Underwent External Ventricular Drain Placement Research Articles

Association Between Early External Ventricular Drain Insertion and Functional Outcomes 6 Months Following Moderate-to-Severe Traumatic Brain Injury.

Traumatic brain injury (TBI) is a leading global cause of morbidity and mortality. Intracranial hypertension following moderate-to-severe TBI (m-sTBI) is a potentially modifiable secondary cerebral insult and one of the central therapeutic targets of contemporary neurocritical care. External ventricular drain (EVD) insertion is a common therapeutic intervention used to control intracranial hypertension and attenuate secondary brain injury. However, the optimal timing of EVD insertion in the setting of m-sTBI is uncertain and practice variation is widespread. Therefore, we aimed to assess if there is an association between timing of EVD placement and functional neurological outcome at 6 months post m-sTBI. We pooled individual patient data for all relevant harmonizable variables from the Erythropoietin in Traumatic Brain Injury (EPO-TBI) and Prophylactic Hypothermia Trial to Lessen Traumatic Brain Injury (POLAR) randomized control trials, and the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) Core Study version 3.0 and Australia-Europe NeuroTrauma Effectiveness Research in TBI (Oz-ENTER) prospective observational studies to create a combined dataset. The Glasgow Coma Scale (GCS) score was used to define TBI severity and we included all patients admitted to an intensive care unit with a GCS ≤12, who were 15 years or older and underwent EVD placement within 7 days of injury. We used hierarchical multi-variable logistic regression models to study the association between EVD insertion within 24 h of injury (early) compared with EVD insertion more than 24 h after injury (late) and 6-month functional neurological outcome measured using the Glasgow Outcome Score Extended (GOSE). In total, 2536 patients were assessed. Of these, 502 (20%) underwent early EVD insertion and 145 (6%) underwent late EVD insertion. Following adjustment for the IMPACT (International Mission for Prognosis and Analysis of Clinical Trials in TBI) score extended (Core + CT), sex, injury severity score, study and treatment site, patients receiving a late EVD had higher odds of death or severe disability (GOSE 1-4) at 6 months follow-up than those receiving an early EVD adjusted odds ratio; 95% confidence interval, 2.14; 1.22-3.76; p = 0.008. Our study suggests that in patients with m-sTBI where an EVD is needed, early (≤ 24 h post-injury) insertion may result in better long-term functional outcomes. This finding supports future prospective investigation in this area.

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.

Effects of an external ventricular drain alert protocol on venticulostomy placement time in the emergency department.

Timely ventriculostomy placement is critical in the management of neurosurgical emergencies. Prompt external ventricular drain (EVD) placement has been shown to improve long-term patient outcomes and decrease the length of ICU and hospital stays. Successful and efficient EVD placement requires seamless coordination among multiple healthcare teams. In this study, the authors sought to identify factors favoring delayed ventriculostomy via a quality improvement initiative and to implement changes to expedite EVD placement. Through process mapping, root cause analysis, and interviews with staff, the authors identified the lack of a standardized mechanism for alerting necessary healthcare teams as a major contributor to delays in EVD placement. In December 2019, an EVD alert system was developed to automatically initiate an EVD placement protocol and to alert the neurosurgery department, pharmacy, core laboratory, and nursing staff to prepare for EVD placement. The time to EVD placement was tracked prospectively using time stamps in the electronic medical record. A total of 20 patients who underwent EVD placement between December 2019 and April 2021, during the EVD alert protocol initiation, and 18 preprotocol control patients (January 2018 to December 2019) met study inclusion criteria and were included in the analysis. The mean time to EVD placement in the control group was 71.88 minutes compared with 50.3 minutes in the EVD alert group (two-tailed t-test, p = 0.025). The median time to EVD placement was 64 minutes in the control group compared with 52 minutes in the EVD alert group (rank-sum test, p = 0.0184). All patients from each cohort exhibited behavior typical of stable processes, with no violation of Shewhart rules and no special cause variations on statistical process control charts. A quality improvement framework helped identify sources of delays to EVD placement in the emergency department. An automated EVD alert system was a simple intervention that significantly reduced the time to EVD placement in the emergency department and can be easily implemented at other institutions to improve patient care.

Predictors of ventriculostomy infection in a large single-center cohort.

