External Ventricular Drain Placement Research Articles

Pilot study of a new type of machine vision-assisted stereotactic neurosurgery for EVD placement.

The usage of machine vision technologies for image-based analysis and inspection is increasing. With the advent of the ability to process high-dimension data instantly, the possibilities of machine vision multiply exponentially. Robots now use this technology to assist in surgery. The aim of this study is to explore the efficacy of Surgical Navigation Robot NaoTrac (Brain Navi Biotechnology Co., Ltd.), which utilizes machine vision-inspired technology for patient registration and stereotactic external ventricular drainage (EVD) by the robotic arm. Preoperative and postoperative computed tomography (CT) scans were acquired for each case. The surgeons planned the targets and trajectories with the preoperative CT images. The postoperative CT images were utilized in the accuracy measurements. All 14 cases had cerebrospinal fluid drained through the catheter. The NaoTrac placed the catheter into the frontal horn in one attempt in 13 cases and was able to drain CSF in 12 cases. Not a single case had any bleeding or intraoperative complications. The average time spent on the patient registration was 142.8s. The mean target deviation was 1.68mm, and the mean angular deviation was 1.99°, all within the accepted tolerance for minimal tissue damage. The results of this report demonstrate that machine vision-inspired patient registration is feasible and fast. NaoTrac has demonstrated its accuracy and safety in performing frameless catheter placement in 13 clinical cases. Other stereotactic neurosurgical operations such as stereotactic biopsy, depth electrode placement, deep brain stimulation electrode positioning, and neuroendoscopy may also be benefited from the assistance of NaoTrac.

The Role of Recorded Volume of Cerebrospinal Fluid Output in Predicting Modified Rankin Scale Score at Discharge in Patients with Subarachnoid Hemorrhages (DROPSS)

Introduction. External ventricular drain (EVD) placement is common among aneurysmal subarachnoid hemorrhage (aSAH). Draining cerebrospinal fluid (CSF) from the EVD is also common, yet little is known about how much to drain, the length of time to drain, or how drainage impacts patient outcomes.
 Aim. The purpose of this study is to correlate amount of CSF drainage to patient outcomes, via modified Rankin Score (mRS).
 Material and Methods. This retrospective review of data located in a local hospital-based registry and electronic medical record. A linear mixed effects model was constructed to examine CSF drainage volume as a predictor of mRS at discharge.
 Results. Data from 82 patients was included in this analysis. There was no statistically significant relationship between CSF totals and mRS at hospital discharge (p = 0.3614, r² = 0.01). After controlling for age, Hunt and Hess score, and subject as random effect, there was still no significant relationship between CSF drained and mRS score at hospital discharge (p = .9042).
 Conclusions. There is no correlation between the total volume of CSF drained and mRS at discharge. Future research should explore CSF drainage documentation practices. (JNNN 2022;11(2):43–48)
 Key Words: acute care, aneurysmal subarachnoid hemorrhage, cerebrospinal fluid, external ventricular drain, patient outcomes

Pseudoaneurysm of Distal Anterior Cerebral Artery Secondary to External Ventricular Drain: A Case Report and Review of the Literature

BACKGROUND AND IMPORTANCE: External ventricular drain (EVD) placement is a common neurosurgical procedure. The risk of hemorrhage is well documented, and the associated risk of pseudoaneurysm is quite rare. Our objective is to report our case of EVD-associated pseudoaneurysm, review the published literature, and suggest management. CLINICAL PRESENTATION: A 66-year-old woman presented with subarachnoid hemorrhage secondary to a ruptured posterior communicating artery aneurysm, hydrocephalus was managed with bilateral EVD placement, and the ruptured aneurysm treated with coil embolization. The EVDs were removed, and a tract hemorrhage was noted on the right. Routine imaging 3 months later revealed a cortical pseudoaneurysm along the previous right-sided EVD tract. The pseudoaneurysm was successfully treated with clipping, and the patient is neurologically intact. CONCLUSION: This is the first case to report pseudoaneurysm diagnosis after tract hemorrhage upon EVD removal. Prompt treatment is imperative. We recommend considering vascular imaging in any case with hemorrhage upon EVD removal.

