Ventricular Drainage Research Articles

External ventriculostomy-associated infection reduction after updating a care bundle

BackgroundDespite the clinical benefits of external ventricular drains (EVD), these devices can lead to EVD-related infections (EVDRI). The drainage insertion technique and standardized guidelines can significantly reduce the risk of infection, mainly caused by gram-positive bacteria. However, gram-negative microorganisms are the most frequent causative microorganisms of EVDRI in our hospital. We aimed to determine whether a new bundle of measures for the insertion and maintenance of a drain could reduce the incidence of EVDRI. This cohort study of consecutive patients requiring EVD from 01/01/2015 to 12/31/2018 compared the patients’ characteristics before and after introducing an updated protocol (UP) for EVD insertion and maintenance in 2017.ResultsFrom 204 consecutive patients, 198 requiring EVD insertion were included (54% females, mean age 55 ± 15 years). The before-UP protocol included 87 patients, and the after-UP protocol included 111 patients. Subarachnoid (42%) and intracerebral (24%) hemorrhage were the main diagnoses at admission. The incidence of EVDRI fell from 13.4 to 2.5 episodes per 1000 days of catheter use. Gram-negative bacteria were the most frequent causative microorganisms. Previous craniotomy remained the only independent risk factor for EVDRI. EVDRI patients had increased mechanical ventilation durations, hospital and ICU stays, and percutaneous tracheostomy requirements.ConclusionsA care bundle focusing on fewer catheter sampling and more accurate antiseptic measures can significantly decrease the incidence of EVDRI. After implementing the management protocol, a decreased incidence of infections caused by gram-negative and gram-positive bacteria and reduced ICU and hospital lengths of stay were observed.

Posthemorrhagic Hydrocephalus in Patients with Subarachnoid Hemorrhage Occurs Independently of CSF Osmolality.

The molecular mechanisms underlying the development of posthemorrhagic hydrocephalus (PHH) remain incompletely understood. As the disease pathogenesis often cannot be attributed to visible cerebrospinal fluid (CSF) drainage obstructions, we here aimed to elucidate whether elevated CSF osmolality following subarachnoid hemorrhage (SAH) could potentiate the formation of ventricular fluid, and thereby contribute to the pathological CSF accumulation observed in PHH. The CSF osmolality was determined in 32 patients with acute SAH after external ventricular drainage (EVD) placement and again upon EVD removal and compared with the CSF osmolality from 14 healthy control subjects undergoing vascular clipping of an unruptured aneurism. However, we found no evidence of elevated CSF osmolality or electrolyte concentration in patients with SAH when compared to that of healthy control subjects. We detected no difference in CSF osmolality and electrolyte content in patients with successful EVD weaning versus those that were shunted due to PHH. Taken together, elevated CSF osmolality does not appear to underlie the development of PHH following SAH. The pathological CSF accumulation observed in this patient group must thus instead be attributed to other pathological alterations associated with the abnormal presence of blood within the CSF compartments following SAH.

Augmented Reality-Assisted versus Freehand Ventriculostomy in a Head Model.

Ventriculostomy (VST) is a frequent neurosurgical procedure. Freehand catheter placement represents the standard current practice. However, multiple attempts are often required. We present augmented reality (AR) headset guided VST with in-house developed head models. We conducted a proof of concept study in which we tested AR-guided as well as freehand VST. Repeated AR punctures were conducted to investigate if a learning curve can be derived. Five custom-made 3D-printed head models, each holding an anatomically different ventricular system, were filled with agarose gel. Eleven surgeons placed two AR-guided as well as two freehand ventricular drains per head. A subgroup of four surgeons did a total of three series of AR-guided punctures each to test for a learning curve. A Microsoft HoloLens served as the hardware platform. The marker-based tracking did not require rigid head fixation. Catheter tip position was evaluated in computed tomography scans. Marker-tracking, image segmentation, and holographic display worked satisfactorily. In freehand VST, a success rate of 72.7% was achieved, which was higher than under AR guidance (68.2%, difference not statistically significant). Repeated AR-guided punctures increased the success rate from 65 to 95%. We assume a steep learning curve as repeated AR-guided punctures led to an increase in successful attempts. Overall user experience showed positive feedback. We achieved promising results that encourage the continued development and technical improvement. However, several more developmental steps have to be taken before an application in humans can be considered. In the future, AR headset-based holograms have the potential to serve as a compact navigational help inside and outside the operating room.

