condition did not improve, and he eventually died. Contributing factors included unfamiliarity with the EVD system, similarity to IV connectors, and poor visibility during procedures. Importantly, the novel ISO 80369 standard for all neuraxial connectors, including NRFit® connectors that have a 20% smaller nozzle outside diameter than traditional Luer connectors, has been recommended to prevent misconnection errors and mitigate associated risks. Misadministration to EVD connectors is a preventable event that highlights the need for enhanced safety solutions. Adoption of ISO standard neuraxial connectors, thorough training, and the use of distinctly marked equipment are critical steps in minimizing risks.

Advancing the management of neonatal hemorrhages: clinical evaluation of external ventricular drainage efficacy.

To evaluate the clinical efficacy of external ventricular drainage (EVD) in the treatment of neonatal intraventricular hemorrhage (IVH). A retrospective analysis was conducted on the clinical data of neonates with IVH admitted to the Department of Neurosurgery at Qingdao Women and Children's Hospital from January 2018 to February 2024. All patients received a definitive diagnosis followed by EVD treatment. Regular follow-ups were conducted, and patients who developed posthemorrhagic hydrocephalus (PHH) underwent ventriculoperitoneal shunt (VPS) procedures. Among the 44 neonates with IVH, 28 were male and 16 were female. The median gestational age at birth was 36weeks (range: 24-40weeks), and the median birth weight was 2.9kg (range: 0.78-4.33kg). There were 3 cases of grade II IVH, 34 cases of grade III IVH, and 7 cases of grade IV IVH. The average duration of EVD was 12.2 ± 5.6days. All patients were followed up for at least 1year. Twelve patients (27%) developed hydrocephalus, of which 8 cases (18%) with progressive ventricular enlargement underwent VPS, and 4 cases (9%) had arrested hydrocephalus and remained stable without VPS. During the follow-up period, 39 patients exhibited normal development, 3 patients (6.8%) developed epilepsy, and 2 patients (4.5%) developed cerebral palsy. EVD is an effective treatment for intraventricular hemorrhage. It improves survival rates and outcomes for patients while effectively reducing the incidence of hydrocephalus.

Transient and permanent hydrocephalus following resection of brain metastases located in the posterior fossa: incidence, risk factors and the necessity of perioperative external ventricular drainage placement.

Prophylactic insertion of an external ventricular drainage (EVD) prior to the resection of posterior fossa metastases (PFMs) is a common approach to address postoperative transient and permanent hydrocephalus. However, predicting surgery-related hydrocephalus in the preoperative phase continues to be a challenge. This study aims to analyze the incidence, preoperatively collectable risk factors and necessity of perioperative external ventricular drainage placement after posterior fossa metastasis surgery. All patients undergoing surgery for PFMs at the authors' neuro-oncological center between 2015 and 2021 were identified and assessed for postoperative hydrocephalus occurrence. Tumour volume, edema volume, and 4th ventricle volume were assessed on preoperative magnetic resonance imaging scans using the IntelliSpace Portal 5.0. A multivariable logistic regression analysis was performed to identify possible predictors for postoperative hydrocephalus occurrence. Postoperative hydrocephalus occurred in 14 of the 130 identified PFM patients (11%). Multivariable analysis and receiver operating characteristic (ROC) analysis revealed a 4th -ventricle-to-tumor-volume ratio ≤ 0.02 (OR 33.1, 95% CI 3.8-284.3, p = 0.001), an edema-to- tumor-volume ratio ≤ 0.85 (OR 10.6, 95% CI 2.4-47.4, p = 0.002), an imaging-morphological contact to the 4th ventricle (OR 5, 95% CI 1.4-18, p = 0.013), and multiple intracranial metastases (OR 2.4, 95% CI 1-5.9, p = 0.045) as independent predictors for surgery-related postoperative hydrocephalus occurrence. The present study identifies preoperatively detectable risk factors for the occurrence of postoperative hydrocephalus following surgery for PFMs. These findings may provide guidance in clinical decision-making regarding prophylactic EVD placement.

Stereotactic radiosurgery for fourth ventricle brain metastases: tumor control outcomes and the need for CSF diversion. Patient series.