Challenges and Controversies in the Management of Tuberculous Meningitis with Hydrocephalus: A Systematic Review and Sarawak Institution's Experience.

Introduction To date, there are no standard practice guidelines available and no universal consensus regarding treatment protocol in management of tuberculous meningitis (TBM) with hydrocephalus. Over the years, diverse views have existed in neurosurgical management of TBM with hydrocephalus. Some authors advocate ventriculo-peritoneal (VP) shunt, while others suggest that external ventricular drainage (EVD) may be the preferable neurosurgical procedure for a poor-grade patient. Method We systematically reviewed published literature and presented our institution's experience. We performed a retrospective case study in our Sarawak neurosurgical center from 2018 to 2020. We tabulated the outcome according to preoperative classifications, which were Vellore Grading (VG), Modified Vellore Grading (MVG), British Medical Research Council Classification (MRC), and others: author-defined. Result In our center, there were 20 cases of TBM with hydrocephalus treated by EVD and VP shunt from 2018 to 2020. We systematically searched published medical literature, and 23 articles were retrieved and analyzed. Poor outcomes were observed in poor-grade patients, especially VG/MVG 3/4 and MRC 3, from both institution and systemic review data. Shunt complication rate was lower in our center as compared with published literature. Conclusion Unfortunately, morbidity and mortality were approximately twofold higher in poor-grade as compared with good-grade patients. However, about one-third of poor-grade patients achieved a good outcome. Cerebrospinal fluid (CSF) diversion would be an unavoidable treatment for hydrocephalus. Poor-grade patients tend to have cerebral infarcts in addition to hydrocephalus. An extended duration of EVD placement could be a potential measure to assess Glasgow coma scale recovery and monitor serial CSF samples.

Overcoming Barriers in Neurosurgical Education: A Novel Approach to Practical Ventriculostomy Simulation.

In the high-risk, high-stakes specialty of neurosurgery, traditional teaching methods often fail to provide young residents with the proficiency needed to perform complex procedures in stressful situations, with direct effects on patient outcomes. Physical simulators provide the freedom of focused, hands-on training in a more controlled environment. However, the adoption of simulators in neurosurgical training remains a challenge because of high acquisition costs, complex production processes, and lack of realism. To introduce an easily reproducible, cost-effective simulator for external ventricular drain placements through various ventriculostomy approaches with life-like tactile brain characteristics based on real patients' data. Whole brain and skull reconstruction from patient's computed tomography and MRI data were achieved using freeware and a desktop 3-dimensional printer. Subsequently, a negative brain silicone mold was created. Based on neurosurgical expertise and rheological measurements of brain tissue, gelatin in various concentrations was tested to cast tactilely realistic brain simulants. A sample group of 16 neurosurgeons and medical students tested and evaluated the simulator in respect to realism, haptics, and general usage, scored on a 5-point Likert scale. We saw a rapid and significant improvement of accuracy among novice medical students. All participants deemed the simulator as highly realistic, effective, and superior to conventional training methods. We were able to demonstrate that building and implementing a high-fidelity simulator for one of the most important neurosurgical procedures as an effective educational and training tool is achievable in a timely manner and without extensive investments.

Andexanet alfa after 4-factor PCC administration for intracranial hemorrhage: a case series.

The ongoing controversy regarding optimal reversal agent for factor Xa-inhibitors is mainly due to lack of comparative data of andexanet alfa (AA) to 4-factor prothrombin complex concentrate (4F-PCC), institutional formulary restrictions, and navigation of clinical scenarios involving patients clinically worsen despite initial reversal efforts. The combination use of 4F-PCC and AA has not been evaluated in clinical trials and the outcomes of such patients with FXA-inhibitor associated intracranial hemorrhage (ICH) are unknown. A total of five patients, including four outside hospital transfers, received 4F-PCC prior to AA for FXa-inhibitor associated ICH (n = 3 apixaban, n = 2 rivaroxaban; n = 4 ICH, n = 1 TBI). The doses of 4F-PCC ranged from 25 to 60 units/kg and were administered within a range of 1.5-4.2h prior to AA. One patient required surgical intervention with craniotomy and three patients underwent external ventricular drain placement. Two of the five patients developed an ischemic or thromboembolic complication within one week from 4F-PCC and AA administration. This case series discusses multiple unique patient cases in which 4F-PCC and AA were both administered for FXa-inhibitor associated ICH. The results highlight thepotentially increased thrombotic risk associated with combination use. Ongoing post-marketing data collection of real patient case scenarios are essential to the establishment of consensus guidelines on how to prioritize initial reversal efforts and manage these patients during the course of their bleed.