Bilateral vocal cord palsy as complication of CNS tuberculosis

BackgroundTuberculous meningitis, a rare but severe form of extrapulmonary tuberculosis, frequently affects cranial nerves. While nerves III, VI and VII are commonly involved, involvement of caudal cranial nerves is rarely described. Here, we report a rare case of bilateral vocal cord palsy secondary to caudal cranial nerve involvement in tuberculous meningoencephalitis, that occurred in Germany, a country with low tuberculosis incidence.Case presentationA 71-year-old woman was transferred for further treatment of hydrocephalus as a complication of presumed bacterial meningitis with unknown pathogen at that time. Because of decreased consciousness, intubation was performed and an empiric antibiotic therapy with ampicillin, ceftriaxone and acyclovir was initiated. Upon admission to our hospital, an external ventricular drainage was placed. Cerebrospinal fluid analysis revealed Mycobacterium tuberculosis as the causative pathogen, and antitubercular treatment was initiated. Extubation was possible one week after admission. Eleven days later, the patient developed inspiratory stridor that worsened within a few hours. Flexible endoscopic evaluation of swallowing (FEES) revealed new-onset bilateral vocal cord palsy as the cause of respiratory distress, which required re-intubation and tracheostomy. The bilateral vocal cord palsy persisted despite continued antitubercular therapy on the follow-up examination.ConclusionConsidering the aetiology of infectious meningitis, cranial nerve palsies may be suggestive for tuberculous meningitis as underlying disease given their rarity in other bacterial forms of meningitis. Nevertheless, intracranial involvement of inferior cranial nerves is rare even in this specific entity, as only extracranial lesions of inferior cranial nerves have been reported in tuberculosis. With this report of a rare case of bilateral vocal cord palsy due to intracranial involvement of the vagal nerves, we emphasize the importance of timely initiation of treatment for tuberculous meningitis. This may help to prevent serious complications and associated poor outcome since the response to anti-tuberculosis therapy may be limited.

Obstructive Infantile Hydrocephalus Secondary to Meningoventriculitis: A Case Report

Obstructive infantile hydrocephalus may arise due to anatomic or functional obstruction of cerebrospinal fluid flow. Obstruction of the aqueduct of sylvius (aqueductal stenosis) causes dilation of the lateral and third ventricles, while the size of the fourth ventricle remains relatively normal. Obstructive infantile hydrocephalus with meningoventriculitis is a rare phenomenon, and literature with only 2 other children with similar findings have been reported. We hereby report a case of a 16-week-old infant who developed Escherichia coli meningoventriculitis, later complicated by the development of hydrocephalus, challenging the management. The diagnosis was based on the magnetic resonance imaging of the brain, which showed hydrocephalus, and the cerebrospinal fluid culture showing Escherichia coli meningoventriculitis. The case was managed with serial ventricular drainage along with antibiotics followed by staged ventriculoperitoneal shunting. Serial measurement of head circumference is essential to prompt diagnostic suspicion in the case of paediatric meningitis.

