Use Of External Ventricular Drainage Research Articles

Local fibrinolisis in nontraumatic intraventricular hemorrhages

The management of patients with hemorrhagic stroke is an important problem in modern neurology and neurosurgery. The proportion of hemorrhagic stroke is only 15% of all cases of acute cerebrovascular accident, but mortality reaches 50% (and with intraventricular hemorrhages up to 80%), and disability is over 75%. Minimally invasive methods are being developed to reduce intraoperative damage to brain and improve the prognosis for the patient. One of them is ventricular external drainage (EVD) in combination with local fibrinolysis (LF). Intraventricular injection of thrombolytics allows the acceleration of the process of lysis and evacuation of blood. In this clinical observation, a 52-year-old female patient was admitted to the clinic with intracerebral hematoma and intraventricular hemorrhage, complicated by acute occlusive hydrocephalus. In the case of this patient, the use of external ventricular drainage in combination with local fibrinolysis made it possible to quickly resolve occlusive hydrocephalus, reduce the risk of death and increase the patient's rehabilitation potential.

Endoscopic third ventriculostomy in previously shunt-treated patients.

Endoscopic third ventriculostomy (ETV) is an option for treatment of hydrocephalus, including for patients who have a history of previous treatment with CSF shunt insertion. The purpose of this study was to report the success of postshunt ETV by using data from a multicenter prospective registry. Prospectively collected data in the Hydrocephalus Clinical Research Network (HCRN) Core Data Project (i.e., HCRN Registry) were reviewed. Children who underwent ETV between 2008 and 2019 and had a history of previous treatment with a CSF shunt were included. A Kaplan-Meier survival curve was created for the primary outcome: time from postshunt ETV to subsequent CSF shunt placement or revision. Univariable Cox proportional hazards models were created to evaluate for an association between clinical and demographic variables and subsequent shunt surgery. Postshunt ETV complications were also identified and categorized. A total of 203 children were included: 57% male and 43% female; 74% White, 23% Black, and 4% other race. The most common hydrocephalus etiologies were postintraventricular hemorrhage secondary to prematurity (56, 28%) and aqueductal stenosis (42, 21%). The ETV Success Score ranged from 10 to 80. The median patient age was 4.1 years. The overall success of postshunt ETV at 6 months was 41%. Only the surgeon's report of a clear view of the basilar artery was associated with a lower likelihood of postshunt ETV failure (HR 0.43, 95% CI 0.23-0.82, p = 0.009). None of the following variables were associated with postshunt ETV success: age at the time of postshunt ETV, etiology of hydrocephalus, sex, race, ventricle size, number of previous shunt operations, ETV performed at time of shunt infection, and use of external ventricular drainage. Overall, complications were reported in 22% of patients, with CSF leak (8.6%) being the most common complication. Postshunt ETV was successful in treating hydrocephalus, without subsequent need for a CSF shunt, in 41% of patients, with a clear view of the basilar artery being the only variable significantly associated with success. Complications occurred in 22% of patients. ETV is an option for treatment of hydrocephalus in children who have previously undergone shunt placement, but with a lower than expected likelihood of success.

Endoscopic-Assisted Trans-Lateral Ventricular Transchoroidal Fissure Trans-Aqueductal Approach for Evacuation of Severe Intraventricular Hemorrhage

Intraventricular hemorrhage (IVH) is one of the most fatal types of intracerebral hemorrhage (ICH), especially when the third and the fourth ventricles are involved. The use of external ventricular drainage is limited for evacuation of hemorrhage in the lateral ventricles. Endoscopic surgery can provide visualized evacuation of the hemorrhage in the lateral and third ventricles. However, it is usually challenging to access the fourth ventricle using a routine endoscopic approach. We have reported 3 cases of severe IVH with cast fourth ventricles treated using an endoscopic-assisted trans-lateral ventricular transchoroidal fissure trans-aqueductal approach. The average preoperative Graeb score was 11, and the average IVH volume was 75.12 mL. The IVH evacuation rate was 97.5%-100%. The average Glasgow coma scale score had increased to 12 at discharge from 6.6 at admission. At 3 months after surgery, the average modified Rankin scale score was 3. No cerebrospinal fluid shunt had been required and no surgery-related complication had occurred in any patient. Our results have shown that the endoscopic-assisted trans-lateral ventricular transchoroidal fissure trans-aqueductal approach is a feasible and safe endoscopic option that can achieve one-off complete removal of clots in all 4 ventricles in patients with severe IVH.

Hydrocephalus Associated with Posterior Fossa Tumors: How to Manage Effectively?