Frameless neuronavigation with computer vision and real-time tracking for bedside external ventricular drain placement: a cadaveric study.

A major obstacle to improving bedside neurosurgical procedure safety and accuracy with image guidance technologies is the lack of a rapidly deployable, real-time registration and tracking system for a moving patient. This deficiency explains the persistence of freehand placement of external ventricular drains, which has an inherent risk of inaccurate positioning, multiple passes, tract hemorrhage, and injury to adjacent brain parenchyma. Here, the authors introduce and validate a novel image registration and real-time tracking system for frameless stereotactic neuronavigation and catheter placement in the nonimmobilized patient. Computer vision technology was used to develop an algorithm that performed near-continuous, automatic, and marker-less image registration. The program fuses a subject's preprocedure CT scans to live 3D camera images (Snap-Surface), and patient movement is incorporated by artificial intelligence-driven recalibration (Real-Track). The surface registration error (SRE) and target registration error (TRE) were calculated for 5 cadaveric heads that underwent serial movements (fast and slow velocity roll, pitch, and yaw motions) and several test conditions, such as surgical draping with limited anatomical exposure and differential subject lighting. Six catheters were placed in each cadaveric head (30 total placements) with a simulated sterile technique. Postprocedure CT scans allowed comparison of planned and actual catheter positions for user error calculation. Registration was successful for all 5 cadaveric specimens, with an overall mean (± standard deviation) SRE of 0.429 ± 0.108 mm for the catheter placements. Accuracy of TRE was maintained under 1.2 mm throughout specimen movements of low and high velocities of roll, pitch, and yaw, with the slowest recalibration time of 0.23 seconds. There were no statistically significant differences in SRE when the specimens were draped or fully undraped (p = 0.336). Performing registration in a bright versus a dimly lit environment had no statistically significant effect on SRE (p = 0.742 and 0.859, respectively). For the catheter placements, mean TRE was 0.862 ± 0.322 mm and mean user error (difference between target and actual catheter tip) was 1.674 ± 1.195 mm. This computer vision-based registration system provided real-time tracking of cadaveric heads with a recalibration time of less than one-quarter of a second with submillimetric accuracy and enabled catheter placements with millimetric accuracy. Using this approach to guide bedside ventriculostomy could reduce complications, improve safety, and be extrapolated to other frameless stereotactic applications in awake, nonimmobilized patients.

Cerebrospinal fluid white cell count to red cell count ratio as a predictor of ventriculitis in patients with external ventricular drains.

External ventricular drain (EVD) associated ventriculitis is a complication of EVD placement associated with significant morbidity and mortality. Gold-standard for EVD associated bacterial ventriculitis diagnosis involves cerebrospinal fluid (CSF) sampling from the EVD with microscopy, culture and sensitivity testing. The ratio of white blood cells to red blood cells has anecdotally been considered a predictive factor in diagnosing EVD associated ventriculitis, however no study has been done demonstrating this. A retrospective cross-sectional study was designed to assess whether the ratio of CSF white blood cells to red blood cells could be used to diagnose EVD associated ventriculitis. Data was collected for all patients undergoing EVD insertion at a major neurosurgical unit in Sydney, Australia. A receiver operator characteristics (ROC) curve was used to determine if this ratio was useful, and Youden's index was calculated to determine the appropriate cut-off point. This sample of n=157 consecutive patients a total of 29 patients were diagnosed with ventriculitis. The area under the ROC curve was significant (0.706, P <0.001), and Youden's index demonstrated an appropriate cut-off point was a ratio of 1:106. CSF parameters have long been considered predictive of EVD associated ventriculitis. We demonstrated that using a component of routine testing it is possible to accurately predict a ventriculitis diagnosis. As the ratio is used, it enables discrimination in a raised white blood cell count due to local trauma with interventricular bleeding. CSF white blood cell to red blood cell ratio is an appropriate diagnostic test for ventriculitis.