Unilateral rete mirabile in multiple intracranial arteries with ipsilateral agenesis of the internal carotid artery: a case report

BackgroundRete mirabile of the cerebral artery is a rare anomaly, with most previous cases occurring in the middle cerebral artery or internal carotid artery. Here, we present the first report of unilateral rete mirabile in multiple intracranial arteries with ipsilateral internal carotid artery agenesis.Case presentationA 64-year-old Japanese woman was brought to the emergency department of our hospital in a deep coma. Computed tomography of the head showed severe intraventricular hemorrhage with subarachnoid hemorrhage. Computed tomography angiography showed not only congenital left internal carotid artery agenesis, but also rete mirabile of the left posterior communicating artery, the left posterior cerebral artery, and the left anterior cerebral artery. This unilateral vessel anomaly complex may have contributed to the formation of a peripheral aneurysm arising from a perforating branch of the pericallosal artery, which ruptured. The patient underwent urgent bilateral external ventricular drainage, but deteriorated and was declared brain dead.ConclusionsWe report the first case of unilateral rete mirabile in multiple intracranial arteries. Because the cerebral arteries in patients with rete mirabile may be vulnerable, close attention should be paid to the development of cerebral aneurysms.

Comparison of External Ventricular Drains with Ventricular Access Devices for the Emergency Management of Adult Hydrocephalus

We compared external ventricular drains (EVDs) with percutaneous continuous CSF drainage via ventricular access devices (VADs) for the acute management of hydrocephalus in adults. This was a retrospective review of all ventricular drains inserted for a new diagnosis of hydrocephalus into non-infected CSF over 4 years. We compared infection rates, return to theatre, and patient outcome between EVDs and VADs. We explored the effect of duration of drainage, frequency of sampling, hydrocephalus aetiology, and catheter location on these outcomes using multivariable logistic regression modelling. We included 179 drains (76 EVDs and 103 VADs). EVDs were associated with a higher rate of unplanned return to theatre for replacement or revision (27/76, 36%, vs 4/103, 4%, OR:13.4 95%CI:4.3-55.8). However, infection rates were higher in VADs (13/103, 13% vs 5/76, 7%, OR:2.0, 95%CI:0.65-7.7). EVDs were 91% antibiotic impregnated whereas VADs were 98% non-impregnated. In multivariable analysis, infection was associated with duration of drainage (median:11 days prior to infection for infected drains vs 7 days total for non-infected drains), but not drain type (VADs vs EVDs OR:1.6, 95%CI:0.5-6). EVDs had a higher rate of unplanned revisions but a lower infection rate compared to VADs. However, in multivariable analysis choice of drain type was not associated with infection. We suggest a prospective comparison of antibiotic impregnated VADs and EVDs using similar sampling protocols to assess whether VADs or EVDs for acute hydrocephalus have a lower overall complication rate.

Nocturnal increase in cerebrospinal fluid secretion as a circadian regulator of intracranial pressure

BackgroundIt is crucial to maintain the intracranial pressure (ICP) within the physiological range to ensure proper brain function. The ICP may fluctuate during the light-dark phase cycle, complicating diagnosis and treatment choice in patients with pressure-related disorders. Such ICP fluctuations may originate in circadian or sleep-wake cycle-mediated modulation of cerebrospinal fluid (CSF) flow dynamics, which in addition could support diurnal regulation of brain waste clearance.MethodsICP was monitored continuously in patients who underwent placement of an external ventricular drain (EVD) and by telemetric monitoring in experimental rats. CSF was collected via the EVD in patients and the rodent CSF secretion rate determined by in vivo experimentation. Rodent choroid plexus transporter transcripts were quantified with RNAseq and transport activity with ex vivo isotope transport assays.ResultsWe demonstrated that ICP increases by 30% in the dark phase in both species, independently of vascular parameters. This increase aligns with elevated CSF collection in patients (12%) and CSF production rate in rats (20%), the latter obtained with the ventriculo-cisternal perfusion assay. The dark-phase increase in CSF secretion in rats was, in part, assigned to increased transport activity of the choroid plexus Na+,K+,2Cl- cotransporter (NKCC1), which is implicated in CSF secretion by this tissue.ConclusionCSF secretion, and thus ICP, increases in the dark phase in humans and rats, irrespective of their diurnal/nocturnal activity preference, in part due to altered choroid plexus transport activity in the rat. Our findings suggest that CSF dynamics are modulated by the circadian rhythm, rather than merely sleep itself.

