Ventricular Drain Insertion Research Articles

A wearable mixed-reality holographic computer for guiding external ventricular drain insertion at the bedside.

The goal of this study was to explore the feasibility and accuracy of using a wearable mixed-reality holographic computer to guide external ventricular drain (EVD) insertion and thus improve on the accuracy of the classic freehand insertion method for EVD insertion. The authors also sought to provide a clinically applicable workflow demonstration. Pre- and postoperative CT scanning were performed routinely by the authors for every patient who needed EVD insertion. Hologram-guided EVD placement was prospectively applied in 15 patients between August and November 2017. During surgical planning, model reconstruction and trajectory calculation for each patient were completed using preoperative CT. By wearing a Microsoft HoloLens, the neurosurgeon was able to visualize the preoperative CT-generated holograms of the surgical plan and perform EVD placement by keeping the catheter aligned with the holographic trajectory. Fifteen patients who had undergone classic freehand EVD insertion were retrospectively included as controls. The feasibility and accuracy of the hologram-guided technique were evaluated by comparing the time required, number of passes, and target deviation for hologram-guided EVD placement with those for classic freehand EVD insertion. Surgical planning and hologram visualization were performed in all 15 cases in which EVD insertion involved holographic guidance. No adverse events related to the hologram-guided procedures were observed. The mean ± SD additional time before the surgical part of the procedure began was 40.20 ± 10.74 minutes. The average number of passes was 1.07 ± 0.258 in the holographic guidance group, compared with 2.33 ± 0.98 in the control group (p < 0.01). The mean target deviation was 4.34 ± 1.63 mm in the holographic guidance group and 11.26 ± 4.83 mm in the control group (p < 0.01). This study demonstrates the use of a head-mounted mixed-reality holographic computer to successfully perform hologram-assisted bedside EVD insertion. A full set of clinically applicable workflow images is presented to show how medical imaging data can be used by the neurosurgeon to visualize patient-specific holograms that can intuitively guide hands-on operation. The authors also provide preliminary confirmation of the feasibility and accuracy of this hologram-guided EVD insertion technique.

Role of Cerebrospinal Fluid Markers for Predicting Shunt-Dependent Hydrocephalus in Patients with Subarachnoid Hemorrhage and External Ventricular Drain Placement

We sought to identify potential risk factors for the development of shunt-dependent chronic hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH) and external ventricular drain (EVD) insertion. In particular, the role of inflammatory markers within the cerebrospinal fluid (CSF) was assessed. For this single-center analysis, data were generated from consecutive patients with SAH and the need for EVD implantation treated on our neurosurgical intensive care unit between 2013 and 2015. Parameters were patient characteristics (age, sex, comorbidity), severity of SAH (according to the World Federation of Neurological Society score), imaging findings (intraventricular hemorrhage, diameter of the third ventricle, location of the ruptured aneurysm), and acute course of disease (cerebral infarction, vasospasm). Moreover, the impact of EVD drainage volume and CSF markers (total protein [CSFTP], red blood cell count [CSFRBC], interleukin-6 [CSFIL-6], and glucose [CSFGlc]) was assessed. Statistics including receiver-operating-curve with corresponding area-under-the-curve (AUC) analysis were calculated using SPSS. Overall, 63 patients (21 males, mean age 55.2 years) were included. Twenty-one patients (30%) developed a shunt-dependent hydrocephalus. Significant risk factors for shunt dependency were the World Federation of Neurological Society score, cerebral infarction, and diameter of the third ventricle (P < 0.05). Moreover, CSF markers associated with shunt-dependent hydrocephalus included increased levels of CSFTP on days 5 (AUC= 0.72)/11 (AUC= 0.97)/14 (AUC= 0.98), CSFIL-6 on day 14 (AUC= 0.81), and CSFRBC on day 15 (AUC= 0.83). The EVD drainage volume was not prognostic. The time course of selected inflammatory markers in CSF may support management considerations in the early phase after SAH and critical impairment of CSF circulation.

Pediatric neurosurgical bellwether procedures for infrastructure capacity building in hospitals and healthcare systems worldwide.