External ventricular drain (EVD) placement is a common neurosurgical procedure. While this procedure is simple and effective, infection is a major limiting factor. Factors predictive of infection reported in the literature are not conclusive. The aim of this retrospective, single-center large series was to assess the rate and independent predictors of ventriculostomy-associated infection (VAI). The authors performed a retrospective chart review of consecutive patients who underwent EVD placement between January 2012 and January 2018. A total of 389 patients were included in the study. The infection rate was 3.1% (n = 12). Variables that were significantly associated with VAI were EVD replacement (OR 10, p = 0.001), bilateral EVDs (OR 9.2, p = 0.009), duration of EVD placement (OR 1.1, p = 0.011), increased CSF output/day (OR 1.0, p = 0.001), CSF leak (OR 12.9, p = 0.001), and increased length of hospital stay (OR 1.1, p = 0.002). Using multivariate logistic regression, independent predictors of VAI were female sex (OR 7.1, 95% CI 1.1-47.4; p = 0.043), EVD replacement (OR 8.5, 95% CI 1.44-50.72; p = 0.027), increased CSF output/day (OR 1.01, 95% CI 1.0-1.02; p = 0.023), and CSF leak (OR 15.1, 95% CI 2.6-87.1; p = 0.003). The rate of VAI was 3.1%. Routine CSF collection (every other day or every 3 days) and CSF collection when needed were not associated with VAI. The authors recommend CSF collection when clinically needed rather than routinely.

Patterns of Health Care Costs Due to External Ventricular Drain Infections

External ventricular drain (EVD) infections are a significant cause of morbidity among neurosurgical patients and have been correlated with increased length of hospital stay and longer requirements for intensive care. To date, no studies have examined the financial impact of EVD infections. Patients who underwent EVD placement between December 2010 and January 2016 were included in the study. Clinical records were retrospectively reviewed and health care cost data were obtained from the hospital's finance department. Clinical information included patient demographics, details from the hospital course, and outcomes. Total costs, direct/indirect, and fixed/variable costs were analyzed for every patient. Over the 5-year study period, 246 EVDs were placed in 243 patients with an overall infection rate of 9.9% (N= 24). The median EVD duration for infected versus noninfected patients was 19 and 9 days, respectively (P<0.0001). Median length of intensive care unit stay also was increased for patients with EVD infection (30 days vs. 13 days, P < 0.0001). Total health care costs were significantly greater for infected patients (US$ 168,692 vs. US$ 83,919, P < 0.0001). This trend was comparable for all other cost subtypes, including fixed-direct costs, fixed-indirect costs, variable direct costs, and variable-indirect costs. EVD infection has a substantial effect on clinical morbidity and healthcare costs. These results demonstrate the imperative need to improve EVD infection prevention, particularly in the setting of a value-based health care system.

A novel grading system for the prediction of the need for cerebrospinal fluid drainage following posterior fossa tumor surgery.

Prophylactic placement of an external ventricular drain (EVD) is often performed prior to resection of a posterior fossa tumor (PFT); however, there is no general consensus regarding the indications. The purpose of this study was to establish a novel grading system for the prediction of required CSF drainage due to symptomatic elevated intracranial pressure (ICP) after resection of a PFT to identify patients who require an EVD. The authors performed a retrospective analysis of data from a prospective database. All patients who had undergone resection of a PFT between 2012 and 2017 at the University Hospital, Goethe University Frankfurt, were identified and data from their cases were analyzed. PFTs were categorized as intraparenchymal (iPFT) or extraparenchymal (ePFT). Prior to resection, patients underwent EVD placement, prophylactic burr hole placement, or neither. The authors assessed the amount of CSF drainage (if applicable), rate of EVD placement at a later time point, and complication rate and screened for factors associated with CSF drainage. By applying those factors, they established a grading system to predict the necessity of CSF drainage for elevated ICP. A total of 197 patients met the inclusion criteria. Of these 197, 70.6% received an EVD, 15.7% underwent prophylactic burr hole placement, and 29.4% required temporary CSF drainage. In the prophylactic burr hole group, 1 of 32 patients (3.1%) required EVD placement at a later time. Independent predictors for postoperative need for CSF drainage due to symptomatic intracranial hypertension in patients with iPFTs were preoperative hydrocephalus (OR 2.9) and periventricular CSF capping (OR 2.9), whereas semi-sitting surgical position (OR 0.2) and total resection (OR 0.3) were protective factors. For patients with ePFTs, petroclival/midline tumor location (OR 12.2/OR 5.7), perilesional edema (OR 10.0), and preoperative hydrocephalus (OR 4.0) were independent predictors of need for CSF drainage. According to our grading system, CSF drainage after resection of iPFT or ePFT, respectively, was required in 16.7% and 5.1% of patients with a score of 0, in 21.1% and 12.5% of patients with a score of 1, in 47.1% and 26.3% of patients with a score of 2, and in 100% and 76.5% of patients with a score ≥ 3 (p < 0.0001). The rate of relevant EVD complications was 4.3%, and 10.1% of patients were shunt-dependent at 3-month follow-up. This novel grading system for the prediction of need for CSF drainage following resection of PFT might be of help in deciding in favor of or against prophylactic EVD placement.