Drainage, Irrigation, and Fibrinolytic Therapy (DRIFT) for Adult Intraventricular Hemorrhage Associated with Primary Hypertensive Hemorrhages Using IRRAflow Self-Irrigating Catheter: A Report of Three Cases and Prior Historical Controls

Spontaneous primary intracerebral hemorrhage(ICH) accounts for 10-15% of strokes and is accompanied by ventricular involvement in 10-30% of cases. Intraventricular hemorrhage(IVH) is a poor prognostic factor and the current treatment paradigm of external ventricular drainage requires frequent flushing and replacement. Given the documented high rate of failure standard EVD catheters, we sought to determine if the use of the IRRAflow® system with the addition of alteplase would be beneficial in this patient population for the treatment of IVH associated with primary hypertensive ganglionic hemorrhages METHODS: Three patients with ganglionic hemorrhages and IVH underwent treatment with the IRRAflow system at our institution from December 2022 to January 2023. A retrospective review was then performed of patients with primary hypertensive ganglionic hemorrhages and EVD placement at our institution from January 2021 to present day. Three patients underwent treatment with the IRRAflow® system and continuous lavage of tPA. The IVH was efficiently cleared in all cases and the drains were removed within 8 days in all cases. No patients required replacement of the drain and there were no hemorrhagic complications noted. In our retrospective review, 28 patients were identified who underwent placement of a standard EVD for the treatment of primary hypertensive ganglionic hemorrhages. When patients who had early withdrawal of care were excluded, the average length of EVD treatment was 11.3 days and the EVD replacement rate was 24%. We demonstrate here that the use of the IRRAflow system for the treatment of primary hypertensive hemorrhages with IVH results in rapid clearance of the IVH without safety concerns. Compared to historical controls there was a decrease in EVD duration, EVD replacement and ICU LOS.

Terson syndrome secondary to aneurysmal subarachnoid hemorrhage in a child: illustrative case.

Terson syndrome is the phenomenon of intraocular hemorrhage in the setting of subarachnoid hemorrhage (SAH). Vision loss can lead to morbidity for the affected individual. Aneurysmal SAH related to intracranial aneurysms is rare in children. Studies have shown the incidence of Terson syndrome in adults with aneurysmal SAH to be over 40%; however, few cases of Terson syndrome in pediatric aneurysmal SAH have been reported. A 9-year-old male presented with altered mental status and seizures. Computed tomographic angiography showed aneurysmal SAH from a ruptured, left-sided posterior inferior cerebellar artery aneurysm. The patient underwent endovascular treatment with coiling and external ventricular drainage for SAH. Ophthalmological consultation for blurry vision revealed the diagnosis of Terson syndrome with decreased vision in the left eye, which was managed conservatively. Terson syndrome after SAH can occur in children. Prompt ophthalmological evaluation in pediatric patients with aneurysmal SAH is vital for recognition and management to decrease overall morbidity.

Low- and Negative-Pressure Hydrocephalus: New Report of Six Cases and Literature Review.

Low- or very-low-pressure hydrocephalus is a serious and rare phenomenon, which is becoming better known since it was first described in 1994 by Pang and Altschuler. Forced drainage at negative pressures can, in most cases, restore the ventricles to their original size, thus achieving neurological recovery. We present six new cases that suffered this syndrome from 2015 to 2020: two of them after medulloblastoma surgery; a third one as a consequence of a severe head trauma that required bifrontal craniectomy; another one after craniopharyngioma surgery; a fifth one with leptomeningeal glioneuronal tumor; and, finally, a patient with a shunt for normotensive hydrocephalus. Before the development of this condition, four of them had mid-low-pressure cerebrospinal fluid (CSF) shunts. Four patients required cerebrospinal fluid (CSF) drainage at negative pressures oscillating from zero to -15 mmHg by external ventricular drainage until ventricular size normalized, followed by the placement of a new definitive low-pressure shunt, one of them to the right atrium. The duration of drainage in negative pressures through external ventricular drainage (EVD) ranged from 10 to 40 days with concomitant intracranial pressure monitoring at the neurointensive care unit. Approximately 200 cases of this syndrome have been described in the literature. The causes are varied and superimposable to those of high-pressure hydrocephalus. Neurological impairment is due to ventricular size and not to pressure values. Subzero drainage is still the most commonly used method, but other treatments have been described, such as neck wrapping, ventriculostomy of the third ventricle, and lumbar blood patches when associated with lumbar puncture. Its pathophysiology is not clear, although it seems to involve changes in the permeability and viscoelasticity of the brain parenchyma together with an imbalance in CSF circulation in the craniospinal subarachnoid space.