Quantifying the global burden of pediatric neurosurgical disease-and current efforts addressing it-is challenging, particularly in the absence of uniform terminology. We sought to establish bellwether procedures for pediatric neurosurgery, in order to standardize terminology, establish priorities, and facilitate goal-oriented capacity building. Members of international pediatric neurosurgical and pediatric surgical societies were surveyed via the Research Electronic Data Capture (REDCap) platform. Among 15 proposed neurosurgical procedures, respondents assigned numerical grades of surgical necessity and selected hospital-level designation within a three-tiered system. A procedure was considered a bellwether if (a) the majority of respondents deemed it necessary for either a primary- or secondary-level hospital and (b) the procedure was graded at or above the 90th percentile on a continuous scale of essentiality. Data were compiled and analyzed using Stata software. Complete responses were obtained from 459 surgeons from 76 countries, the majority of whom practiced in a tertiary referral hospital (88%), with a primarily public patient population (64%). Six bellwether procedures were identified for pediatric neurosurgery: shunt for hydrocephalus, myelomeningocele closure, burr holes, trauma craniotomy, external ventricular drain (EVD) insertion, and cerebral abscess evacuation. Few differences in bellwether criteria designations were observed among respondents from different World Health Organization regions and World Bank income groups. The six bellwether procedures identified can be used as markers of infrastructure capacity at various hospital levels, hence allowing targeted neurosurgical capacity-building in low-resource settings in order to avert disability and death from childhood neurosurgical disease.

P.126 A nation-wide prospective multi-centre study of external ventricular drainage accuracy, safety, and related complications: Interim analysis

Background: External ventricular drain (EVD) insertion is a common neurosurgical procedure performed in patients with life-threatening conditions, but can be associated with complications. The objectives of this study are to evaluate data on national practice patterns and complications rates in order to optimize clinical care Methods: The Canadian Neurosurgery Research Collaborative conducted a prospective multi-centre registry of patients undergoing EVD insertions at Canadian residency programs Results: In this interim analysis, 4 sites had recruited 46 patients (mean age: 53.9 years, male:female 2:1). Most EVD insertions occurred outside of the operating theatre, using free-hand technique, and performed by junior neurosurgery residents (R1-R3). The catheter tip was in the ipsilateral frontal horn or body of the lateral ventricle in 76% of cases. Suboptimally placed catheters did not have higher rates of short-term occlusion. EVD-related hemorrhage occurred in 6.5% (3/45) with only 1 symptomatic patient. EVD-related infection occurred in 13% (6/46) at a mean of 6 days and was associated with longer duration of CSF drainage (P=0.039; OR: 1.13) Conclusions: Interim results indicate rates of EVD-related complications may be higher than previously thought. This study will continue to recruit patients to confirm these findings and determine specific risk factors associated with them

The Organisms and Factors Affecting Outcomes of External Ventricular Drainage Catheter-Related Ventriculitis: A Penang Experience.

Introduction:Ventriculostomy-related infection (VRI) from external ventricular drain (EVD) insertion is a common complication and carries a high mortality rate. Choice of empiric antibiotics depends on the institutions common causative organisms and their susceptibility. We determined risk factors for mortality in patients with VRI, the common organisms causing VRI, and the rate of EVD-related VRI at our institution.Methods:Medical records and operative data of patients with cerebrospinal fluid positive cultures with an EVD inserted from 2012 to 2015 were traced. Forty-five patients with EVD-related VRI were included in the study.Results:The overall rate of VRI was 6.3%, and the overall mortality rate due to VRI was 48.9%. Acinetobacter baumannii was the most common organism causing VRI (14 patients, 29.2%) with a mortality rate of 64.3%. Only 14.3% of A. baumannii are sensitive to meropenem and imipenem. We found that patients that had a decompressive craniectomy (DC) had a lower mortality rate (P = 0.042) and patients with a longer duration of the EVD being in place before the diagnosis of VRI had poor outcome (P = 0.040). Multivariate logistic regression was performed and we found that the use of steroid (P = 0.014), Pseudomonas aeruginosa infection (P = 0.010), multiple organism infection (P = 0.017), lower Glasgow Coma Scale (P = 0.043), and a longer duration the EVD was in place before the diagnosis of VRI (P = 0.008) were related with higher mortality.Conclusion:VRI mortality rate is high with an alarming resistance pattern seen in Acinetobacter VRI. EVDs should be removed as soon as feasible, and DC may be offered to patients with severe ventriculitis or meningitis.