Hydrocephalus associated with posterior fossa tumor (PFT) is a common neurosurgical problem, the management of which is still controversial. To provide an overview of the advantages and limitations of different management strategies for hydrocephalus associated with PFT both before and after resection of these tumors. Structured review of the literature on the management of hydrocephalus in PFT both in children and adults. The incidence of hydrocephalus associated with PFT at the time of presentation is more in children (70-90%) than adults (10-21%). This difference is maintained for hydrocephalus after the resection of PFT (~30% for children and 1.2-6.9% for adults). Preresection hydrocephalus is obstructive while emerging evidence in the literature suggests that postresection hydrocephalus may have a communicating component. The treatment of preresection hydrocephalus associated with PFT has undergone a paradigm shift in the past two decades. Preoperative Cerebrospinal Fluid (CSF) diversion is less commonly used except when required by the clinical condition of the patient. Preresection hydrocephalus may be treated by steroid use and early tumor removal, perioperative use of external ventricular drainage, or endoscopic third ventriculostomy in selected patients. Various prediction scales are available to assess the risk of postresection hydrocephalus in PFT. Certain histological tumor types and molecular phenotypes of PFT are more commonly associated with hydrocephalus. CSF diversion through endoscopic third ventriculostomy or ventriculoperitoneal shunts remains the management strategies for postresection hydrocephalus. The failure rates and the time-to-failure of both endoscopic third ventriculostomy and CSF shunts in PFT are variable and surgeons should be aware of these while taking management decisions. Hydrocephalus associated with PFT affects the quality of life of patients with such lesions. Routine preoperative CSF diversion is not necessary for the vast majority of patients with posterior fossa tumor-related hydrocephalus. A high index of suspicion and aggressive surveillance is required for the early identification and appropriate management of postresection hydrocephalus. Future studies are needed to address several unanswered questions pertaining to the management of this condition.

The Use of External Ventricular Drainage to Reduce the Frequency of Wound Complications in Myelomeningocele Closure

Introduction: Myelomeningocele (MMC) is an open neural tube defect routinely surgically closed within 48 h of birth to prevent secondary infection. Up to 18% of patients experience wound complications, and 85% require shunting for hydrocephalus. We hypothesized that wound complications could be reduced by cerebrospinal fluid (CSF) diversion at the time of closure. Methods: Institutional review board approval was obtained to review records of the 88 patients who underwent MMC closure between January 2005 and June 2016 at the Children's Hospital of Pittsburgh. Twenty-three patients (26%) had an external ventricular drain (EVD) placed at the time of MMC closure and underwent 7-11 days of CSF drainage. Fourteen patients (16%) had a shunt placed at the time of MMC closure, and 51 (58%) had no form of CSF diversion at the time of MMC closure. Results: Patients with an EVD or shunt placed at the time of closure had no wound complications. In contrast, 8 patients (16%) without CSF diversion at closure developed wound complications (p = 0.048). Seven of the 8 wound complications occurred in the 71 patients with evidence of hydrocephalus at birth (p = 0.98). Of patients with evidence of hydrocephalus at the time of MMC closure, wound complications had a higher rate of occurrence among patients who did not receive a shunt or EVD at closure (p = 0.01). When comparing only patients with evidence of hydrocephalus at birth, the EVD group alone had a lower rate of wound complications than patients who did not receive CSF diversion at the time of closure (p = 0.031). Conclusions: These results suggest that addressing hydrocephalus at the time of MMC closure significantly reduces the likelihood of wound complications and may justify temporary CSF diversion at birth, at least in those patients manifesting hydrocephalus.

The incidence and risk factors of meningitis after major craniotomy in China: a retrospective cohort study.

BackgroundMeningitis after neurosurgery can result in severe morbidity and high mortality. Incidence varies among regions and limited data are focused on meningitis after major craniotomy.AimThis retrospective cohort study aimed to determine the incidence, risk factors and microbiological spectrum of postcraniotomy meningitis in a large clinical center of Neurosurgery in China.MethodsPatients who underwent neurosurgeries at the Department of Neurosurgery in Huashan Hospital, the largest neurosurgery center in Asia and the Pacific, between 1stJanuary and 31st December, 2008 were selected. Individuals with only shunts, burr holes, stereotactic surgery, transsphenoidal or spinal surgery were excluded. The complete medical records of each case were reviewed, and data on risk factors were extracted and evaluated for meningitis.ResultsA total of 65 meningitides were identified among 755 cases in the study, with an incidence of 8.60%. The risk of meningitis was increased by the presence of diabetes mellitus (odds ratio [OR], 6.27; P = 0.009), the use of external ventricular drainage (OR, 4.30; P = 0.003) and the use of lumbar drainage (OR, 17.23; P<0.001). The isolated microorganisms included Acinetobacter baumannii, Enterococcus sp, Streptococcus intermedius and Klebsiella pneumonia.ConclusionsMeningitis remains an important source of morbidity and mortality after major craniotomy. Diabetic patients or those with cerebral spinal fluid shunts carry significant high risk of infection. Thus, identification of the risk factors as soon as possible will help physicians to improve patient care.