Shunt-Dependent Post-Traumatic Hydrocephalus: Predictors and Long-Term Functional Outcomes.

As a disorder of the brain in adults and children, traumatic brain injury (TBI) is considered the major cause of mortality and morbidity. As a serious complication of TBI, post-traumatic hydrocephalus (PTH) is commonly identified and significantly associated with neurocognitive impairment, motor dysfunction, and growth impairment. The long-term functional outcomes after shunt dependence are totally not clear. This study included 6279 patients between 2012 and 2022. To identify the unfavorable functional outcomes and the PTH-related factors, we carried out univariable logistic regression analyses. To identify the occurrence time of PTH, we conducted the log-rank test and Kaplan-Meier analysis. Mean patient age was 51.03 ± 22.09years. Of the 6279 patients with TBI, 327 developed PTH (5.2%). Several PTH development-associated factors, such as intracerebral hematoma, diabetes, longer initial hospital stay, craniotomy, low GCS (Glasgow Coma Scale), EVD (external ventricular drain), and DC (decompressive craniectomy) (p < 0.01), were identified. We also analyzed the factors of unfavorable outcomes after TBI including > 80years, repeated operations, hypertension, EVD, tracheotomy, and epilepsy (p < 0.01). Ventriculoperitoneal shunt (VPS) itself is not an independent factor of the unfavorable outcome but shunt complication is a strong independent factor of unfavorable outcome (p < 0.05). We should emphasize the practices that can minimize the risks of shunt complications. Additionally, the rigorous radiographic and clinical surveillance will benefit those patients at high risk of developing PTH. ClinicalTrials.gov identifier, ChiCTR2300070016.

Persistent neurological symptoms and elevated intracranial pressures in a previously healthy host with cryptococcal meningitis

Cryptococcal meningoencephalitis can occur in both previously healthy and immunocompromised hosts. Here, we describe a 55 year-old HIV-negative male with no known prior medical problems, who presented with three months of worsening headaches, confusion, and memory changes without fever. Magnetic resonance imaging of the brain demonstrated bilateral enlargement/enhancement of the choroid plexi, with hydrocephalus, temporal and occipital horn entrapments, as well as marked periventricular transependymal cerebrospinal fluid (CSF) seepage. CSF analysis yielded a lymphocytic pleocytosis and cryptococcal antigen titer of 1:160 but sterile fungal cultures. Despite standard antifungal therapy and CSF drainage, the patient had worsening confusion and persistently elevated intracranial pressures. External ventricular drainage led to improved mental status but only with valve settings at negative values. Ventriculoperitoneal shunt placement could thus not be considered due to a requirement for drainage into the positive pressure venous system. Due to this persistent CSF inflammation and cerebral circulation obstruction, the patient required transfer to the National Institute of Health. He was treated for cryptococcal post-infectious inflammatory response syndrome with pulse-taper corticosteroid therapy, with resultant reductions in CSF pressures along with decreased protein and obstructive material, allowing successful shunt placement. After tapering of corticosteroids, the patient recovered without sequelae. This case highlights (1) the necessity to consider cryptococcal meningitis as a rare cause of neurological deterioration in the absence of fever even in apparently immunocompetent individuals and (2) the potential for obstructive phenomena from inflammatory sequelae and the prompt response to corticosteroid therapy.

Association between external ventricular drain removal or replacement and prophylactic anticoagulation in patients with aneurysmal subarachnoid hemorrhage: a propensity-adjusted analysis.