Stereotactic radiosurgery is a favorable alternative to surgery for intracranial cerebral metastases. Fourth ventricle (V4) metastases are challenging because of the location and surrounding structures, with a high risk for obstructive hydrocephalus and brainstem compression. Here, the authors evaluate the effectiveness in terms of safety, tumor control rates, and permanent cerebrospinal fluid (CSF) diversion of primary Gamma Knife radiosurgery (GKRS) in treating V4 metastases. Eleven of 1060 patients had V4 brain metastases. No patients had pre-GKRS hydrocephalus. The mean tumor volume was 3.3 cm3, treatment dose was 18 Gy to the 50.5% isodose line (average 14 shots), conformity index was 1.4, and volume of brainstem receiving greater than 12 Gy was 0.2 cm3. Eight patients had radiographic and clinical follow-ups. The average time to initial follow-up was 3.1 months. Karnofsy Performance Status did not change from the initial consultation to the post-GKRS follow-up. No patients developed hydrocephalus or required permanent CSF diversion. One patient required transient external ventricular drain placement; however, neurological symptoms resolved with steroid therapy. Seven patients received steroid therapy post-GKRS. Seven patients had radiographic disease control at the 6-month follow-up. One patient had tumor progression at 6 months and underwent surgery. Primary GKRS for V4 metastases with a close follow-up is safe and optimizes quality of life for patients with significant cancer burden. https://thejns.org/doi/10.3171/CASE24293.

Incidence of Subdural Hygroma on Routine Early Postoperative Imaging Following Foramen Magnum Decompression for Chiari Malformation Type 1 in 156 Patients

To determine the incidence of subdural hygroma(SDH) on routine early post-operative imaging following foramen magnum decompression(FMD) with dural opening in patients with Chiari 1 malformation (CM1). Clinical and radiological data of 156 consecutive patients with CM1 who underwent FMD (2006-2023) were retrospectively analysed. Computed tomography (CT) scans done on the 7th postoperative day or earlier were reviewed for the presence of SDH (infra-and supratentorial) and ventriculomegaly. There were 96 (61.5%) males. The median age was 29.1 years. 64/156 (41 %) patients had SDH on postoperative CT done at median interval of 7 days (IQR, 5.8-7 days) after surgery. 22/64 (34.4%) patients were symptomatic for SDH, the main symptoms being holocranial headache (n=16), CSF leak (n=5) and acute respiratory distress (n=3). There was significant association between development of ventriculomegaly or worsening of preexisting ventriculomegaly and presence of SDH (p=0.004). The associated ventriculomegaly, present in 7/22 patients with symptomatic SDH, was managed with external ventricular drainage (EVD)(n=2), ventriculoperitoneal shunt (n=3) or widening of FMD and EVD (1)/ventriculo peritoneal shunt (1) (n=2). Two patients with SDH and ventriculomegaly died and 2 were moribund at 3 months after surgery. At median follow up of 12 months, the other 18 patients with symptomatic SDH had symptom resolution. SDH is a common finding in the early post-operative scans of patients undergoing FMD and dural opening for CM1. While nearly two-thirds of these patients are asymptomatic, SDH with ventriculomegaly can be associated with mortality and significant morbidity and may require emergency treatment.

Reconstructive Endovascular Treatment of Intracranial Ruptured Posterior Circulation Aneurysms Located on Small Arteries: Complications and Long-Term Results

ObjectiveAssess the complications, clinical outcomes, and angiographic results of ruptured intracranial posterior circulation aneurysms in small arteries, and identify their risk factors. MethodsWe conducted a retrospective analysis of 79 patients with ruptured posterior circulation aneurysms in small arteries (the diameter of the parent artery was ≤2 mm) treated at our hospital between January 2014 and August 2023. All patients received endovascular treatment. The study examined risk factors associated with in-hospital complications and clinical outcomes. ResultsThe incidence of in-hospital complications among all patients receiving reconstructive endovascular treatment was 12.7% (10/79). The patients were followed up for a median of 45 months (IQR 28-65), with an overall complication rate of 38.0%. Favorable clinical outcomes were observed in 85.3% (66/79) of patients, while the mortality rate was 11.4% (9/79). Of the 70 survivors, 59 (84.3%) underwent angiographic follow-up, revealing a median follow-up time of 11 months (IQR 6-12) and a complete occlusion rate of 84.7% (50/70). Aneurysm recanalization occurred in 6.8% (4/59) of patients. Survival analysis indicated 1-year and 3-year complication-free survival rates of 70.9% and 65.5%, respectively, and overall 1-year and 3-year survival rates of 89.6% and 87.6%. Multivariate analysis identified surgery within 72 hours of onset (p=0.043) and external ventricular drainage (p=0.023) as independent risk factors for in-hospital complications. Older age (p=0.024) and a WFNS grade of 4-5 (p<0.001) were independent risk factors for unfavorable clinical outcomes. ConclusionReconstructive endovascular treatment for ruptured intracranial posterior circulation small artery aneurysms is generally safe and effective. However, the risk of complications and unfavorable clinical outcomes persists. Early surgery within 72 hours post-rupture and external ventricular drainage are significant risk factors for in-hospital complications, whereas older age and higher WFNS grades are predictors of poor clinical outcomes.