A Multicenter, Randomized, Double-Blinded, Placebo-Controlled Phase III Study of Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage (CLEAR III)

In adults, intraventricular thrombolytic therapy with recombinant tissue plasminogen activator (rtPA) facilitates resolution of intraventricular haemorrhage (IVH), reduces intracranial pressure, decreases duration of cerebrospinal fluid diversion, and may ameliorate direct neural injury. We hypothesize that patients with small parenchymal haematoma volumes (<30 cc) and relatively large IVH causing acute obstructive hydrocephalus would have improved clinical outcomes when given injections of low-dose rtPA to accelerate lysis and evacuation of IVH compared with placebo. The Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage III trial is an investigator-initiated, phase III, randomized, multicenter, double-blind, placebo-controlled study comparing the use of external ventricular drainage (EVD) combined with intraventricular injection of rtPA to EVD plus intraventricular injection of normal saline (placebo) for the treatment of IVH. Patients with known symptom onset within 24 h of the computed tomography scan confirmed IVH and third or fourth ventricle obstruction, with or without supratentorial intracerebral haemorrhage volume <30 cc, who require EVD are screened with a computed tomography scan at least six hours after EVD placement and, if necessary, at consecutive 12-h intervals until stabilization of any intracranial bleeding has been established. Patients who meet clinical and imaging criteria (no ongoing coagulopathy and no suspicion of aneurysm, arteriovenous malformation, or any other vascular anomaly) will be randomized to either intraventricular rtPA or placebo. The primary outcome measure is dichotomized modified Rankin Scale 0-3 vs. 4-6 at 180 days. Clinical secondary outcomes include additional modified Rankin Scale dichotomizations at 180 days (0-4 vs. 5-6), ordinal modified Rankin Scale (0-6), mortality and safety events at 30 days, mortality at 180 days, functional status measures, type and intensity of intensive care unit management, rate and extent of ventricular blood clot removal, and quality of life measures.

P232: Prospective surveillance of intracranial infection in neurosurgical intensive care unit

IntroductionIntracranial infection (ICI) is a dangerous complicationfor neurosurgical patients at the intensive care unit(ICU). A comprehensive information about the infectionrates and risk factors is not available.ObjectivesThe prospective study was conducted to establish theICI rates and risk factors for patients at Neuro-ICU.MethodsAll the data on patients staying in Neuro-ICU for morethan 48 hours in 2010 - 2012 (30 months) was dailyentered into a database. These data included the use ofmechanical ventilation, intravascular devices, externalventricular/lumbar drains, urinary catheters, Levin tubesetc. The presence of intracranial, respiratory, blood andurinary infections was con sidered based on the CDCDefinitions of Nosocomial Infections (2008). All thedata were analyzed statistically.ResultsThe collected data for a total of 777 ICU patients withneurosurgical pathology were saved in the electronicdatabase .Patients with ICI (109 pers.) showed the same distri-bution of the main neurosurgical pathology (p = 0.7)and gender structure (p = 0.08) as the group of othercases. The differences were found in patients  age (aver-age 35.2 years and 42.1 years respectively, p = 0.0003).The ICI rate was 14% ± 1,2% (CI 11.65% - 16.35%). Inthis group of patients bloodstream infections occurredsignificantly more often (p = 0.002), as well as respira-tory (p = 0.035) and urinary tract infections (p <0.000)were more common. Significant differences wereobserved in the use of external ventricular drainage (p<0.000). No differences were seen in the use of intracra-nial pressure monitoring (26.6% in the studied groupversus 20.1%). The presence of ICI significantly pro-longed the length of stay in ICU (an average of 38.9days versus 18.1 days, p <0.000) and increased mortality(p = 0.008).ConclusionNeurosurgical patients with i ntracranial infection staylonger in ICU, they show more frequent manifestationof other sites infections, and are at greater risk of death.Among the risk factors for intracranial infection a morefrequent use of external ventricula r drainage is signifi-cantly notable.Disclosure of interestNone declared.

