External Ventricular Drain Placement Research Articles

Wound dehiscence from a prominent external occipital protuberance: An indication for prophylactic drilling?

Abstract Background Wound complications including CSF leaks, pseudomeningoceles, and infections after a craniotomy is a known risk, but dehiscence after suboccipital approaches remain a rare event. Objective Here we present a patient whose exceptionally prominent external occipital protuberance caused wound breakdown after a suboccipital craniotomy, and suggest that prophylactic drilling of this protuberance would have prevented this complication. Methods A 52 year old male on Aspirin and Plavix presents with sudden onset headache, nausea, and vomiting, with a computed tomography (CT) scan of the head showing a 60 cm 3 right cerebellar hemorrhage. He underwent a suboccipital paramedian craniotomy for hematoma evacuation, and external ventricular drain placement. His hospitalization was complicated by respiratory failure, pneumonia, bacteremia, and finally sterile wound breakdown over his prominent external occipital protuberance 5 weeks after his initial operation. Results The wound was debrided and his 14 mm tall occipital protuberance drilled flush allowing for excellent healing without further complications. Conclusion While the incidence of prominent external occipital protuberances is unknown, we suggest that surgeons consider prophylactic drilling of this prominence or making a paramedian incision when performing suboccipital approaches to prevent subsequent wound complications.

Hemorrhage Rate After External Ventricular Drain Placement in Subarachnoid Hemorrhage: Time to Heparin Administration.

The use of antiplatelet or anticoagulants has previously been shown to increase hemorrhagic complications of ventricular catheterization. Although heparin use 24h after ventriculostomy appears safe, the safety of heparin immediately (within 4h) after ventriculostomy is unknown. The objective of this study was to assess the safety of heparin immediately (within 4h) after ventriculostomy in subarachnoid hemorrhage (SAH) patients undergoing endovascular treatment. This is a retrospective cohort study of 46 patients with aneurysmal SAH secondary to aneurysm rupture who required ventriculostomy. Post-ventriculostomy imaging was carefully reviewed for tract hemorrhaging. Timing of heparinization was noted. Early heparinization was within 4h after ventriculostomy, and intermediate heparinization was between 4 and 24h after ventriculostomy. Overall, the tract hemorrhage rate was 26.1% for the study cohort-mostly grade I tract hemorrhages-consistent with the existing literature. The tract hemorrhage rate in the early (<4h) heparin group was a remarkable 58.8%. The hemorrhages were also notably larger in the early (<4h) heparin group. Although heparin appears to be safe after 4h, immediate heparinization (within 4h) after ventriculostomy significantly increases the odds of tract hemorrhage. Additional time should be afforded between ventriculostomy and heparinization to avoid potentially devastating external ventricular drain tract hemorrhage. It is advisable to wait a sufficient time (at least 4h) after ventriculostomy before embarking on endovascular treatment of ruptured aneurysms.

Thrombolysis for non-traumatic intra-ventricular hemorrhage in adults: a critical reappraisal.

Intra-ventricular hemorrhage (IVH) is a critical condition with high rate of morbidity and mortality due to acute hydrocephalus and secondary brain injury. Mechanisms underlying the clinical deterioration are not only related to the appearance of an acute hydrocephalus but also to blood-clot mass effect and the inflammatory effects of blood break-down products which impede local blood flow and exert a direct toxic effect on the peri-ventricular structures leading to chronic hydrocephalus. An effective treatment strategy should aim at IVH fast removal and reduction of blood-clot mass effect. Although external ventricular drainage placement is an intuitive treatment for obstructive hydrocephalus this treatment does not address in total the aforementioned pathophysiological mechanisms underlying secondary brain damage. Intra-ventricular fibrinolysis, with tissue plasminogen activator or urokinase, is a level of evidence B, class IIB treatment which has proved to be beneficial in lowering the mortality rates. Its effectiveness on functional outcome has been assessed on three large meta-analysis and a recent large randomized control trial (CLEAR III). Results from the CLEAR III multicenter trial suggest that a routine extra-ventricular drain, irrigation with alteplase reduced mortality but did not substantially improve functional outcomes compared with irrigation with saline. Protocol-based use of alteplase with extra-ventricular drain seemed safe, therefore such approach may be a potential option in individual cases. Currently no consensus has been reached and extrapolation of data from the literature does not permit to identify a uniform therapeutic approach but merely to outline some rational procedural modalities. Further research and studies are needed to compare the efficacy of the different fibrinolytic agents and protocols on functional outcome.