The Incidence of Meningitis in Patients with Traumatic Brain Injury Undergoing External Ventricular Drain Placement: A Nationwide Inpatient Sample Analysis.

Infection is the most common complication of external ventricular drain (EVD) placement. National trends in the annual incidence of meningitis among patients with traumatic brain injury (TBI) who have undergone EVD placement have not been reported. The Nationwide Inpatient Sample was used to select adults with a primary diagnosis of TBI who underwent EVD placement between 2002 and 2011. Annual rates of meningitis among patients who underwent EVD placement were determined. We also calculated mortality rates and length of stay (LOS). Potential factors associated with meningitis were evaluated in a binary logistic regression analysis. Out of 1,571,927 adult discharges with a primary diagnosis of TBI between 2002 and 2011, 39,029 (2.5%) underwent EVD placement. Of these, 1544 (4.3%) patients developed meningitis. There was no significant trend in the annual incidence of meningitis (p = 0.88), mortality (p = 0.55), or mean LOS (p = 0.13) during the study period. Meningitis and mortality rates remained stable when stratifying patients by hospital volume. In the binary logistic regression, acquired immunodeficiency syndrome, sepsis, and cerebrospinal fluid leak were associated with meningitis. The incidence of meningitis in patients who underwent EVD placement remained stable between 2002 and 2011. Further prospective studies are needed to identify approaches for preventing these infections.

Trends in Ventriculostomy-Associated Infections and Mortality in Aneurysmal Subarachnoid Hemorrhage: Data From the Nationwide Inpatient Sample.

Patients with aneurysmal subarachnoid hemorrhage (aSAH) are susceptible to various medical complications, including ventriculostomy-associated infections (VAIs) in those who undergo external ventricular drain (EVD) placement. Many preventative strategies for VAIs have been used during the last 20 years, but their overall effect is unknown. Using the Nationwide (National) Inpatient Sample, we examined trends in VAI rates and mortality during a recent 12-year period in the aSAH population. In this retrospective analysis, data from the Nationwide Inpatient Sample was obtained from January 1, 2000, through December 31, 2011, using International Classification of Diseases, 9th Revision, Clinical Modification codes. After adjustment for age, sex, race, and subarachnoid severity, annual estimated event rates of VAI, in-hospital mortality, and hospital length of stay were calculated. Changes in these parameters during the study period were analyzed. From years 2000 through 2011, there were 116,013 aSAH admissions, with EVD placement in 38,163 (32.9%) cases. In patients who underwent EVD placement, the mean annual rate of VAI was 7.3 per 100 patients, with no change during the 12-year period (absolute risk reduction per year of-0.05%, 95% confidence interval-0.22, 0.13). The mean mortality rate in this population was 19.8 per 100 patients, significantly declining over the study period (absolute risk reduction per year of-0.55%, 95% confidence interval-0.82,-0.29). Despite numerous VAI-preventative strategies, the national VAI rate in aSAH patients has not changed; however, a reduction in mortality is suggested. Further studies are needed to determine how best to reduce VAIs, and to identify factors influencing observed trends in VAI and mortality.

Hemorrhagic Complications Associated with Ventriculostomy in Patients Undergoing Endovascular Treatment for Intracranial Aneurysms: A Single-Center Experience.

Currently, a complete understanding of post-ventriculostomy hemorrhagic complications in subarachnoid hemorrhage due to ruptured aneurysms remains unknown. The present study evaluates the impact of periprocedural risk factors on rates of external ventricular drain (EVD)-associated hemorrhage in the setting of endovascular treatment of intracranial aneurysms. A retrospective chart review of 107 patients who underwent EVD placement within 24h of endovascular coiling was performed. CT of head without contrast was obtained after drain placement and before endovascular treatment. Post-procedural CT was also obtained within 48h of embolization and was reviewed for new/worsened track hemorrhages. Chi-squared test was used in evaluation. Ninety-three of the 107 patients reviewed met the inclusion criteria. Four (25%) of the 16 patients on antiplatelet medications at presentation experienced post-EVD hemorrhage compared to 11 (14.3%) of 77 that were not (p=0.29). Of the 13 patients given intraprocedural antiplatelets, 3 (23.1%) demonstrated hemorrhage compared to 12 (15%) of 80 not administered these medications (p=0.46). Further, of 36 patients with intraprocedural anticoagulation, 6 (16.7%) exhibited hemorrhage compared to 9 (15.8%) of 57 in those without (p=0.91). In 17 patients who received DVT prophylaxis, 2 (11.8%) exhibited hemorrhage compared to 13 (17.1%) of 76 who did not (p=0.59). No post-EVD hemorrhage had attributable neurologic morbidity. Our results, demonstrating no significant risk factor related to EVD-associated hemorrhage rates, support the safety of EVD placement in the peri-endovascular treatment period.