Quantity of Caloric Support After Pediatric Severe Traumatic Brain Injury: Description of Associated Outcomes in a Single Retrospective Center Cohort, 2010–2022

Objectives: To examine the relationship between adequacy of caloric nutritional support during the first week after severe traumatic brain injury (TBI) and outcome. Design: Single-center retrospective cohort, 2010–2022. Setting: Tertiary care children’s hospital with a level 1 trauma center. Patients: Children younger than 18 years with PICU stay greater than 7 days for management of TBI, who had severe TBI, defined as Glasgow Coma Scale (GCS) score less than or equal to 8 at initial presentation and/or placement of an intracranial pressure monitor or external ventricular drain, and/or decompressive hemicraniectomy. Interventions: None. Measurements and Main Results: A total of 93 patients were identified (median age 46 mo; 53% male; median GCS 5; hospital mortality 4%). Caloric goal was assigned by a dietician and the proportion of prescribed calories delivered to each patient over the first 7 days of PICU admission were analyzed. At the end of the first 7 days post-injury, overall median (interquartile range [IQR]) caloric and protein adequacies were 42% (IQR, 28–62%) and 48% (IQR, 29–61%), respectively. We failed to identify an association between adequacy of caloric support and greater odds of higher Functional Status Scale (FSS) score or higher Glasgow Outcome Scale Extended for Pediatrics score at discharge. However, at outpatient follow-up, prior adequacy of PICU caloric support was associated with greater odds of worse FSS (multiplicative increase per 10% increase in calories [MI], 1.10; 95% CI, 1.03–1.18; p = 0.002) and worse GOS E-Peds (MI, 1.16; 95% CI, 1.08–1.27; p &lt; 0.001) at outpatient follow-up. Conclusions: In pediatric patients with severe TBI, there is an association between delivery of a greater proportion of their goal calories during the first 7 days after injury and greater odds of worse outcome at outpatient follow-up.

Microbiological spectrum of organisms in patients undergoing external ventricular drain insertion at a tertiary care hospital

Objective: To assess the incidence, causative pathogens, and impact of external ventricular drain-related infection on disease prognosis. Method: The observational, cross-sectional study was conducted September 2022 to March 2023 after obtaining approval from the ethics review board of Shifa International Hospital, Islamabad, Pakistan, and comprised patients having no prior cerebrospinal fluid infection. The patients underwent external ventricular drain administration as part of their treatment. Unneeded antibiotics or cerebrospinal fluid sampling before removing the drain were avoided. External ventricular drain-related infection was defined as pathogenic growth on one or more cerebrospinal fluid culture/sensitivity test post-insertion of the drain. Data was analysed using SPSS 26. Results: Of the 74 patients, 42(56.8%) were males and 32(43.2%) were females. Overall, 25(33.8%) patients were aged 20-50 years. A total of 86 external ventricular drain were inserted for a mean period of 10.77+/-7.42 days (range: 1-40), with a total of 797 catheter days. Hydrocephalus 21(28.4%) and tumours 20(27%) were the most common aetiologies for external ventricular drain, but no significant aetiological risk factors for external ventricular drain-related infection were identified (p&gt;0.05). Overall, 39(52.7%) patients recovered with external ventricular drain removal, and 12(16.2%) needed a shunt. External ventricular drain-related infection developed in 12(16.2%) patients (95% confidence interval: 4.15-4.75), having external ventricular drain for a mean period of 14.92+/-10.5 days (range 5-40) and 179 total catheter days. Coagulase-negative staphylococcus epidermidis was found in 4(33.3%) and it was sensitive to vancomycin, followed by Klebsiella pneumoniae and Pseudomonas aeruginosa 2(16.7%) each, and they were sensitive to amikacin and colistin, respectively. External ventricular drain-related infection was associated with poor outcomes (p=0.04), a longer intensive care unit stay (p&lt;0.05), a longer hospital stay (p&lt;0.05), and a longer external ventricular drain in-situ (p=0.05). Conclusion: Aseptic external ventricular drain placement and its early removal could avoid external ventricular drain-related infections. Key Words: Extra-ventricular drainage, EVD, EVD-related infection, ERI, Ventriculitis, Hydrocephalus, HCP.