Placement accuracy of external ventricular drain when comparing freehand insertion to neuronavigation guidance in severe traumatic brain injury.

External ventricular drain (EVD) placement is a frequently performed neurosurgical procedure. Inaccuracies in drain positioning and the need for multiple passes using the classic freehand insertion technique is well reported in the literature, especially in the traumatic brain injury (TBI) population. The purpose of this study was to evaluate if electromagnetic neuronavigation guidance for EVD insertion improves placement accuracy and minimizes the number of passes in severe TBI patients. Navigation was applied prospectively for all new severe TBI patients who required ventricular catheter placement over a period of 1 year, and compared with a retrospective cohort of severe TBI patients who had EVD inserted freehand in the preceding year. The placement accuracy was evaluated using the Kakarla grading system; the number of passes was also compared. Fifty-four cases were recruited: 35 (64.8%) had their EVD placed using the freehand technique and 19 (35.2%) using navigation guidance. In the navigation group, the placement accuracy was: 94.7% (18/19) grade 1, 5.3% (1/19) grade 2, and none at grade 3. In comparison, freehand placement was associated with misplacement (grades 2 and 3) in 42.9% of the cases (p value=0.009). The number of passes was significantly lower in the navigation group (mean of 1.16±0.38), compared with the freehand group (mean of 1.63±0.88) (p value=0.018). Using the navigation to guide EVD placement was associated with a significantly better accuracy and a lower number of passes in severe TBI patients.

Timing of Permanent Ventricular Shunt Placement Following External Ventricular Drain Placement in Primary Intracerebral Hemorrhage

Intraventricular hemorrhage requiring ventriculostomy placement is a frequent complication of spontaneous intracerebral hemorrhage. Although a subset of patients will require permanent ventricular shunt placement, little is known about contemporary practices regarding the timing of ventriculostomy and ventricular shunt placement after intracerebral hemorrhage. Using the 2010-2012 National Inpatient Sample, we identified patients with International Classification of Diseases, Ninth Revision codes for intracerebral hemorrhage, excluded secondary causes, and examined procedure dates. Of 35,899 patients with primary intracerebral hemorrhage, 2443 (6.8%) received ventriculostomy, 93% within the first 3 days of admission and 66% within the first day. Permanent shunt placement occurred in 173 (7.1%) patients following ventriculostomy at a median interval of 15 days (interquartile range: 11-20). Among those remaining alive and in hospital at 14, 21, and 28 days, 5%, 11%, and 15%, respectively, underwent shunt placement following ventriculostomy, and 24% of those with multiple ventriculostomy insertions required permanent shunt by 4 weeks of hospitalization. Multiple ventriculostomies, tracheostomy, and black race were associated with longer time to permanent shunt. A wide variation in delay to permanent shunt placement is present, with substantial and increasing prevalence with time in hospital. Better understanding of the risk factors associated with persistent hydrocephalus will help optimize patient selection and timing of treatment.

Pipeline flow diversion of ruptured blister aneurysms of the supraclinoid carotid artery using a single-device strategy.

OBJECTIVE Ruptured blister aneurysms remain challenging lesions for treatment due to their broad, shallow anatomy and thin, fragile wall. Historical challenges with both open microsurgical approaches and intrasaccular endovascular approaches have led to increased use of flow diversion for management of these aneurysms. However, the optimum paradigm, including timing of treatment, use of dual antiplatelet therapy, and number of flow-diverter devices to use remains unknown. The authors describe their experience with ruptured blister aneurysms treated with flow diversion at their institution, and discuss rates of rebleeding and number of devices used. METHODS All patients presenting with subarachnoid hemorrhage from a ruptured blister aneurysm and treated with Pipeline flow diversion were identified. Patient demographic data, clinical status and course, need for external ventricular drain (EVD), timing of treatment, and angiographic details and follow-up were recorded. RESULTS There were 13 patients identified (11 women and 2 men), and 4 had multiple aneurysms. Two aneurysms were treated on initial angiography, with average time to treatment of 3.1 days for the remainder, after discussion with the family and institution of dual antiplatelet therapy. Device placement was technically successful in all patients, with 2 patients receiving 2 devices and the remainder receiving 1 device. There was 1 intraoperative complication, of a wire perforation causing intracerebral hemorrhage requiring decompressive craniectomy. Three patients had required EVD placement for management of hydrocephalus. There was no rebleeding from the target lesion; however, one patient had worsening intraventricular hemorrhage and another had rupture of an unrecognized additional aneurysm, and both died. Of the other 11 patients, 10 made a good recovery, with 1 remaining in a vegetative state. Nine underwent follow-up angiography, with 5 achieving complete occlusion, 2 with reduced aneurysm size, and 2 requiring retreatment for aneurysm persistence or enlargement. There were no episodes of delayed rupture. CONCLUSIONS Pipeline flow diversion is a technically feasible and effective treatment for ruptured blister aneurysms, particularly in good-grade patients without hydrocephalus. Patients with a worse grade on presentation and requiring EVDs may have higher risk for bleeding complications and poor outcome. There was no rebleeding from the target lesion with use of a single device in this series.