Image guidance and improved accuracy of external ventricular drain tip position particularly in patients with small ventricles.

External ventricular drain (EVD) insertion is one of the most common emergency neurosurgical procedures. EVDs are traditionally inserted freehand (FH) in an emergency setting, but often result in suboptimal positioning. Image-guided surgery (IGS) is selectively used to assist placement. However, the accuracy and practicality of IGS use is yet to be reported. In this study, the authors set out to assess if IGS is practical and improves the accuracy of EVD placement. Case notes and images obtained in patients who underwent frontal EVD placement were retrospectively reviewed. Ventriculomegaly was determined by the measurement of the Evans index. EVD location was classified as optimal (ipsilateral frontal horn) or suboptimal (any other location). Propensity score matching of the two groups (IGS vs FH) for the Evans index was performed. Data were analyzed for patient age, diagnosis, number of EVDs, and complications. Those without postoperative CT scans were excluded. A total of 607 patients with 760 EVDs placed were identified; 331 met inclusion criteria. Of these, 287 were inserted FH, and 44 were placed with IGS; 60.6% of all unmatched FH EVDs were optimal compared with 75% of the IGS group (p = 0.067). The IGS group had a significantly smaller Evans index (p < 0.0001). Propensity score matching demonstrated improved optimal position in the IGS group when compared with the matched FH group (75% vs 43.2%, OR 4.6 [1.5-14.6]; p = 0.002). Patients with an Evans index of ≥ 0.36 derived less benefit (75% in IGS vs 66% in FH, p = 0.5), and those with an Evans index < 0.36 derived more benefit (75% in IGS vs 53% in FH, p = 0.024). The overall EVD complication rate was 36% in the FH group versus 18% in the IGS group (p = 0.056). Revision rates were higher in the FH group (p = 0.035), and the operative times were similar (p = 0.69). Long intracranial EVD catheters were associated with tip malposition irrespective of the group. Image guidance is practical and improves the accuracy of EVD placement in patients with small ventricles; thus, it should be considered for these patients.

Recurrent sampling and ventriculostomy-associated infections: a case-control study.

External ventricular drain (EVD) insertion is a common neurosurgical procedure with a significant risk of ventriculostomy-associated infections (VAIs), other morbidities and mortality. Several risk factors have been identified but their effect is unclear. Our primary objective was to assess whether recurrent EVD sampling increased the risk of VAIs. The secondary objective was to explore the effect of sampling frequency, duration of EVD stay, presence of cerebrospinal fluid leak and concurrent infections. Ours was a retrospective, single-centre, age-matched, case control study of 83 patients and 249 controls who underwent EVD insertion between 1 January 2010- 31 December 2016. Patients with primary CNS infections, age under 1year and death within 5days of EVD insertion were excluded. Blinded abstractors collected all patient data through the electronic patient record system and regression analysis was used to compare the two groups. Sampling the EVD more than once did not increase the risk of infection (OR 0.47, 95% CI 0.27-0.83, p = 0.01). Risk factors significantly associated with VAI included CSF leak (OR 2.06, 95% CI 1.16-3.67, p = 0.01), concurrent infection (OR 1.85, 95% CI 1.09-3.16, p = 0.02), and an EVD duration of >10days (OR 2.28, 95% CI 1.24-4.18, p = 0.01). Our findings do not support the notion that increased sampling of EVDs is associated with a higher risk of VAI. CSF leaks, concurrent infection and long-term EVDs are also statistically significant risk factors for infection.