Withholding prophylactic anticoagulation from patients with aneurysmal subarachnoid hemorrhage (aSAH) before external ventricular drain (EVD) removal or replacement remains controversial. This study analyzed whether prophylactic anticoagulation was associated with hemorrhagic complications related to EVD removal. All aSAH patients treated from January 1, 2014, to July 31, 2019, with an EVD placed were retrospectively analyzed. Patients were compared based on the number of prophylactic anticoagulant doses withheld for EVD removal (> 1 vs. ≤ 1). The primary outcome analyzed was deep venous thrombosis (DVT) or pulmonary embolism (PE) after EVD removal. A propensity-adjusted logistic-regression analysis was performed for confounding variables. A total of 271 patients were analyzed. For EVD removal, > 1 dose was withheld from 116 (42.8%) patients. Six (2.2%) patients had a hemorrhage associated with EVD removal, and 17 (6.3%) patients had a DVT or PE. No significant difference in EVD-related hemorrhage after EVD removal was found between patients with > 1 versus ≤ 1 dose of anticoagulant withheld (4 of 116 [3.5%] vs. 2 of 155 [1.3%]; p = 0.41) or between those with no doses withheld compared to ≥ 1 dose withheld (1 of 100 [1.0%] vs. 5 of 171 [2.9%]; p = 0.32). After adjustment, withholding > 1 dose of anticoagulant versus ≤ 1 dose was associated with the occurrence of DVT or PE (OR 4.8; 95% CI, 1.5-15.7; p = 0.009). In aSAH patients with EVDs, withholding > 1 dose of prophylactic anticoagulant for EVD removal was associated with an increased risk of DVT or PE and no reduction in catheter removal-associated hemorrhage.

Venous thromboembolism in aneurysmal subarachnoid hemorrhage: Risk factors and timing of chemoprophylaxis

IntroductionVenous thromboembolism (VTE) is a significant contributor to morbidity and mortality among patients recovering from aneurysmal subarachnoid hemorrhage (aSAH). Prophylactic heparin reduces the risk of VTE, but the optimal timing for its initiation among aSAH patients remains unclear. ObjectiveTo conduct a retrospective study assessing risk factors for VTE and optimal timing of chemoprophylaxis in patients treated for aSAH. MethodsFrom 2016–2020, 194 adult patients were treated for aSAH at our institution. Patient demographics, clinical diagnoses, complications, pharmacologic interventions, and outcomes were recorded. Risk factors for symptomatic VTE (sVTE) were analyzed via Chi-squared, univariate, and multivariate regression. ResultsIn total 33 patients presented with sVTE (25 DVT, 14 PE). Patients with sVTE had longer hospital stays (p < 0.01) and worse outcomes at one-month (p < 0.01) and three-month follow-up (p = 0.02). Univariate predictors of sVTE included male sex (p = 0.03), Hunt Hess score (p = 0.01), Glasgow Coma scale (p = 0.02), intracranial hemorrhage (p = 0.03), hydrocephalus requiring external ventricular drain (EVD) placement (p < 0.01), and mechanical ventilation (p < 0.01). Only hydrocephalus requiring EVD (p = 0.01) and ventilator use (p = 0.02) remained significant upon multivariate analysis. Patients with delayed heparin introduction were significantly more likely to sustain sVTE on univariate analysis (p = 0.02) with a trend-level significance on multivariate analysis (p = 0.07). ConclusionsPatients with aSAH are more likely to develop sVTE following use of perioperative EVD or mechanical ventilation. sVTE leads to longer hospital stays and worse outcomes among patients treated for aSAH. Delayed heparin initiation increases the risk of sVTE. Our results may help guide surgical decision-making during recovery from aSAH and improve VTE-related postoperative outcomes.