Assessing residents' operative skills for external ventricular drain placement and shunt surgery in pediatric neurosurgery.

OBJECTIVE The authors previously demonstrated the use of a validated Objective Structured Assessment of Technical Skills (OSATS) tool for evaluating residents' operative skills in pediatric neurosurgery. However, no benchmarks have been established for specific pediatric procedures despite an increased need for meaningful assessments that can either allow for early intervention for underperforming trainees or allow for proficient residents to progress to conducting operations independently with more passive supervision. This validated methodology and tool for assessment of operative skills for common pediatric neurosurgical procedures-external ventricular drain (EVD) placement and shunt surgery- was applied to establish its procedure-based feasibility and reliability, and to document the effect of repetition on achieving surgical skill proficiency in pediatric EVD placement and shunt surgery. METHODS A procedure-based technical skills assessment for EVD placements and shunt surgeries in pediatric neurosurgery was established through the use of task analysis. The authors enrolled all residents from 3 training programs (Baylor College of Medicine, Houston Methodist Hospital, and University of Texas-Medical Branch) who rotated through pediatric neurosurgery at Texas Children's Hospital over a 26-month period. For each EVD placement or shunt procedure performed with a resident, the faculty and resident (for self-assessment) completed an evaluation form (OSATS) based on a 5-point Likert scale with 7 categories. Data forms were then grouped according to faculty versus resident (self) assessment, length of pediatric neurosurgery rotation, postgraduate year level, and date of evaluation ("beginning of rotation," within 1 month of start date; "end of rotation," within 1 month of completion date; or "middle of rotation"). Descriptive statistical analyses were performed with the commercially available SPSS statistical software package. A p value < 0.05 was considered statistically significant. RESULTS Five attending evaluators (including 2 fellows who acted as attending surgeons) completed 260 evaluations. Twenty house staff completed 269 evaluations for self-assessment. Evaluations were completed in 562 EVD and shunt procedures before the surgeons left the operating room. There were statistically significant differences (p < 0.05) between overall attending (mean 4.3) and junior resident (self; mean 3.6) assessments, and between overall attending (mean 4.8) and senior resident (self; mean 4.6) assessment scores on general performance and technical skills. The learning curves produced for the residents demonstrate a stereotypical U- or V-shaped curve for acquiring skills, with a significant improvement in overall scores at the end of the rotation compared with the beginning. The improvement for junior residents (Δ score = 0.5; p = 0.002) was larger than for senior residents (Δ score = 0.2; p = 0.018). CONCLUSIONS The OSATS is an effective assessment tool as part of a comprehensive evaluation of neurosurgery residents' performance for specific pediatric procedures. The authors observed a U-shaped learning curve, contradicting the idea that developing one's surgical technique and learning a procedure represents a monotonic, cumulative process of repetitions and improvement.

P16.21 Medulloblastoma in adult: a case report and literature review

Introduction: Medulloblastoma is an embryonic tumor mainly located at the level of structures derived from the myelencephalon. It is the most common malignant tumor in children with a prevalence of 15-20% of intracranial tumors. In adult constitutes less than 1% of encephalic tumors. Method: The authors report a case of a 34 years old woman, who started complaining of occipital headache with morning predominance that prompted several visits to general emergency, with no other focal neurological signs. The clinical and imagiological investigation revealed a left cerebellar hemisphere lesion with about 40 mm larger diameter, heterogeneous signal capture T2, with apparent implantation base on the tentorium and edema that determinated partial collapse of the IV ventricle. Meningioma, pilocytic astrocytoma, glioma, cerebellar abscess, hemangioblastoma and metastasis were considered in the diferential diagnosis. The patient underwent total excision of well-defined contours lesion with lower tentorial insertion. Results: Pathological examination was consistent with medulloblastoma with neuronal and glial differentiation, IV grade (WHO classification). Postoperatively she presented loca haematoma with associated edema, conditioning acute hydrocephalus. The patient was reoperated with hematoma drainage and placement of external ventricular drainage. She has a follow-up of 2 years, with no evidence of recurrence or tumor dissemination. Karnofski performance score of 100% Conclusions: Although Medulloblastoma is a relatively rare brain lesion it should be considered in the differential diagnosis of posterior fossa tumors. The diagnosis is histological only and in cases of a high grade lesions maximum excision is indicated, once complete recession is the strongest good prognostic factor in this pathology.