The normalization trend of ventricular morphology after lateral ventricular tumor resection without additional diversion

Intraventricular tumors frequently provoke alterations in ventricular morphology. This study aims to quantificational assess perioperative dynamic fluctuations in the cerebrospinal fluid (CSF) volume within the lateral ventricles of patients harboring lateral ventricular tumors. A retrospective review encompassing 90 patients who underwent surgical intervention for lateral ventricular tumors at our institution was undertaken. Comprehensive observations at multiple perioperative time points were conducted, and LVCV analyses were performed to delineate the longitudinal dynamic alterations in ventricular morphology. Additionally, LVCV measurements were juxtaposed with data from 19 healthy subjects to stratify patients into two cohorts: those exhibiting preoperative increased LVCV and those without such changes. After surgical excision of intraventricular tumors, alterations in LVCV were compared between these cohorts, with a factor analysis undertaken specifically among patients demonstrating increased LVCV to elucidate potential influencing variables. 40 patients (44.4%) diagnosed with intraventricular tumors presenting with enlarged preoperative LVCV [74.6 (49.3–101.8) cm3] compared with the normal subject group, and the LVCV demonstrated a significant postoperative [41.3 (27.6–67.5) cm3] reduction in 3 months (p < 0.001). Meanwhile, 50 patients (55.6%) without LVCV enlargement [14.5 (8.1–21.0) cm3] experienced a notable increase following surgery in 3 months [20.2 (14.1–33.3) cm3, p = 0.002]. Preoperative increased LVCV is an important factor leading to the increased LVCV postoperatively (p = 0.022, OR = 26.239), however, compared to healthy subjects, both groups exhibited a trend toward normalization of LVCV value postoperatively (p = 0.165, p = 0.072, respectively). Following appropriate surgical excision of the tumor, the preoperative increased LVCV associated with intraventricular tumors does not hinder the normalization trend of ventricular morphology. Not all ventricular dilation requires preventive long-term external ventricular drainage and aggressive ventriculoperitoneal shunt treatment.

Predictors of tract hemorrhage after external ventricular drain placement: a single-center retrospective study

External ventricular drain (EVD) placement is often associated with complications; however, predictors of adverse outcomes after EVD placement are not well understood. This study aimed to identify predictors of EVD tract hemorrhage and to compare post-EVD hemorrhage rates between computer-assisted navigation and freehand technique EVD placement. This retrospective study included 147 consecutive patients who presented with increased intracranial pressure (ICP) requiring an EVD. Multivariable logistic regression was used to assess the relationship between predictors and adverse outcomes after EVD placement. The most common presenting pathologies in patients who had EVD placement were intraparenchymal hemorrhage (IPH) (43%) and subarachnoid hemorrhage (SAH) (28%). 14% of patients experienced EVD tract hemorrhage. Patients with platelet counts < 120 × 10³/µL (OR = 4.47, 95% CI = 1.01-20, p = 0.038), white blood cell counts < 11 × 10³/µL (OR = 3.3, 95% CI = 1.01–10.7, p = 0.048), and IPH (OR = 2.97, 95% CI = 1.06–10.7, p = 0.048) had increased risks of tract hemorrhage. The use of computer-assisted navigation did not reduce the risk of tract hemorrhage after EVD placement compared to the freehand technique. This study identified factors associated with increased risks of hemorrhage after EVD placement, which can help triage at-risk patients and reduce adverse outcomes of this procedure.

Abstract 4114994: Nursing Management Practice Variations related to Externalized Ventricular and Lumbar Drains

Introduction/Background: Nursing management of neurologic patients may include placement of externalized ventricular drains (EVDs) or lumbar drains (LDs) to monitor/drain cerebrospinal fluid (CSF), but knowledge and practice related to EVD management varies widely, despite a high potential for life-threatening complications. Limited data exists relative to the relationship between intracranial pressure (ICP) and CSF drainage. These gaps may undermine patient safety. Research Question: What are the nursing practices and perspectives regarding management of EVDs and LDs? Methods/Approach: A 16-question multiple-choice/text entry survey was distributed electronically to nurses and advanced practice nurses who were members of the American Association of Neuroscience Nurses. Data analysis included chi-square test for multiple choice responses, and qualitative data was analyzed using a six-step thematic analysis and an inductive approach. Results/Data: Of 219 participants, 42.8% reported roles as Neuroscience ICU nurses, and 39.2% managed an EVD at least 75% of the time. Neuro ICU nurses were most likely to have a patient with an EVD ( p =.002). Approximately 63% of respondents reported consulting with colleagues about EVDs nearly every time they cared for a patient with an EVD. Nurses reported a very high care burden, including re-leveling the transducer 4 or more times per shift (n=76), and re-zeroing every 8 hours (n=72) to assure accurate calibration. Of these 82.2% reported that they re-zeroed the EVD more often to obtain an accurate reading. Approximately 25% reported accidental over-drainage, some with negative outcomes. Many (79.3%) reported caring for patients with LDs, 47.4% to diagnose normal pressure hydrocephalus. The nursing care workload was described as 30-120 minutes each shift. Conclusion: A wide heterogeneity of nursing practices was revealed in EVD and LD management. No standardized nursing care practices have been adopted by nurses for the management of CSF. The complications of these practice variations have been shown to result in untoward patient outcomes. Increased patient morbidity and mortality are linked to catheter infection and over/under drainage of CSF and may be directly related nursing practice. This reveals critical need for improved, standardized care nursing practices in the management of EVDs and LDs, and an empiric understanding of the relationship between intracranial pressure and the volume and rate of CSF drainage.