"Catheter-Locking Device-Assisted" External Ventricular Drain Placement: A New Surgical Technique Preventing Intracranial Drain Displacement-Technical Note with Preliminary Single-Center Results.

Background External ventricular drain (EVD) placement is frequently performed in neurosurgical patients to divert cerebrospinal fluid (CSF) and monitor intracranial pressure. The traditional practice is the tunneled EVD technique performed in the operating room. EVD insertion through a bolt in intensive care units has also been reported. We describe here the usage of a novel technique, the “ catheter-locking device -assisted” EVD placement, reporting our preliminary, observational single-center results. Methods From January to October 2021, 15 patients underwent a “catheter-locking device-assisted” EVD placement at our institute. For each of these patients, the following data were evaluated: (1) demographics, (2) etiology, (3) clinical presentation, (4) EVD complications, and (5) final clinical outcomes. Results Median age of our population was 64 years, with a female/male ratio of 2:1. Average Glasgow Coma Scale score on admission was 8. Each patient maintained the drainage for an average time of 14 days. None of the patients suffered from postoperative intracerebral hemorrhage, CSF leakage, catheter migration, or discontinuation of the drainage system; none developed signs of infection. Nine patients required a permanent CSF diversion system. Outcome was good in 14 patients. One patient died for the underlying disease. Conclusions The “catheter-locking device-assisted” EVD placement appears to be a safe and accurate alternative to both the standard tunneled and the bolt-assisted EVD insertion techniques. The use of this procedure may significantly reduce the incidence of the commonest EVD complications, though further investigation is required.

118 Delayed Cranial Decompression Rates After Initiation of Unfractionated Heparin Versus Low-Molecular-Weight Heparin in Traumatic Brain Injury

INTRODUCTION: Both unfractionated heparin (UH) and low-molecular weight heparin (LMWH) are routinely used prophylactically after traumatic brain injury (TBI) to prevent deep vein thrombosis. Their comparative risk for intracranial hemorrhage (ICH) development or worsening necessitating cranial decompression after prophylaxis initiation is unclear. Furthermore, the absence of a specific antidote for LMWH may lead to UH being used more often for high-risk patients. METHODS: We compared the incidence of delayed cranial decompression occurring after initiation of prophylactic UH vs. LMWH using the National Trauma Data Bank. Cranial decompression procedures included craniotomy, craniectomy, and external ventricular drain placement. Multiple imputation was utilized for missing data. To account for selection bias between UH and LMWH, we conducted propensity score matching using factors that were significantly different between the two groups. The matched UH and LMWH groups were then compared using logistic regression for the primary outcome of post-prophylaxis cranial decompression. RESULTS: A total of 218,594 TBI patients were included, with 61,998 (28.3%) receiving UH and 156,596 (71.7%) receiving LMWH as DVT prophylaxis. The UH group had significantly higher patient age, BMI, comorbidity rates, injury severity score, and worse motor Glasgow coma scale. After matching the UH and LMWH groups for these factors, logistic regression demonstrated lower rates of post-prophylaxis cranial decompression for the LMWH group (OR 0.13, 95% CI 0.11-0.16, P &lt; 0.001). CONCLUSION: Despite the absence of a specific antidote, LMWH was associated with substantially lower rates of post-DVT-prophylaxis cranial decompression. This indicates that UH may not be the safer alternative in TBI patients at high risk for intracranial hemorrhagic complications.

Emergency department and transport predictors of neurological deterioration in patients with spontaneous intracranial hemorrhage.