Intracranial Pressure Values Are Highly Variable After Cerebral Spinal Fluid Drainage.

Intracranial pressure (ICP) is often obtained via external ventricular drain (EVD) placement and is discussed as a key vital sign in neuroscience. Nurses are most often delegated the task of observing, adjudicating, and documenting ICP. Cerebrospinal fluid drainage requires that the transducer connected to the EVD is open to drain, prohibiting ICP monitoring. There are no recent data to support an evidence-based standard for the period an ICP waveform should be observed, after the EVD is clamped, to be able to adjudicate a value that represents the patient's status. Therefore, the purpose of this study is to determine the optimal period for which an EVD should be closed to obtain an accurate ICP value. In a sample of 30 subjects who received continuous ICP monitoring for 15 minutes, there was no universal pattern to ICP after clamping an EVD. The conditional probability of observing a patient's highest ICP, if ICP is observed for 5 minutes, is 0.0181. The conditional probability increased to 0.0402 if ICP is observed for 10 minutes. There were no instances of ICP elevation requiring intervention. The results suggest that at least 5 minutes of ICP monitoring is safe and is required to provide an ICP value that reflects true ICP.

Cerebelitis aguda en Pediatría: nuestra experiencia

IntroductionAcute cerebellitis is a rare inflammatory disease with a highly variable clinical course that ranges from benign self-limiting symptoms to a fulminant presentation associated with a high risk of death due to compression of the posterior fossa, acute hydrocephalus, and intracranial hypertension. MethodsWe reviewed clinical, laboratory, and radiological findings from children diagnosed with acute cerebellitis between May 2007 and November 2016. We analysed treatments and clinical and radiological progression. ResultsNine children met the diagnostic criteria for cerebellitis. Headache, vomiting, and drowsiness were the most frequent initial symptoms; ataxia, dysarthria, and dysmetria were the most common cerebellar signs. Cerebellitis was diagnosed with magnetic resonance imaging, which revealed cerebellar involvement (unilateral or bilateral); computerised tomography images either were normal or showed indirect signs such as triventricular hydrocephalus due to extrinsic compression of the aqueduct of Sylvius. Corticosteroids were the most commonly used treatment (6 patients). One patient required surgery due to triventricular hydrocephalus. Eight patients recovered completely, whereas the ninth displayed neurological sequelae. ConclusionsCerebellitis is a medical and surgical emergency; diagnosis requires a high level of suspicion and an emergency brain magnetic resonance imaging study. It is a clinical-radiological syndrome characterised by acute or subacute encephalopathy with intracranial hypertension and cerebellar syndrome associated with T2-weighted and FLAIR hyperintensities in the cerebellar cortex (unilaterally or bilaterally) and possible triventricular dilatation. Treatment is based on high-dose corticosteroids and may require external ventricular drain placement and decompressive surgery.

Remote cerebellar haemorrhage after placement of an external ventricular drainage for acute hydrocephalus: A case report

IntroductionRemote cerebellar haemorrhage (RCH) is a rare complication following a craniotomy. This generally benign phenomenon is an identifiable complication of supratentorial craniotomies and should not be mistaken with other pathologies. The most common presenting symptom is a decrease in the level of consciousness but in some cases the RCH may be asymptomatic and accidentally discovered in follow-up CT scans. Case reportA 70-year-old man was admitted to our emergency department with sudden mental status deterioration. A head CT scan was carried out and an acute hydrocephalus was diagnosed. The patient was transferred to the operating room for external ventricular drainage (EVD) placement via a frontal burr-hole. At 24hours, the patient made a complete neurological recovery. On third postoperative day, a follow-up CT scan showed an asymptomatic right remote cerebellar haemorrhage. The MRI assessment confirmed the diagnosis. The EVD was removed on the 6th postoperative day and the patient was discharged after one week with no further symptoms. DiscussionThis case report is the first documented case, to our knowledge, of a remote cerebellar haemorrhage after placement of external ventricular drainage via a frontal burr-hole. The precise aetiology of remote cerebellar haemorrhage remains unclear. One of the most accepted theories is the “cerebellar sag” explanation, which defends hypothesis that peri-operative over drainage of cerebrospinal fluid (CSF) is the main mechanism involved. Further investigation is required to understand the pathogenesis and risk factors for the occurrence of this phenomenon.