BIOM-15. METASTATIC BIFOCAL GERMINOMA: A CASE HIGHLIGHTING DRAMATIC EARLY RADIOLOGICAL RESPONSE TO STEROIDS AND REBOUND FOLLOWING DISCONTINUATION, AND THE UTILITY OF CIRCULATING MIR-371A-3P QUANTIFICATION AND VINBLASTINE MONOTHERAPY PRIOR TO DEFINITIVE CRANIOSPINAL IRRADIATION

Abstract BACKGROUND In Europe, bifocal germinoma is diagnosed based on typical age (&amp;gt;8-10y), symptoms (diabetes insipidus), radiological appearances, and serum/CSF AFP/HCG markers below thresholds. A 12yo male presented with 4-month headaches, 3-month polyuria/polydipsia, visual and somnolence/memory issues. Weight=71.1kg; height=166cm. MRI head/spine revealed hydrocephalus and 19×14×15mm (volume=2.09cm3) enhancing pineal lesion with nodular suprasellar and septum-pellucidum soft tissue. CSF positive for malignant cells. Serum/CSF AFP/HCG markers below thresholds. Metastatic bifocal germinoma diagnosed. Dexamethasone (8mg/day=4.4mg/m2/day) commenced for raised pressure. Proton referral (craniospinal-irradiation) made, but 8 weeks to expected start; hence, external-ventricular-drain (EVD) placed and weekly vinblastine commenced (PMIDs:32642701/34520101). METHODS Serum/CSF placental-alkaline-phosphatase (PLAP) and miR-371a-3p measured at diagnosis and CSF longitudinally. MRI performed at d9+d19 post-vinblastine. RESULTS. At diagnosis, CSF miR-371a-3p PCR positive (raw-Cq=18.64) (PMID:37386046); serum miR-371a-3p and serum/CSF PLAP all negative. In follow-up, CSF miR-371a-3p levels fell with weekly vinblastine, consistent with treatment response; PLAP remained non-informative. Repeat CSF cytology after two vinblastine doses was negative. D9 MRI showed reduction in tumour size/enhancement [pineal lesion 13×7×12mm (0.57cm3) from 19×14×15mm] and reduced ventricular size. Dexamethasone switched to maintenance-dose hydrocortisone (10mg+5mg+2.5mg=9.7mg/m2/day). D19 MRI, however, showed increased tumour volume again (pineal=17×10×14mm; 1.25cm3), albeit less than at diagnosis, with CSF miR-371a-3p down to raw-Cq=26.92 (&amp;gt;300-fold reduction from diagnosis). EVD removed and septostomy performed; biopsy confirmed germinoma only (&amp;lt;5% cells) with &amp;gt;95% inflammatory cells (lymphocytes/macrophages). Vinblastine continued until protons without further tumour-associated comorbidity; MRI pre-protons showed pineal 10×10×12mm (0.63cm3; partial-remission) and post-protons complete-remission. Conclusion. Early radiological response to dexamethasone, with rebound on maintenance hydrocortisone, presumably secondary to lymphocytic re-infiltration of tumour (PMID:18000859). Reassuringly, circulating miR-371a-3p was informative for germinoma diagnosis (confirmed by biopsy) and treatment response. Weekly vinblastine useful bridge to definitive radiotherapy, explored in upcoming MonoGerm trial.