Abstract TP432: Ventriculostomy Placement Improves Outcome in Hunt and Hess Grade 3-5 Subarachnoid Hemorrhage Patients Irrespective of Hydrocephalus

Background: Cerebrospinal fluid diversion may be necessary in the acute period after subarachnoid hemorrhage (SAH) if patients develop hydrocephalus. Though there is an opinion that certain ‘severe grade’ patients, e.g. Hunt and Hess (HH) grades 3-5, should have external ventricular drain (EVD) placement, regardless of hydrocephalus, there is no firm data, leaving the decision up to the judgement of the evaluating clinical team. Objective: We sought to measure changes in HH grades among grade 3-5 patients based on whether or not they had EVD placement. Methods: We prospectively collect demographic, clinical, and radiographic data on our SAH patients since January 2014. We selected HH grades 3-5 patients and compared admission and discharge HH grades among groups of patients who underwent EVD placement or surgical decompression within the first 24 hours and those who did not, using chi square test. Results: Among 54 total patients, there were 37 grades 3-5 patients (HH 3, n=26, 70.3%; HH 4, n=5, 13.5%; HH 5, n=6, 16.2%) in two groups: no EVD, n=22 (59.5%) and EVD, n=14 (37.8%, data unavailable for 1 patient). At discharge HH grades were: HH 1, n=10 (27%); HH 2, n=1 (2.7%); HH 3, n=10 (27%); HH 4, n=3 (8.1%); HH 5, n=1 (2.7%); dead, n=11 (29.7%); missing data, n=1. Mean age of 37 HH 3-5 patients was 58 years with no significant difference between the 2 groups. Hydrocephalus was seen in 11 of the 22 no EVD group and 13 of the 14 EVD group, p=0.007. Improvement in HH score between admission and discharge was seen in 10/14 EVD group, compared with 5/22 of the no EVD group, p=0.010. Worsening of HH score was found in 8/17 no EVD group (5 HH grade 5 patients excluded from this analysis), and 1 HH 4 patient (out of 14) in the EVD group, p=.014. Mortality occurred in 11/22 of the no EVD group (HH 3=5; HH 4-5=6) and 1/14 of the EVD group (HH 4, p=0.007). Conclusion: While the presence of hydrocephalus could potentially be a determinant in the decision to place EVDs among HH grades 3-5 patients, clinical change in patients who did not have an EVD placed occurred independently of hydrocephalus. Improvement of HH grade was more frequent, while its worsening was less common, among patients who underwent EVD or surgery within the first 24 hours. Mortality of HH grade 3 patients may also be impacted with EVD placement.

Hemorrhagic complications of ventriculostomy: incidence and predictors in patients with intracerebral hemorrhage

Ventriculostomy--the placement of an external ventricular drain (EVD)--is a common procedure performed in patients with acute neurological injury. Although generally considered a low-risk intervention, recent studies have cited higher rates of hemorrhagic complications than those previously reported. The authors sought to determine the rate of postventriculostomy hemorrhage in a cohort of patients with intracerebral hemorrhage (ICH) and to identify predictors of hemorrhagic complications of EVD placement. Patients with ICH who underwent EVD placement and had both pre- and postprocedural imaging available for analysis were included in this study. Relevant data were prospectively collected for each patient who satisfied inclusion criteria. Variables with a p < 0.20 on univariate analyses were included in a stepwise logistic regression model to identify predictors of postventriculostomy hemorrhage. Sixty-nine patients were eligible for this analysis. Postventriculostomy hemorrhage occurred in 31.9% of patients. Among all patients with intraparenchymal hemorrhage, the mean hemorrhage volume was 0.66 ± 1.06 cm(3). Stratified according to ventricular catheter diameter, patients treated with smaller-diameter catheters had a significantly greater mean hemorrhage volume than patients treated with larger-diameter catheters (0.84 ± 1.2 cm(3) vs 0.14 ± 0.12 cm(3), p = 0.049). Postventriculostomy hemorrhage was clinically significant in only 1 patient (1.4%). Overall, postventriculostomy hemorrhage was not associated with functional outcome or mortality at either discharge or 90 days. In the multivariate model, an age > 75 years was the only independent predictor of EVD-associated hemorrhage. Advanced age is predictive of EVD-related hemorrhage in patients with ICH. While postventriculostomy hemorrhage is common, it appears to be of minor clinical significance in the majority of patients.

Safety of intravenous heparin administration after endovascular treatment for ruptured intracranial aneurysms

IntroductionThromboembolic events are the primary complications encountered during endovascular treatment (EVT) of intracranial aneurysms. Intraprocedural heparinization is common during EVT but is less common post-procedure. The safety of heparinization following...