Aneurysm rebleeding after placement of external ventricular drainage: a systematic review and meta-analysis.

The association between external ventricular drainage (EVD) and aneurysm rerupture is still a controversial issue. We performed a systematic review and meta-analysis of published series reporting data of EVD placement in aneurysmal subarachnoid hemorrhage (SAH) with the aim to evaluate the relationship between ventricular drainage and aneurysm rebleeding. PRISMA/MOOSE guidelines were followed. The Newcastle-Ottawa Scale was used to assess the quality of the studies. We conducted a comprehensive literature search of three databases (PubMed, Ovid MEDLINE, and Ovid EMBASE) on series reporting patients with EVD placement and aneurysmal SAH. The reported studies were analyzed with a primary aim to calculate the strength of the association (odds ratio) between rebleeding and EVD placement in patients with SAH. Our systematic review included 16 articles with a total of 6804 patients with SAH of which 595 (8.7%) had aneurysmal rebleeding. Ventricular drainage was inserted in 19% of patients. Rebleeding occurred in 18.8% (95% CI = 16.4-20.6%) of patients requiring EVD and in 6.4% (95% CI = 5.8-7.1%) of patients who did not require EVD (OR = 3.92, p < 0.0001). The mean time between EVD placement and rebleeding was 1h (range, 0-8h). The maximal aneurysm diameter of patients with rerupture was larger when compared with patients without rerupture (9.9mm vs. 7.5mm; p < 0.04). High Fisher grades (III-IV) were present in 75% of patients with rerupture and in 60% of patients without aneurysmal rerupture (p < 0.0001). Our study conclusively defined an association between EVD and rebleeding. However, the effective role of EVD in aneurysm rebleeding is insufficiently investigated in the literature. Other significant factors of rebleeding are usually observed in patients requiring ventricular drainage. According to our findings, a causal relationship between EVD and aneurysm rebleeding could be a plausible hypothesis, at least in certain cases.

Factors Associated with Fever in Intracerebral Hemorrhage

Fever is common in patients with intracerebral hemorrhage (ICH). We sought to identify predictors of fever in patients hospitalized with ICH, and compare infectious fever with noninfectious fever. A retrospective review on consecutive spontaneous ICH patients from April 2009 to March 2010 was performed. Fever was defined as temperature 100.9°F or higher and attributed to infectious versus noninfectious etiology, based upon the National Healthcare Safety Network criteria. Univariate analysis and multivariable logistic regression model were used to determine factors associated with fever and with infection. Among the 351 ICH patients, 136 (39%) developed fever. Factors associated with fever included mean ICH volume, intraventricular hemorrhage (IVH), external ventricular drain (EVD) placement or surgical evacuation, positive microbial cultures, longer length of stay (LOS), and higher in-hospital mortality. Among patients with fever, 96 (71%) were noninfectious and 40 (29%) were infectious. Infectious fever was associated with higher LOS. Noninfectious fever was associated with higher in-hospital mortality. In multivariable analysis, ICH volume (OR = 1.01, P = .04), IVH (OR = 2.0, P = .03), EVD (OR = 3.7, P < .0001), and surgical evacuation (OR = 6.78, P < .0001) were significant predictors of fever. Infectious fever (OR = 5.26, P = .004), EVD (OR = 4.86, P = .01), and surgical evacuation (OR = 4.77, P = .04) correlated with prolonged LOS when dichotomized using a median of 15 days. Fever is common in ICH patients and is not associated with a clear infectious etiology in the majority of patients. Patients with noninfectious fever have higher in-hospital mortality, but survivors have shorter LOS. Further studies are warranted to better understand fevers in ICH.