A Complex Case of Infective Endocarditis With Systemic Complications

A 25-year-old female, with a known case of small perimembranous VSD who was started on empirical anti-tubercular drugs for suspected bilateral tubercular sacroiliitis for the last 1 month presented with persistent fever and increasing shortness of breath. Transthoracic echocardiography revealed concurrent infective endocarditis (IE) affecting the aortic and mitral valves, with small perimembranous ventricular septal defect (VSD), and severe aortic and mitral regurgitation. Repeated blood cultures did not show any growth. Empirical management with intravenous ceftriaxone and gentamicin was initiated. After completing 2 weeks of IV Gentamicin, the patient developed severe headache, vomiting, and transient loss of consciousness. MRI Head confirmed subarachnoid hemorrhage. Emergency External ventricular drain placement ameliorated intracranial pressure-related symptoms. Digital subtraction angiography identified a mycotic aneurysm at left MCA bifurcation as a complication of IE, which was successfully managed through endovascular coiling. Repeat MRI showed subsiding SAH with areas of ischemia, most probably related to cerebral vasospasm. Her blood cultures were still negative, hence shifted to Inj Vancomycin. After a few days, the patient developed a fever with a fall in GCS. Lumbar puncture confirmed bacterial meningitis, subsequently treated with intravenous meropenem. Cardiac CT was done which revealed a small perimembranous VSD along with a small ruptured Sinus of Valsalva draining in the right ventricle. After successful treatment of SAH and meningitis, the patient underwent dual valve replacement (aortic and mitral), VSD closure, and Ruptured sinus of Valsalva repair. Postoperative recovery was uneventful, and the patient was discharged on the fifth postoperative day.

Predictive factors for shunt dependency in patients with spontaneous intraventricular hemorrhage

Intraventricular hemorrhage (IVH) occurs in approximately 30–50% patients with spontaneous intracerebral hemorrhage (ICH), with a high 30-day mortality rate. Excess accumulation of parenchymal or ventricular blood associated with the development of acute hydrocephalus leads to poor outcomes. The prediction of shunt dependency is important to identify patients susceptible to requiring permanent shunt placement and benefit from the diversion. This retrospective analytical study aimed to establish a predictive model of shunt dependency in patients with IVH. This study included 179 patients with primary IVH with supratentorial origin or spontaneous ICH with extension into the ventricles between 2015 and 2021. Patients were grouped into “shunt required” and “shunt not required” groups. Variables, including age, sex, preexisting hypertension and diabetes, initial Glasgow Coma Scale scores, ICH location and volume, urokinase administration, modified Graeb score (mGraeb score), and bicaudate index, were analyzed. The shunt required group had significantly higher mGraeb scores (12.0 (6.5–15.0) vs. 7.0 (4.0–12.0), p = 0.001) and higher bicaudate index (0.20 (0.17–0.23) vs. 0.16 (0.13–0.18), P < 0.001) than the shunt not required group. The receiver operating characteristic curve (ROC curve) analysis revealed that a cut-off value of 0.16 of the bicaudate index was significantly related to shunt dependency. The subgroup statistical analysis revealed that neither urokinase administration (p = 0.533) nor urokinase dosage (p = 0.117) showed significant relevance in shunt dependency in patients who received external ventricular drainage. In logistic regression adjusted for the confounders, thalamic ICH (odds ratio (OR) 3.55; 95% confidence interval [(95%CI), 1.13–11.18], an mGraeb score greater than 8 (OR, 3.93; 95%CI, 1.84–8.38), and a bicaudate index greater than 0.16 (OR, 9.87; 95%CI, 3.79–25.73) were factors associated with a higher tendency for shunting. The findings of this study may help identify patients at risk for a permanent shunt after IVH.

Clinical Characteristics and Predictors of Mortality of Patients with Post-Neurosurgical Meningitis-A 900-Cases Cohort Study.

To express the clinical characteristics of patients with post-neurosurgical meningitis (PNM) and launch a survival analysis to screen mortality predictors. A cohort analysis containing more than 70000 patients was evaluated, and all of them received neurosurgical procedure. Clinical and microbial epidemiology, therapy and mortality of PNM patients were reviewed. Multi-variable Cox proportional hazard models were applied to achieve survival analysis. About 900 PNM patients from 3244 cases were selected for characteristics and survival analysis, the mean age of them was 41 (27-54) years, 516 (57.3%) were men and 384 (42.7%) were women. The 28-day mortality was 12.4% (112 of 900) in patients with PNM. Hypertension, external ventricular drainage (EVD), and lumbar drainage (LD) are mortality predictors for PNM, with a hazard ratio (HR) of 2.641 (95% C.I. 1.563-4.464, P<0.001), 2.196 (95% C.I. 1.317-3.662, P=0.003), and 1.818 (95% C.I. 1.126-2.936, P=0.014). In treatment, the outcome of patients receiving three or more antibiotic combinations is better than that of patients receiving dual-drug combinations. The mortality of patients with PNM was relatively high, and the risk factors related to 28-days mortality were hypertension, EVD and LD and treatment with three or more antibiotics are much better.