Intracerebral hemorrhage after external ventricular drain placement: an evaluation of risk factors for post-procedural hemorrhagic complications

BackgroundThe objective of this study was to evaluate and identify the risk factors for developing a new or enlarged intracranial hemorrhage (ICH) after the placement of an external ventricular drain.MethodsA single center, nested case-control study of individuals who received an external ventricular drain from June 1, 2011 to June 30, 2014 was conducted at a large academic medical center. A bivariate analysis was conducted to compare those individuals who experienced a post-procedural intracranial hemorrhage to those who did not experience a new bleed. The variables identified as having a p-value less than 0.15 in the bivariate analysis were then evaluated using a multivariate logistic regression model.ResultsTwenty-seven of the eighty-one study participants experienced a new or enlarged intracranial hemorrhage after the placement of an external ventricular drain. Of these twenty-seven patients, 6 individuals received an antiplatelet within ninety-six hours of external ventricular drain placement (p = 0.024). The multivariate logistic regression model identified antiplatelet use within 96 h of external ventricular drain insertion as an independent risk factor for post-EVD ICH (OR 13.1; 95% CI 1.95–88.6; p = 0.008).ConclusionCompared to those study participants who did not receive an antiplatelet within 96 h of external ventricular drain placement, those participants who did receive an antiplatelet were 13.1 times more likely to exhibit a new or enlarged intracranial hemorrhage.

Complication rates of external ventricular drain insertion by surgeons of different experience.

Introduction Insertion of external ventricular drain (EVD) is a widely accepted, routinely performed procedure for treatment of hydrocephalus and raised intracranial pressure. The purpose of this study was to investigate whether a surgeon's experience affects the associated complication rate. Methods This retrospective study included all adult patients undergoing EVD insertion at a single centre between July 2013 and June 2015. Medical records were retrieved to obtain details on patient demographics, surgical indication, risk factors for infection and use of anticoagulants or antiplatelets. Surgeon experience, operative time, intraoperative antibiotic prophylaxis, need for revision surgery and EVD associated infection were examined. Information on catheter tip position and radiological evidence of intracranial haemorrhage was obtained from postoperative imaging. Results A total of 89 patients were included in the study. The overall infection, haemorrhage and revision rates were 4.8%, 7.8% and 13.0% respectively, with no significant difference among surgeons of different experience. The mean operating time for patients who developed an infection was 22 minutes while for those without an infection, it was 33 minutes (p=0.474). Anticoagulation/antiplatelet use did not appear to increase the rate of haemorrhage. The infection rate did not correlate with known risk factors (eg diabetes and steroids), operation start time (daytime vs out of hours) or duration of surgery although intraoperative (single dose) antibiotic prophylaxis seemed to reduce the infection rate. There was also a correlation between longer duration of catheterisation and increased risk of infection. Conclusions This is the first study demonstrating there is no significant difference in complication rates between surgeons of different experience. EVD insertion is a core neurosurgical skill and junior trainees should be trained to perform it.

Developing a pediatric neurosurgical training model.

OBJECTIVE One of the greatest challenges of pediatric neurosurgery training is balancing the training needs of the trainee against patient safety and parental expectation. The traditional "see one, do one, teach one" approach to training is no longer acceptable in pediatric neurosurgery. The authors have developed the baby Modeled Anatomical Replica for Training Young Neurosurgeons (babyMARTYN). The development of this new training model is described, its feasibility as a training tool is tested, and a new approach of integrating simulation into day-to-day training is suggested. METHODS In part 1 (development), a prototype skull was developed using novel model-making methods. In part 2 (validation), 18 trainee neurosurgeons (at various stages in training) performed the following 4 different procedures: 1) evacuation of a posterior fossa hematoma; 2) pterional craniotomy; 3) tapping of the fontanelle to obtain a CSF specimen; and 4) external ventricular drain insertion. Completion of the procedural stages (scored using a curriculum-based checklist) was used to test the feasibility of babyMARTYN as a training tool. Likert scale-based questionnaires were used to assess the model for face and content validity. Training benefit was assessed using pre- and posttraining ratings on the Physician Performance Diagnostic Inventory Scale (PPDIS). To determine the significance of improvement in median PPDIS score, the Wilcoxon matched-pairs signed-rank test was performed. RESULTS In part 1 (development), the model was successfully developed with good fidelity. In part 2 (validation), the validation data demonstrated feasibility, face, and content validity. The PPDIS score significantly increased for all groups after babyMARTYN training, thereby indicating a potential future role for babyMARTYN in the training of pediatric neurosurgeons. CONCLUSIONS This recent collaborative neurosurgical development by the Royal College of Surgeons of England is designed to supplement current neurosurgical training. High-fidelity, portable, operation-specific models enable preoperative planning and have the potential to be used in an operating room environment prior to novel operations. A "see one, simulate one, do one" approach for pediatric neurosurgical training using babyMARTYN is suggested.