Abstract TP422: Platelet Transfusion In Patients Presenting With Aneurysmal Subarachnoid Hemorrhage Does Not Improve Outcome

Introduction: The effect of platelet transfusion (PT) has been studied in patients with intracerebral hemorrhage, but has not been reported for aneurysmal subarachnoid hemorrhage (aSAH). We investigated the effect of PT on the outcome of patients with aSAH. Methods: We retrospectively evaluated 84 patients admitted with aSAH to a Comprehensive Stroke Center in the United States between 2011 and 2015. Charts were reviewed for variables including length of hospitalization, 3-month modified Rankin Scale (mRS), and complications related to endovascular treatment of cerebral aneurysm. Intergroup differences were evaluated with the Chi-squared and Student’s t-test. mRS was evaluated using multivariate ordinal logistic regression. Variables with a univariate p-value &lt;0.2 association with 3 month mRS were included in the ordinal logistic regression model. Results: Patient demographics and clinical variables are seen in Table 1. 30% of patients received PT. PT was associated with male gender, Hunt-Hess score, Fisher Score, external ventricular drain placement, and longer hospital length of stay. After multivariate ordinal regression, PT was associated with higher mRS and there was a trend for association with Hunt-Hess score (Table 2). Conclusion: Our findings suggest that platelet transfusion is common in patients presenting with aSAH. Platelet transfusion in these patients is associated with longer hospital stay and a significantly lower rate of good clinical outcome, with a nearly 4- to 6-fold higher odds of a one-point increase in mRS at 3 months. The association of platelet transfusion to worse outcome in patients with aSAH warrants further study.

Abstract WMP29: Trends of Angioplasty for Cerebral Vasospasm in Endovascularly Treated Aneurysmal Subarachnoid Hemorrhages

Introduction: Treatment of the sequale following aSAH such as vasospasm has evolved to include different options ranging from endovascular angioplasty to administration of intra-arterial calcium channel blockers and permissive hypertension. Our study examines trends of angioplasty for cerebral vasospasm usage in endovascularly treated aSAH. Methods: We used Nationwide Inpatient sample data from 2002 to 2012. ICD9 codes 430, 431 and 432 in conjunction with ICD9 procedure code 39.72 (endovascular repair/embolization of head and neck vessel) were used to identify endovascularly treated aSAH patients (Excluding ICD9 747.81 - cerebral AVM). Cerebral vasospasm treated with angioplasty was identified with ICD procedure code 00.62 and 39.50. Patients requiring external ventricular drain (EVD) were also identified to stratify higher severity of aSAH. Comorbidities were controlled using Charlson’s Index. The population was divided into Age &lt;50 and Age &gt;=50 groups to understand differences in angioplasty trends in these groups, as there is evidence of increased risk of cerebral vasospasm in patients with age less than 50 years. Trend of angioplasty were evaluated using a multivariate model with survey logistics using SAS 9.2. Results: We identified 9,856 hospitalizations with 62.6% in Age &gt; 50 and 37.4% in Age &lt; 50 group. Overall 4.04% in Age &gt;50 and 5.80% in Age &lt;50 group required angioplasty. In Age &gt;50 group, Increasing year from 2002 to 2012 predicted decreased requirement of angioplasty with Odds Ratio(OR) of 0.935 (95% Confidence Interval (CI) 0.879-0.995, p=0.03) after controlling for increasing age, Chanrlson’s co-morbidity index and EVD placement; however the same trend was not statistically significant for Age &lt; 5o (OR - 0.967, 95%CI 0.917-1.020, p=0.2150). Conclusion: Decreasing trend of angioplasty for aSAH related cerebral vasospasm was observed during the past decade in population with age more than 50 years in our study. Advances in endovascular care such as administration of intra arterial calcium channel blockers as well as enhanced neuro-critical management of vasospasm may have contributed to a decrease in the trend of angioplasty treatment of vasospasm after aSAH.

Safety of Intraventricular rt-PA for Pan-Ventricular IVH Caused by a Ruptured AVM: A Case Report.

Intraventricular recombinant tissue plasminogen activator (IVT rt-PA) has improved outcomes for intraventricular hemorrhage (IVH). Patients with suspected or untreated arteriovenous malformations (AVMs) have been excluded from clinical trials. We present a patient with IVH secondary to a ruptured AVM safely treated with IVT rt-PA. A 48-year-old Hispanic male with a history of dermatomyositis presented to the emergency department with sudden left-sided weakness. En route to computed tomography (CT), he became lethargic. Computed tomography revealed extensive IVH with acute hydrocephalus, which was treated with the placement of external ventricular drain with clinical improvement. Computed tomography angiogram performed did not reveal AVM. Cerebral digital subtraction angiogram (DSA) was planned due to suspicion of AVM. Prior to DSA, patient became acutely lethargic. Computed tomography imaging revealed worsening hydrocephalus. External ventricular drain was noted to be draining. Repeat CT revealed improved hydrocephalus but with left lateral ventricle dilatation. Risks and benefits of IVT rt-PA were discussed with the family and a decision was made to treat. Three doses of 1 mg IVT rt-PA were administered with resolution of midline blood and lateral ventricular dilatation with clinical improvement. Digital subtraction angiogram revealed early draining vein on right internal carotid artery injection draining into the inferior sagittal sinus representing ruptured AVM without clear nidus. Repeat DSA with possible embolization was planned after discharge. In spite of additional in-hospital complications, the patient gradually improved and was ultimately discharged home. Our case supports the idea that the use of IVT rt-PA following an IVH caused by an underlying AVM could be further explored in carefully designed clinical trials.