Patients with spontaneous intracranial hemorrhage (sICH) and intracranial hypertension are associated with poor outcomes. Blood pressure variability (BPV) and neurological deterioration (ND) are known factors associated with sICH outcomes, but the relationship between BPV and ND in the hyperacute phase remains poorly described. We hypothesized that BPV is associated with ND during patients' initial emergency department (ED) stay and during interhospital transport (IHT) to a tertiary care center. A retrospective study of adult patients with sICH was performed. Patients who were transferred from an ED to a tertiary care center between 01/01/2011 and 09/30/2015 and underwent external ventricular drainage were eligible. The outcome was ND at any time before arrival at a tertiary care center. Classification and Regression Tree (CART) analysis, a machine learning algorithm, was used to assign "relative variable importance" (RVI) for important predictive clinical factors. 153 eligible patients were analyzed. Sixty-five (42%) patients developed ND. Maximum ED systolic blood pressure (ED SBPMax) was most predictive of sICH patients developing ND (RVI=100%). Other important factors for ND included standard deviation in SBP (SBPSD) during ED stay and IHT, with RVI of 43% and 20%, respectively. ED SBPMax was the strongest predictive factor of ND, while other BPV components were also significant. Our study found evidence that BPV should be prioritized as it may also increase the risk of ND among patients with sICH who required external ventricular drain placement. Future studies should examine whether fluctuations in BP in an ED or IHT setting are associated with increased risk of worsening outcomes.

External Ventricular Drainage Reduces Mortality in Spontaneous Intraventricular Hemorrhage of Brain: A Comparative Study

Introduction: External ventricular drain (EVD) usage in patients with intraventricular hemorrhage (IVH) is variable in current practice and clinical trials, and its impact on outcome remains controversial. Aim of this study was to see the outcome of EVD in management of spontaneous IVH of brain assessing by Glasgow outcome scale (GOS) and modified Rankin scale (mRS) score compared with conservative management. Materials and Methods: Between July 2018 and June 2019, a consecutive 125 admitted patients with spontaneous IVH were enrolled in this quasi-experimental study. Among them 56 patient’s relative agreed to surgery who were accepted as case group and had EVDs. Remaining 69 patient’s relative declined authorization for surgery and were accepted as control group and underwent conservative management. Baseline demographics, clinical presentation, and hospital course, Glasgow coma scale score (GCS) for level of consciousness and modified Graeb score (mGS) for severity of ventricular haemorrhage were recorded at baseline and postoperatively. Admission Computed tomography (CT) scans performed within 24 hours of admission were reviewed for IVH type and hydrocephalus. Patients were followed up for 3 months post operatively and assessed using the GOS score and mRS score. Results: Both the groups were similar at baseline in terms of age (mean±SD: 59±14 vs 60±14, p = 0.645), sex and comorbidity distributions. However, patients who received EVDs had lower mean GCS score (p=&lt;0.001) and higher mean mGS score (p= 0.015) than those who did not receive an EVD. Incidence of hydrocephalus was similar in both groups (57.4% vs 46.7%, p = 0.268). Among the 77 survivors at 3 months, there were 23.1% (6/21) patients scored mRSd”2 in case group, while 38.2% (13/34) in control group (P=0.211). After binary logistic regression analysis, EVD placement was independently associated with reduction of 90 days mortality than conservative management (OR: 3.982; 95% CI: 1.3-12.19) but no effect on morbidity and functional dependence. Other independent predictors for mortality were higher age (p=0.002), lower GCS at admission (p=&lt;0.001) and presence of hydrocephalus (p= &lt;0.001) on CT scan. Conclusion:These results suggest that EVD placement may be beneficial for patients with IVH, who have particularly poor prognosis at admission, but our results must be validated in future randomized clinical trial with larger cohorts and longer follow-up periods that are sufficiently powered to control for the heterogeneity of the study population and managements. Bang. J Neurosurgery 2021; 11(1): 3-12

Diagnostic criteria of CNS infection in patients with external ventricular drainage after traumatic brain injury: a pilot study.