Can a single basal cistern urokinase bolus help to prevent subarachnoid hemorrhage consequences?

Study designRetrospective. BackgroundIn the 1980s, aneurysmal subarachnoid clot lysis with urokinase or alteplase (rtPA) was proven to effectively reduce vasospasm and neurological ischemic deficits, improving survival and clinical outcomes. This therapeutic option has been less commonly used since the introduction of endovascular treatment, but renewed interest has sparked in recent years. AimsTo investigate if single bolus cisternal urokinase subarachnoid clot lysis reduces vasospasm, neurological ischemic deficits, mortality, and permanent CSF diversion rates and improves outcomes. Additionally, we want to unveil which subgroup of patients benefit most. Material and methodsStudy period January 2007–December 2019. 415 patients with saccular aneurysms and >1-year follow-up analyzed. Six groups created according to the treatment applied: no treatment (42), only external ventricular drain (16), endovascular treatment (155), clipping (53), clipping + 100,000UI urokinase (116), and incidental brain aneurysm (33). ResultsThe rates and severity of vasospasm, permanent CSF diversion, and mortality in Fisher grades ≥3 subarachnoid hemorrhages were higher with endovascular treatment than with surgical clipping with simultaneous cisternal urokinase administration. The best GOSE results on discharge and 6- and 12-month follow-ups happened in this latter group. The differences were more significant the higher the Fisher grade. We neither saw intraventricular, subarachnoid, subdural, or epidural hemorrhages nor systemic fibrinolysis or infections that could be related to the urokinase administration. ConclusionsSingle bolus cisternal 100,000UI urokinase administration during emergency aneurysm clipping reduces vasospasm, mortality, and the need for permanent CSF diversion. It is not associated with a significant increase in intracranial hemorrhages or systemic fibrinolysis.

Deciphering Proteomic Expression in Inflammatory Disorders: A Mass Spectrometry Exploration Comparing Infectious, Noninfectious, and Traumatic Brain Injuries in Human Cerebrospinal Fluid.

The central nervous system (CNS) evokes a complex inflammatory response to injury. Inflammatory cascades are present in traumatic, infectious, and noninfectious disorders affecting the brain. It contains a mixture of pro- and anti-inflammatory reactions involving well-known proteins, but also numerous proteins less explored in these processes. The aim of this study was to explore the distinct inflammatory response in traumatic brain injury (TBI) compared with other CNS injuries by utilization of mass-spectrometry. In total, 56 patients had their cerebrospinal fluid (CSF) analyzed with the use of mass-spectrometry. Among these, CSF was collected via an external ventricular drain (EVD) from n = 21 patients with acute TBI. The resulting protein findings were then compared with CSF obtained by lumbar puncture from n = 14 patients with noninfectious CNS disorders comprising relapsing-remitting multiple sclerosis, anti-N-methyl-d-aspartate-receptor encephalitis, acute disseminated encephalomyelitis, and n = 14 patients with progressive multifocal leukoencephalopathy, herpes simplex encephalitis, and other types of viral meningitis. We also utilized n = 7 healthy controls (HCs). In the comparison between TBI and noninfectious inflammatory CNS disorders, concentrations of 55 proteins significantly differed between the groups. Among them, 23 and 32 proteins were up- and downregulated, respectively, in the TBI group. No proteins were uniquely identified in either group. In the comparison of TBI and HC, 51 proteins were significantly different, with 24 and 27 proteins being up- and downregulated, respectively, in TBI. Two proteins (fibrinogen gamma chain and transketolase) were uniquely identified in all samples of the TBI group. Also in the last comparison, TBI versus infectious inflammatory CNS disorders, 51 proteins differed between the two groups, with 19 and 32 proteins being up- and downregulated, respectively, in TBI, and no unique proteins being identified. Due to large discrepancies between the groups compared, the following proteins were selected for further deeper analysis among those being differentially regulated: APOE, CFB, CHGA, CHI3L1, C3, FCGBP, FGA, GSN, IGFBP7, LRG1, SERPINA3, SOD3, and TTR. We found distinct proteomic profiles in the CSF of TBI patients compared with HC and different disease controls, indicating a specific interplay between inflammatory factors, metabolic response, and cell integrity. In relation to primarily infectious or inflammatory disorders, unique inflammatory pathways seem to be engaged, and could potentially serve as future treatment targets.

Successful Treatment of MDRAcinetobacter baumannii Meningitis in a Young Adult Patient With Intraventricular and Intravenous Polymyxin B-Tigecycline Based Combinations: A Case Report.