External ventricular drain practice variations: results from a nationwide survey.

OBJECTIVE While guidelines exist for many neurosurgical procedures, external ventricular drain (EVD) insertion has yet to be standardized. The goal of this study was to survey the neurosurgical community and determine the most frequent EVD insertion practices. The hypothesis was that there would be no standard practices identified for EVD insertion or methods to avoid EVD-associated infections. METHODS The American Association of Neurological Surgeons membership database was queried for all eligible neurosurgeons. A 16-question, multiple-choice format survey was created and sent to 7217 recipients. The responses were collected electronically, and the descriptive results were tabulated. Data were analyzed using the chi-square test. RESULTS In total, 1143 respondents (15.8%) completed the survey, and 705 respondents (61.6%) reported tracking EVD infections at their institution. The most common self-reported infection rate ranged from 1% to 3% (56.1% of participants), and 19.7% of respondents reported a 0% infection rate. In total, 451 respondents (42.7%) indicated that their institution utilizes a formal protocol for EVD placement. If a respondent's institution had a protocol, only 258 respondents (36.1%) always complied with the protocol. Protocol utilization for EVD insertion was significantly more frequent among residents, in academic/hybrid centers, in ICU settings, and if the institution tracked EVD-associated infection rates (p < 0.05). A self-reported 0% infection rate was significantly more commonly associated with a higher level of training (e.g., attending physicians), private center settings, a clinician performing 6 to 10 EVD insertions within the previous 12 months, and prophylactic continuous antibiotic utilization (p < 0.05). CONCLUSIONS This survey demonstrated heterogeneity in the practices for EVD insertion. No standard practices have been proposed or adopted by the neurosurgical community for EVD insertion or complication avoidance. These results highlight the need for the nationwide standardization of technique and complication prevention measures.

Efficacy and safety of combined intraventricular fibrinolysis with lumbar drainage for prevention of permanent shunt dependency after intracerebral hemorrhage with severe ventricular involvement: A randomized trial and individual patient data meta-analysis.

Intraventricular hemorrhage (IVH) is a negative prognostic factor in intracerebral hemorrhage (ICH) and is associated with permanent shunt dependency in a substantial proportion of patients post-ICH. IVH treatment by intraventricular fibrinolysis (IVF) was recently linked to reduced mortality rates in the CLEAR III study and IVF represents a safe and effective strategy to hasten clot resolution that may reduce shunt rates. Additionally, promising results from observational studies reported reductions in shunt dependency for a combined treatment approach of IVF plus lumbar drains (LDs). The present randomized, controlled trial investigated efficacy and safety of a combined strategy-IVF plus LD versus IVF alone-on shunt dependency in patients with ICH and severe IVH. This randomized, open-label, parallel-group study included patients aged 18 to 85 years, prehospital modified Rankin Scale ≤3, ICH volume < 60ml, Glasgow Coma Scale of <9, and severe IVH with tamponade of the third and fourth ventricles requiring placement of external ventricular drainage (EVD). Over a 3-year recruitment period, patients were allocated to either standard treatment (control group receiving IVF consisting of 1mg of recombinant human tissue plasminogen activator every 8 hours until clot clearance of third and fourth ventricles) or a combined treatment approach of IVF and-upon clot clearance of third and fourth ventricles-subsequent placement of an LD for drainage of cerebrospinal fluid (CSF; intervention group). The primary endpoint consisted of permanent shunt placement indicated after a total of three unsuccessful EVD clamping attempts or need for CSF drainage longer than 14 days in both groups. Secondary endpoints included IVF- and LD-related safety, such as bleeding or infections, and functional outcome at 90 and 180 days. Conducted endpoint analyses used individual patient data meta-analyses. The study was registered at clinicaltrials.gov (NCT01041950). The trial was stopped upon predefined interim analysis after 30 patients because of significant efficacy of tested intervention. The primary endpoint was analyzed without dropouts and was reached in 43% (7 of 16) of the control group versus 0% (0 of 14) of the intervention group (p = 0.007). Meta-analyses were based on overall 97 patients, 45 patients receiving IVF plus LD versus 42 with IVF only. Meta-analyses on shunt dependency showed an absolute risk reduction of 24% for the intervention (LD, 2.2% [1 of 45] vs no-LD, 26.2% [11 of 42]; odds ratio [OR] = 0.062; confidence interval [CI], 0.011-0.361; p = 0.002). Secondary endpoints did not show significant differences for CSF infections (OR = 0.869;CI, 0.445-1.695; p = 0.680) and functional outcome at 90 days (OR = 0.478; CI, 0.190-1.201; p = 0.116), yet bleeding complications were significantly reduced in favor of the intervention (OR = 0.401; CI, 0.302-0.532; p < 0.001). The present trial and individual patient data meta-analyses provide evidence that, in patients with severe IVH, as compared to IVF alone, a combined approach of IVF plus LD treatment is feasible and safe and significantly reduces rates of permanent shunt dependency for aresorptive hydrocephalus post-ICH. ANN NEUROL 2017;81:93-103.