Ventriculostomy-related infection (VRI) is a common complication in patients with traumatic brain injury (TBI) treated with an external ventricular drain (EVD). The aim of this study was to investigate incidence and characteristics of patients with VRI, and to explore diagnostic criteria to confidently rule out VRI in patients with TBI. This retrospective cohort pilot study included adults with severe TBI who were admitted to the ICU and received an EVD, during a 26-month period. Patients were categorized as having Culture-positive VRI, Culture-negative VRI, or No VRI. Variables that were potentially associated with Culture-positive VRI was analyzed, and predictive values were calculated. 75 of 215 patients with severe TBI (35%) underwent EVD placement; nine of these (12%) were classified as Culture-negative VRI and eight (11%) as Culture-positive VRI. The CSF cell counts that led to VRI treatment were compared with 46 CSF cell counts from No VRI patients. A CSF/plasma glucose ratio below 0.6had a negative predictive value (NPV) for culture-verified VRI of 0.97 (95% CI: 0.85-1), whereas a combination of three CSF-derived biomarkers within the reference limits (white/red blood cell ratio, CSF/plasma glucose ratio, and protein content) ruled out Culture-positive VRI in this cohort (PPV 0, 95% CI: 0-0.14). C-reactive protein did not reliably predict VRI. In this pilot study of patients after severe, a combination of biomarkers within reference limits ruled out VRI (PPV 0, CI: 0-0.14). Hypoglycorrhachia was a sensitive marker of VRI (NPV 0.97, CI: 0.85-1). Systemic signs and markers of infection did not predict VRI.

Pattern and Practice of Paediatric Neurosurgical Procedures- An analysis of one year initial experience at resource challenged setup of Children Hospital, Faisalabad.

patients presenting to Children Hospital, Faisalabad. Materials and Methods: Retrospective case series of 778 consecutive cases admitted in Pediatric Neurosurgery Department, Children Hospital, Faisalabad over one year (October 2019- September 2020). Patients of age less than 15 years, any gender, admitted in Pediatric Neurosurgery ward for management were included and studied for their demographic data hospital stay, a procedure done and outcome. Results: A total of 778 patients who required some neurosurgical intervention were admitted, 725 underwent various types of procedures and the remaining were treated conservatively. 320 (44.14%) were male and405 (55.86%) were female. The age range was 20 days to 13 years. The most common diagnosis was hydrocephalous, and then was Meningomyelocele (MMC). The first three common procedures performed included monitoring of Cerebrospinal fluid (CSF) in 36% of cases, Placement of shunt (21%), and placement of external ventricular drain (EVD) in 13% of cases of cerebrospinal fluid (CNS) infections in patients of hydrocephalous. Conclusion: Pattern of presentation of pediatric neurosurgical cases take in almost all types of diseases like neural tube defects, hydrocephalous, cranial trauma, tumors, cysts, and infections but surgical procedures in routine practice in Faisalabad district cover mainly hydrocephalous and its complications. Endoscopic or advanced procedures are not commonly practiced due to multiple factors but existing constraints do not prevent the best management of pediatric neurosurgery patients.

Abstract TMP12: Artificial Intelligence Prediction Of Delayed Cerebral Ischemia After Cerebral Aneurysm Rupture

Background: Aneurysmal subarachnoid hemorrhage (aSAH) results in significant mortality and disability, which is worsened by the development of Delayed Cerebral Ischemia (DCI). Tests to identify patients with DCI prospectively are needed. Objective: We created a machine learning (ML) system based on clinical variables to predict DCI in aSAH patients and to determine which variables have the most impact on DCI prediction. Methods: We performed a retrospective cohort study of aSAH patients from January 2006 to September 2014. The ML algorithm was trained on age, sex, HTN, diabetes, hyperlipidemia, CHF, CAD, smoking history, family history of aneurysm, Fisher Grade, Hunt and Hess score, and external ventricular drain (EVD) placement. Prediction outcome of the ML algorithm was DCI+, which was defined as new neurologic deterioration that could not be attributed to aneurysm re-bleeding, hydrocephalus, infection, seizure, hyponatremia or other metabolic abnormality. SHAP was used to explain and visualize the role of each feature’s contribution to the model prediction. Results: 500 aSAH patients were identified and 369 met inclusion criteria: 70 patients developed DCI (DCI+) and 299 did not (DCI-). Random Forest was selected for this project after a 5-fold cross validation. 276 cases (222 DCI- and 54 DCI+) were used for training and 93 cases (77 DCI- and 16 DCI+) were used for testing the algorithm. The Random Forest ML algorithm predicted DCI: Accuracy: 81.7%, Sensitivity: 12.5%, Specificity: 96.1%, PPV: 40%, and NPV: 84.1%. SHAP value demonstrated Age, EVD placement, Fisher Grade, and Hunt and Hess score, and HTN had the highest predictive values for DCI. Lower age, absence of hypertension, higher Hunt and Hess score, higher Fisher Grade, and EVD placement increased risk of DCI. Conclusion: ML models based upon clinical variable predict DCI with high specificity and modest accuracy. The addition of imaging or other biomarkers may improve the sensitivity of the ML algorithm.