Suboccipital Decompressive Craniectomy for Cerebellar Infarction: A Systematic Review and Meta-Analysis

Suboccipital decompressive craniectomy (SDC) for cerebellar infarction has been traditionally performed with minimal high-quality evidence. The aim of this systematic review and meta-analysis is to investigate the impact of SDC on functional outcomes, mortality, and adverse events in patients with cerebellar infarcts. A systematic review and meta-analysis in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Our primary outcome was the proportion of patients with moderate-severe disability after SDC. Secondary outcomes included mortality and adverse events. A sensitivity analysis was conducted to examine the roles of age, preoperative neurologic status, external ventricular drain insertion, and debridement of infarcted tissue on SDC outcomes. Eleven studies (with 283 patients) met our inclusion criteria. The pooled event rate for moderate-severe disability was 28% (95% confidence interval [CI], 20%-37%) and for mortality, it was 20% (95% CI, 12%-31%). The estimated overall rate of adverse events for SDC was 23% (95% CI, 14%-35%). Sensitivity analysis found less mortality with mean age <60 years, higher rates of concomitant external ventricular drain insertion, and debridement of infarcted tissue. Several factors were identified for heterogeneity between studies, including follow-up time, outcomes scale, extent of infarction, and other neuroimaging features. The best available evidence for SDC is based on retrospective observational studies. SDC for cerebellar infarction is associated with better outcomes compared with decompressive surgery for hemispheric infarctions. Lack of standardized reporting methods for SDC is a considerable drawback to the development of a better understanding of the impact of this surgery on patient outcomes.

Real-time ultrasound-guided external ventricular drain placement: technical note.

In the United Kingdom, ultrasound-guided external ventricular drain (EVD) insertion is becoming the standard of care to mitigate the morbidity associated with catheter malposition and multiple passes. Many neurosurgeons routinely use ultrasound to check the preinsertion trajectory, although real-time visualization of ventricular cannulation is preferable since minor deviations can be significant in patients with smaller ventricles, and live visualization further enables the catheter tip to be adjusted away from the choroid plexus. Such real-time ultrasound navigation has traditionally been limited by technical factors including the challenge of simultaneously manipulating the probe and inserting the catheter within the same image plane. The authors here describe a simple technique for precise EVD placement using a readily available bur hole ultrasound transducer attached to a 10-gauge needle guide channel (principally used for biopsy procedures) to accommodate a ventriculostomy catheter. The anticipated trajectory line is then projected onto the display and followed into the ipsilateral lateral ventricle. This is illustrated with a representative case and video demonstrating this rapid, user-friendly, and reliable technique. The authors invite others to consider this useful technique to minimize the risks of catheter misplacement or multiple cannulation attempts, which can be of particular benefit to junior neurosurgeons performing difficult cases under pressured conditions.

Prospective, multicentre study of external ventricular drainage-related infections in the UK and Ireland

ObjectivesExternal ventricular drain (EVD) insertion is a common neurosurgical procedure. EVD-related infection (ERI) is a major complication that can lead to morbidity and mortality. In this study, we aimed to...

Successful use of intrathecal colistin in the treatment of Pseudomonas aeruginosa ventriculitis

This case report describes a 56-year-old woman with multi-drug-resistant Pseudomonas aeruginosa ventriculitis secondary to external ventricular drain insertion who was successfully treated with intrathecal colistin, intravenous colistin, and intravenous meropenem. A review of the English-language literature found six similar cases. While the patient did not experience side effects, self-limited paresthesias of the arm were noted in one case report. Intrathecal colistin should be considered as a therapy for ventriculitis when antibiotic choices are limited by resistant organisms. Patients should be monitored for neurological side effects during therapy.