Multiple drug resistance to Acinetobacter baumannii infection treatment is a great challenge for neuro-intensivists due to poor drug penetration through the blood-brain barrier (BBB). Fortunately, the intraventricular administration of polymyxin-B and tigecycline seems to be effective; there are few case reports demonstrating the effectiveness of such treatments. Here, we report the case of a 24-year-old male who presented with fever and neck rigidity after intracranial drainage following lung infection caused by MDR Acinetobacter baumannii. Due to the presence of turbid CSF, the administration of the intrathecal (ITH) route polymyxin-B and tigecycline is not possible. In this situation, the neuro-intensivist decided to start intraventricular tigecycline and polymyxin-B administration along with IV tigecycline and polymyxin-B via the intraventricular route, which was feasible because the patient had an external ventricular drain (EVD) due to obstructive hydrocephalus caused by the neurosurgeon after excision of the tumor.

The Value of Machine Learning Models in Predicting Factors Associated with the Need for Permanent Shunting in Patients with Intracerebral Hemorrhage Requiring Emergency Cerebrospinal Fluid Diversion

ObjectiveTo assess the efficacy of machine learning models (MLMs) in identifying factors associated with the need for permanent ventricular shunt placement in patients experiencing intracerebral hemorrhage (ICH) who require emergency cerebrospinal fluid (CSF) diversion. MethodsA retrospective review was performed on patients with ICH requiring urgent CSF diversion who were admitted to our facility between July 2009 and May 2023. A binary logistic regression analysis was carried out to determine independent predictors linked to the development of shunt-dependent hydrocephalus following ICH. Five different machine learning models—random forest (RF), support vector machine (SVM), k-nearest neighbor (k-NN), logistic regression (LR), and Adaptive Boosting (AdaBoost)—were utilized to predict the need for permanent shunting in those with spontaneous ICH necessitating emergency CSF diversion. Additionally, RF techniques were applied to identify the factors affecting the need for permanent ventricular shunt placement in these patients. ResultsA total of 578 patients were included in the analysis. Shunt-dependent hydrocephalus occurred in 121 individuals (20.9%). In the multivariate analysis, the Graeb Score, the length of time the external ventricular drain (EVD) was in place, and an elevated intracranial pressure (ICP) greater than 30 mm Hg were significant predictors for the need for permanent CSF diversion (p<0.05). All predictive models showed commendable performance, with RF achieving the highest accuracy (0.921), followed by SVM (0.906), k-NN (0.889), LR (0.881), and AdaBoost (0.823). RF also excelled over the other models in terms of sensitivity and specificity, with a sensitivity of 0.912 and specificity of 0.892. The area under the curve (AUC) values for RF, SVM, k-NN, LR, and AdaBoost were recorded at 0.903, 0.820, 0.804, 0.801, and 0.798, respectively. ConclusionThis research demonstrates that machine learning models can effectively predict the need for permanent CSF diversion in patients with ICH who underwent EVD placement for urgent CSF diversion, offering important prognostic insights that could facilitate early intervention and lead to potential cost reductions.

Neurosurgery in Australia's Top End: the lifesaving advantages of developing sustainable neurosurgical care in rural and remote regions.

The authors' goal was to perform a retrospective audit of all emergency cranial neurosurgery performed at the Royal Darwin Hospital in the first 5 years of the unit and to compile their data in a similar fashion to an earlier study titled "Emergency Neurosurgery in Darwin: Still the Generalist Surgeons' Responsibility," which was published in 2015. All emergency cranial neurosurgery performed by a neurosurgeon between 2017 and 2021 was identified. Data were extracted from the National Critical Care and Trauma Response Centre database. Statistical analyses were descriptive logistic regression performed using Stata version 15.1 software to examine factors associated with death. A total of 320 patients (42% Indigenous) underwent 427 emergency neurosurgeries. There were 35 emergency neurosurgeries in 2017 and 82 in 2021. The most common procedure performed was insertion of an external ventricular drain, followed by craniotomy and removal of intracranial hematoma. Mortality was 7.5% overall and 8.4% among patients with trauma. Only age proved to be a statistically significant independent risk factor for death (t = -2.95, p < 0.0041; OR 1.06, p = 0.02). Location, sex, injury severity, and presenting Glasgow Coma Scale score were not associated with death. Indigenous and non-Indigenous patients had similar outcomes. The data illustrate the importance of developing small but sustainable neurosurgical units in rural and remote areas. A dedicated neurosurgical unit at the Royal Darwin Hospital has led to an increase in the amount and variety of emergency neurosurgery performed in Darwin. Interstate transfers have reduced. This has tangible lifesaving and economic advantages.