Successful Treatment of Postneurosurgical Ventriculitis Caused by Extensively Drug-resistant Acinetobacter baumannii in a Child: Case Report

Introduction: The incidence of postneurosurgical Acinetobacter baumannii ventriculitis/meningitis, primarily due to drug-resistant strains, has increased considerably in recent years. However, limited therapeutic options are available because most antibiotics poorly penetrate the blood-brain barrier, especially in pediatric patients. Case Presentation: A five-year-old boy developed ventriculitis due to extensively drug-resistant A. baumannii (XDRAB) after bilateral frontal external ventricular drainage for spontaneous intraventricular hemorrhage. The boy was safely and successfully treated with intraventricular (IVT)/intrathecal (ITH) polymyxin B together with intravenous tigecycline plus cefoperazone/sulbactam. Conclusions: In the present case, postneurosurgical XDRAB ventriculitis was closely associated with intraventricular hemorrhage and the placement of external ventricular drainage. IVT/ITH polymyxin B combined with intravenous tigecycline and cefoperazone sulbactam could be a therapeutic option against XDRAB ventriculitis in children.

Endoscopic Third Ventriculostomy: Our Experience of Consecutive 50 Cases at a Tertiary Care Center

Abstract Objective The aim of this study was to do a retrospective analysis of the various neurosurgical pathologies where endoscopic third ventriculostomy (ETV) was used and to evaluate the outcome and prognosis. Methods The retrospective data collection was done for the patients who underwent ETV with or without other adjunct procedures; the results were prepared for clinical presentation, diagnosis, surgical approach, and surgical goal; and success rate and prognosis were analyzed and compared with other studies. Results A total of 50 patients were included in the study, with overall success rate of ETV as 88%; aqueductal stenosis was the most common indication where ETV was used; headache and vomiting were the most common presenting complaints followed by ataxia and visual blurring; and ETV provided flexibility in its use with biopsy, abscess drainage, temporary external ventricular drain placement, etc. Conclusion ETV being superior to ventriculo-peritoneal shunt for obstructive hydrocephalus provides flexibility in its use and possibly is a useful adjunct to prevent postoperative hydrocephalus after endoscopic intraventricular surgery; proper case selection in accordance to ETV success score yields a better success rate. In experienced hands with proper precautions, perioperative complications can be kept at minimum. Wherever possible, in cases of obstructive hydrocephalus, especially in patients &gt;1 year of age, ETV should be the treatment of choice. We recommend a proper case selection, including preoperative detailed reading of sagittal magnetic resonance imaging scan, to improve the success rate with less complication.

Freehand frontal external ventricular drain (EVD) placement: Accuracy and complications