Factors Related to the Development of Shunt-Dependent Hydrocephalus Following Subarachnoid Hemorrhage in the Elderly.

Surgical procedures for aneurysmal subarachnoid hemorrhage (SAH) are increasing among the elderly as the population ages. Chronic shunt-dependent hydrocephalus is a recognized complication of SAH. The aim of this study was to identify predictive factors for the development of shunt-dependent hydrocephalus among elderly patients with SAH. We retrospectively studied 878 patients, including 275 patients ? 65 years old, with SAH treated between 2005 and 2015 to identify factors contributing to the development of shunt-dependent hydrocephalus. The relationships between shunt-dependent hydrocephalus and the causative factors were analyzed using univariate and multivariate analysis; the causative factors were based on the results of previous studies. In the 878 patients with SAH, there was a significant difference in the incidence of shunt-dependent hydrocephalus between patients < 65 years old and those ? 65 years old (p=0.021). In the 275 patients ? 65 years old, the following were associated with shunt-dependent hydrocephalus on univariate analysis: 1) Hunt and Hess grade (p=0.005), 2) Fisher grade (p < 0.001), 3) intraventricular hemorrhage (p < 0.001), 4) acute hydrocephalus (p=0.003), 5) aneurysm location (p=0.001), and 6) external ventricular drain placement (p < 0.001). On multivariate analysis, only 1) intraventricular hemorrhage (p < 0.001) and 2) a ruptured aneurysm located in the distal posterior circulation (p=0.014) were related to an increased risk for the development of shunt-dependent hydrocephalus. Evaluating risk factors can help identify patients at high risk of developing shunt-dependent hydrocephalus. Identifying these risk factors may help neurosurgeons to provide optimal therapy and improve outcomes in patients with SAH.

Outcomes of post-neurosurgical ventriculostomy-associated infections.

Background:Ventriculostomy-associated infection (VAI) is a major concern to physicians. Limited studies have looked at the outcomes of external ventricular drain (EVD) infection and predictors of unfavorable outcomes. In this study, we assessed the outcomes of EVD infection and predictors of unfavorable outcomes.Methods:This was a retrospective medical chart review, conducted at the Aga Khan University Hospital. All the patients irrespective of age and gender, fulfilling the diagnostic criteria of VAI were included. Patients with preexisting bacterial meningitis or ventriculitis were excluded from the study. Outcome assessment was based on Glasgow outcome scale (GOS) at 1 and 3 months after procedure. Other outcomes included 30-day mortality and total length of hospital stay.Results:We included 256 patients in the study. 66 patients (25.8%) developed VAI. EVD was the primary procedure in 21 (31.8%) cases. Most patients, 24 (36.4%), had EVD as a secondary procedure for tumor surgery. Median interval between EVD placement and diagnosis of infection was 3 days. Mean length of stay in VAI patients was 31.85 ± 20.53 days. Seven patients required ICU care. Ten patients (15.2%) expired during hospital stay or within 30 days of discharge and further four had GOS of 2 or 3. A total of 52 patients had a favorable outcome after 6 months.Conclusions:Rate of VAI in this cohort was high. VAI is associated with increased morbidity, mortality, and prolonged hospital stay.