Treatment optimization by monitoring vancomycin concentration in the serum and cerebrospinal fluid in a child with cystoperitoneal shunt-related infection caused by methicillin-resistant Staphylococcus aureus: a case report and literature review

BackgroundCerebral ventricular shunt infections caused by methicillin-resistant Staphylococcus aureus (MRSA), especially strains with elevated minimum inhibitory concentration (MIC) values, have a poor prognosis. Monitoring serum vancomycin (VCM) levels with therapeutic drug monitoring and maintaining high VCM concentrations in the cerebrospinal fluid (CSF) are critical to treatment success. However, there have been a few reports about the CSF penetration and the pharmacokinetics of VCM in children.Case presentationHere, we report the case of a pediatric patient with cysto-peritoneal shunt-related meningitis caused by MRSA with an MIC of 2 μg/mL. The adequate VCM concentration was maintained by monitoring the VCM concentration in the CSF via the external ventricular drain, and frequent blood taking was avoided. VCM showed a good CSF penetration in our patient, and she was discharged without complications.DiscussionTherapeutic drug monitoring of VCM concentration in the CSF may result in successful treatment even if MRSA shows a higher MIC. Therapeutic drug monitoring of VCM concentration in the CSF may also reduce the side effects.

Risk Factors for External Ventricular Drainage-Related Infection: A Systematic Review and Meta-analysis.

External ventricular drainage (EVD) is one of the most commonly performed neurosurgical procedures, but EVD-related infection constitutes a significant health concern. Yet, little consensus identifies the risk factors for the development of EVD-related infection. Therefore, we performed a meta-analysis to systematically summarize existing evidence on the incidence and risk factors for EVD-related infection. PubMed, Embase, and the Cochrane Library databases from database inception to February 28, 2022, were searched for all studies investigating the incidence and risk factors for EVD-related infection. Data were assessed by R-4.2.0 software. The meta-analysis was used to calculate pooled odds ratios (OR) and 95% confidence intervals (CI). A total of 48 studies were included. Among the 29 factors analyzed, statistically significant risk factors were subarachnoid hemorrhage(SAH)/intraventricular hemorrhage(IVH) (OR = 1.48, 95% CI = 1.20-1.82, p < 0.001), concomitant systemic infection (OR = 1.90, 95% CI = 1.34-2.70, p < 0.001), other neurosurgical procedures (OR = 1.76, 95% CI = 1.02-3.04, p = 0.041), change of catheter (OR = 5.05, 95% CI = 3.67-6.96, p < 0.001), bilateral EVDs (OR = 2.25, 95% CI = 1.03-4.89, p = 0.041), (cerebrospinal fluid) CSF leak (OR = 3.19, 95% CI = 2.12-4.81, p < 0.001) and duration of EVD >7 days (OR = 4.62, 95% CI = 2.26-9.43, p < 0.001). The use of silver-coated catheters (OR = 0.57, 95% CI = 0.38-0.87, p = 0.008) and antibiotic-impregnated catheters (OR = 0.60, 95% CI = 0.41-0.88, p = 0.009) might help reduce the risk of infection. No significant difference was indicated in studies evaluating factors like diabetes mellitus (OR = 1.25, 95% CI = 0.90-1.75, p = 0.178), steroids used (OR = 1.52, 95% CI = 0.96-2.4, p = 0.074), prophylactic antibiotics(OR = 0.87, 95% CI = 0.66-1.14, p = 0.308). The meta-analysis of various relevant factors in the onset of EVD-related infection in patients submitted to EVD enabled us to establish a more probable profile of the patients who are more likely to develop it during the treatment.

Transfrontal External Ventricular Drainage Combined with OMMAYA Sac Implantation under Laser Navigation were Performed: A Technical Note.