Ventriculostomy placement is a life-saving procedure. Our aim was to determine the predictors of inaccurate placement, our infection and hemorrhage rate. This was a retrospective study of EVD placements between January - November 2019. Data related to hemorrhage, infection and catheter misplacement were collected. Univariate and multivariate analyses of predictors of suboptimal catheter placement were performed. 131 consecutive patients underwent freehand EVD placement. The indications were subarachnoid hemorrhage in 36 (27.5%) patients, hemorrhagic stroke in 36 (27.5%), and trauma in 32 (24.4%) patients. Nine patients (6.8%) had culture-proven CSF bacterial infection. Sixteen (12.2%) patients developed small tract hemorrhage, while 8 (6.1%) patients developed large intraparenchymal hemorrhage. There was no correlation between tract hemorrhage or large hemorrhage with the use of antiplatelet or anticoagulation medicines on presentation, diagnosis or Kakarla grade. Trauma diagnosis (odds ratio 2.59, p-value 0.05), left side of EVD placement (odds ratio 2.84, p-value 0.03), increasing midline shift (odds ratio 1.09, p-value 0.03), and lower bicaudate index (odds ratio 0.56, p-value 0.02) were all predictors of Kakarla grade 3 suboptimal placement. When Kakarla grade 2 and 3 were combined, similar results were obtained except that midline shift was no longer statistically significant. The multivariable regression model predicting Kakarla 3 suboptimal placement revealed that low bicaudate index and left sided EVD were predictors of misplaced EVD.

Acute Endovascular Management of a Ruptured Choroidal Artery Arteriovenous Malformation in a Peripartum COVID-19-Positive Patient

AbstractCoronavirus disease 2019 (COVID-19) pandemic has led to significant reduction in specialty care causing delayed presentations and decreased resources for elective procedures. We present here a case of a 29-year-old female, 34 weeks primigravida who presented with a twice ruptured right choroidal artery arteriovenous malformation (AVM). She underwent an immediate external ventricular drain placement followed by an emergency cesarean. She underwent a diagnostic angiogram showing a right choroidal AVM with a feeder artery aneurysm along with small supply to its cortical component by the M4 segment of right middle cerebral artery, draining into the basal vein of Rosenthal and vein of Labbe. The patient underwent embolization of the aneurysm and the choroidal feeders. She improved symptomatically following the procedure with external cerebrospinal fluid diversion for 5 days. At follow-up magnetic resonance imaging, the residual AVM remained stable and is planned for Gamma knife radiosurgery. The newborn was taken care at a neonatal intensive care unit and was started on breastfeed on 16th day of birth once the mother had a negative COVID-19 reverse transcription polymerase chain reaction. In this study, we highlight our experience with the above-mentioned patient profile, the multidisciplinary effort during the pandemic, and the measures taken (isolation ward, COVID-19 dedicated Cath-lab and personal precautions) and advised for tackling COVID-19 patients for endovascular procedures.

Robotic external ventricular drain placement for acute neurosurgical care in low-resource settings: feasibility considerations and a prototype design.

Emergency neurosurgical care in lower-middle-income countries faces pronounced shortages in neurosurgical personnel and infrastructure. In instances of traumatic brain injury (TBI), hydrocephalus, and subarachnoid hemorrhage, the timely placement of external ventricular drains (EVDs) strongly dictates prognosis and can provide necessary stabilization before transfer to a higher-level center of care that has access to neurosurgery. Accordingly, the authors have developed an inexpensive and portable robotic navigation tool to allow surgeons who do not have explicit neurosurgical training to place EVDs. In this article, the authors aimed to highlight income disparities in neurosurgical care, evaluate access to CT imaging around the world, and introduce a novel, inexpensive robotic navigation tool for EVD placement. By combining the worldwide distribution of neurosurgeons, CT scanners, and gross domestic product with the incidence of TBI, meningitis, and hydrocephalus, the authors identified regions and countries where development of an inexpensive, passive robotic navigation system would be most beneficial and feasible. A prototype of the robotic navigation system was constructed using encoders, 3D-printed components, machined parts, and a printed circuit board. Global analysis showed Montenegro, Antigua and Barbuda, and Seychelles to be primary candidates for implementation and feasibility testing of the novel robotic navigation system. To validate the feasibility of the system for further development, its performance was analyzed through an accuracy study resulting in accuracy and repeatability within 1.53 ± 2.50 mm (mean ± 2 × SD, 95% CI). By considering regions of the world that have a shortage of neurosurgeons and a high incidence of EVD placement, the authors were able to provide an analysis of where to prioritize the development of a robotic navigation system. Subsequently, a proof-of-principle prototype has been provided, with sufficient accuracy to target the ventricles for EVD placement.