Hemorrhagic Complications Of External Ventricular Drainage

Despite the widespread use of external ventricular drainage (EVD), the frequency of associated hemorrhagic complications remains unclear. This retrospective study examined the frequency of hemorrhagic complications of EVD and attempted to discern associated risk factors. Treatment records from 160 patients admitted during a 2.5-year period who required EVD placement were reviewed. Indications for placement of EVD included acute complications of cerebrovascular disease (n = 94), traumatic brain injury (n = 36), primary hydrocephalus (n = 16), and tumor (n = 14). Patients received either a 3.0 or 2.5-mm outer diameter ventricular catheter (n = 82 and 78, respectively). Postinsertion computed tomographic scans were obtained within 24 hours on all patients and were analyzed for any new hemorrhage related to the ventricular catheter. Patient age, sex, catheter type, and dimensions of hemorrhage were also analyzed. The incidence of EVD-related hemorrhage was 33 +/- 0.04%. However, the incidence of detectable change in the clinical neurological examination was 2.5%. A significant proportion of EVD-related hemorrhages were small (<4 cm), punctate, intraparenchymal hematomas. Patients with cerebrovascular disease exhibited an increased incidence (39%) of hemorrhage. The mean volume of intraparenchymal hemorrhage was larger in patients who received the 2.5-mm ventricular catheter, as well as those admitted for cerebrovascular disease. Hemorrhagic complications of EVD placement are more common than previously suspected. Admitting diagnosis seems to have an effect on the development of an associated hemorrhage and its size. Catheter gauge has an effect on hematoma volume. Most of the hemorrhages seen on postinsertion computed tomographic scans do not cause detectable changes in the clinical examination.

Severe Dehydration and Acute Renal Failure Associated with External Ventricular Drainage of Cerebrospinal Fluid in Children

We report three paediatric cases of severe dehydration and hyponatraemia with circulatory compromise associated with the use of external ventricular drainage of cerebrospinal fluid. Two of the children had cardiac arrests. All were successfully resuscitated. While there were additional factors that contributed to other fluid losses, and fluid balance data are incomplete, these cases highlight a need for increased vigilance when managing children with external ventricular drains.

Blood clot resolution in human cerebrospinal fluid: evidence of first-order kinetics.

To determine the kinetics of blood clot resolution in human cerebrospinal fluid. Computed tomographic scans of 17 adult patients with intraventricular hemorrhages were analyzed. Intraventricular clot volume was determined and analyzed over time to determine both a standardized percentage rate and an absolute rate of clot resolution. Results were analyzed by use of regression for cross sectional time-series data. To determine the kinetics of intraventricular clot resolution, the effect of the clot volume on the percentage rate of clot resolution, clot half-life, and absolute rate of clot resolution was analyzed. The potential effect of age, sex, type of hemorrhage, and treatment with external ventricular drainage on the percentage rate of clot resolution was assessed. The percentage rate of clot resolution was 10.8% per day (95% confidence interval, 9.05-12.61 %), and it was independent of initial clot volume, age, sex, type of underlying hemorrhage, and use of external ventricular drainage. The absolute rate of clot resolution varied directly with the maximal clot volume (R2 = 0.88; P < 0.001). The percentage clot resolution data are consistent with events during the first 24 to 48 hours that antagonize clot resolution. These findings demonstrate that intraventricular blood clot resolution in patients with intraventricular hemorrhage follows first-order kinetics. The thrombolytic enzyme system responsible for intraventricular clot resolution seems to be saturated at 24 to 48 hours after the initial hemorrhage.

Management of Hydrocephalus Complicating Childhood Posterior Fossa Tumors

We examined the treatment of hydrocephalus in children with posterior fossa tumors to (1) compare the use of external ventricular drainage (EVD) with ventriculoperitoneal shunts (VPS), (2) determine the frequency of postoperative hydrocephalus requiring permanent shunts, and (3) determine which factors predict the need for a permanent shunt. The records of 58 children with posterior fossa tumors and associated hydrocephalus treated at our institution from 1979 to 1987 were retrospectively reviewed. Initial management of hydrocephalus included VPS in 25 patients, EVD in 17, and no treatment in 16. Patients in the 'VPS', 'EVD', and 'no treatment' groups differed only in the severity of hydrocephalus (less severe in the no treatment group than in the VPS and EVD groups) and in the method of dural closure following tumor resection (dura was left open more often in the EVD and no treatment groups). Of the 33 patients not initially shunted, only 9 (27%) subsequently required a shunt. These patients were compared with the remaining 24 patients who did not require a shunt. Two features predicted the need for a subsequent shunt: (1) resection of only a small volume of tumor and (2) the dura open following tumor resection. Complications of EVD were few; no patient deteriorated neurologically during or after ventricular catheter removal. We conclude that between two thirds and three quarters of patients with childhood posterior fossa tumors and associated hydrocephalus may be managed with perioperative EVD and will not require shunts. Patients in whom only a minimal tumor resection is performed and those in whom the dura is left open are more likely to need permanent VPS.

Treatment of ventriculostomy-related infections.

The results of the treatment of 15 cases of ventriculitis related to the use of external ventricular drainage are presented. A review of the literature on the treatment of cerebrospinal fluid shunt infections combined with our data suggest the following treatment of ventriculostomy-related ventriculitis: 1. Antibiotic treatment according to the resistance pattern of the infecting microorganism and 2. Removal or replacement of the ventricular drain. 3. One should wait for bacteriological cure before implanting a permanent internal drainage system.