Hydrocephalus caused by spontaneous intracerebral hemorrhage (ICH) is an independent risk factor with adverse effects on the progression of the disease. Until now, the choice of intraventricular catheter placement and intraventricular fibrinolysis (IVF) has been mainly based on the personal experience of the neurosurgeon. We will introduce the clinical effect of the new external ventricular drainage (EVD), an independent innovation of our medical center, on ICH patients, hoping to inspire more neurosurgeons to apply our method. In this open retrospective study, We analyzed the clinical data, radiological manifestations, and prognostic scores of 10 patients with the spontaneous intracerebral hemorrhage who received transfrontal lateral ventricle puncture and drainage under laser navigation in our hospital. A total of 10 patients with an average age of 58.10±9.97 years were enrolled for emergency surgery. All operations were completed according to the consensus specifications. It took 11.25±3.81 days for the intracranial pressure to return to normal. On admission, patients had a median GCS of 10. The median preoperative GCS was 8. The median GCS at discharge score was 15. At discharge, the median NIHSS score was 4. After 6 months of follow-up, patients had a median NIHSS score of 4. At discharge, the median ADL score of patients was 85. After 6 months of follow-up, the median ADL score of the patients was 95. In treating patients with ICH, the emergency treatment of transfrontal external ventricular drainage combined with OMMAYA sac implantation under laser navigation is a surgical method worthy of further study.

Automatic identification of intracranial pressure waveform during external ventricular drainage clamping: segmentation via wavelet analysis

Objective. The objective of this study is to develop and validate a method for automatically identifying segments of intracranial pressure (ICP) waveform data from external ventricular drainage (EVD) recordings during intermittent drainage and closure. Methods. The proposed method uses time-frequency analysis through wavelets to distinguish periods of ICP waveform in EVD data. By comparing the frequency compositions of the ICP signals (when the EVD system is clamped) and the artifacts (when the system is open), the algorithm can detect short, uninterrupted segments of ICP waveform from the longer periods of non-measurement data. The method involves applying a wavelet transform, calculating the absolute power in a specific range, using Otsu thresholding to automatically identify a threshold, and performing a morphological operation to remove small segments. Two investigators manually graded the same randomly selected one-hour segments of the resulting processed data. Performance metrics were calculated as a percentage. Results. The study analyzed data from 229 patients who had EVD placed following subarachnoid hemorrhage between June 2006 and December 2012. Of these, 155 (67.7%) were female and 62 (27%) developed delayed cerebral ischemia. A total of 45 150 h of data were segmented. 2044 one-hour segments were randomly selected and evaluated by two investigators (MM and DN). Of those, the evaluators agreed on the classification of 1556 one-hour segments. The algorithm was able to correctly identify 86% (1338 h) of ICP waveform data. 8.2% (128 h) of the time the algorithm either partially or fully failed to segment the ICP waveform. 5.4% (84 h) of data, artifacts were mistakenly identified as ICP waveforms (false positives). Conclusion. The proposed algorithm automates the identification of valid ICP waveform segments of waveform in EVD data and thus enables the inclusion in real-time data analysis for decision support. It also standardizes and makes research data management more efficient.

P.128 Recurrent subarachnoid hemorrhage secondary to Chiari 1 malformation

Background: We describe a patient with recurrent subarachnoid hemorrhage (SAH) secondary to Chiari 1 malformation. Methods: A retrospective review of the clinical chart was performed. Results: A previously healthy female in her 70’s presented with worst headache of life. CT demonstrated 4th ventricular hemorrhage with SAH extending into the bilateral cerebellomedullary fissures. CTA did not show a vascular etiology and patient was discharged home. Incidental note was made of a right persistent trigeminal artery. The patient then represented 2 weeks later with worst headache of life and decreased level of consciousness. CT demonstrated extensive SAH extending into the 3rd and 4th ventricles. CTA and diagnostic cerebral angiogram did not show a vascular etiology. MRI brain/C-spine revealed Chiari 1 malformation. An external ventricular drain was placed but could not be weaned. She underwent suboccipital craniectomy with C1 laminectomy. Intraoperatively, there was a prominent dorsal spinal vein that appeared under tension as it pierced the arachnoid membrane and subsequently entering the dura as a rudimentary occipital sinus. This vein was coagulated and divided. The patient recovered well and was at neurological baseline at 6 month follow-up. Conclusions: This is the first reported case of recurrent SAH secondary to Chiari 1 malformation.