Antibiotic Distribution into Cerebrospinal Fluid: Can Dosing Safely Account for Drug and Disease Factors in the Treatment of Ventriculostomy-Associated Infections?

Ventriculostomy-associated infections, or ventriculitis, in critically ill patients are associated with considerable morbidity. Efficacious antibiotic dosing for the treatment of these infections may be complicated by altered antibiotic concentrations in the cerebrospinal fluid due to variable meningeal inflammation and antibiotic properties. Therefore, doses used to treat infections with a higher degree of meningeal inflammation (such as meningitis) may often fail to achieve equivalent exposures in patients with ventriculostomy-associated infections such as ventriculitis. This paper aims to review the disease burden, infection rates, and common pathogens associated with ventriculostomy-associated infections. This review also seeks to describe the disease- and drug-related factors that influence antibiotic distribution into cerebrospinal fluid and provide a critical appraisal of current dosing of antibiotics commonly used to treat these types of infections. A Medline search of relevant articles was conducted and used to support a review of cerebrospinal fluid penetration of vancomycin, including critical appraisal of the recent paper by Beach et al. recently published in this journal. We found that in the intensive care unit, ventriculostomy-associated infections are the most common and serious complication of external ventricular drain insertion and often result in prolonged patient stay and increased healthcare costs. Reported infection rates are extremely variable (between 0 and 45%), hindered by the inherent diagnostic difficulty. Both Gram-positive and Gram-negative organisms are associated with such infections and the rise of multi-drug-resistant pathogens means that effective treatment is an ongoing challenge. Disease factors that may need to be considered are reduced meningeal inflammation and the presence of critical illness; drug factors include physiochemical properties, degree of plasma-protein binding, and affinity to active transporter proteins present in the blood-cerebrospinal fluid barrier. The relationship between cerebrospinal fluid antibiotic exposures in the setting of ventriculostomy-associated infection and clinical response has not been fully elucidated for many of the antibiotics commonly used in its treatment. More thorough and clinically relevant investigations are needed to better define blood pharmacokinetic/pharmacodynamics targets and optimal therapeutic exposures for treatment of ventriculostomy-associated infections. It is hoped that this future research will be able to provide clearer recommendations for clinicians frequently faced with dosing-related dilemmas when treating patients with these challenging infections.

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.

Predictors of Shunt Insertion in Aneurysmal Subarachnoid Hemorrhage

Hydrocephalus is a common complication of aneurysmal subarachnoid hemorrhage (aSAH), requiring permanent cerebrospinal fluid (CSF) diversion in up to two thirds of patients. Factors that predict permanent CSF diversion are not well established. An exploratory analysis of 149 patients enrolled in the CARAS (Cerebral Aneurysm Renin Angiotensin System) study was performed in an effort to identify factors predictive of permanent CSF diversion after aSAH; only the 135 patients surviving the initial hospitalization were included in the present study. CARAS was a prospective, multicenter study investigating the impact of genetic polymorphisms in patients with aSAH and enrolled patients from September 2012 to January2015. One hundred and forty-nine patients with aSAH were enrolled in CARAS, with 135 (90.6%) patients surviving the initial hospitalization. Sixty-four of these patients (47.4%) required permanent CSF diversion. Multivariable analysis identified the following as independent risk factors: sympathomimetic illicit drug use, external ventricular drain (EVD) insertion, and hyponatremia. A scoring system based on EVD insertion (2 points), Hunt and Hess grade (1 point if grade ≥4) and modified Fisher computed tomography grade (1 point if grade 4) produced an area under the curve of 0.8 (P < 0.001). Sympathomimetic illicit drug use, EVD insertion, and hyponatremia are the strongest predictors of shunt insertion in patients with aSAH. Moreover, a scoring system based on EVD insertion, Hunt and Hess grade, and modified Fisher computed tomography grade can reliably predict the need for shunt placement in patients with aSAH.

Predictors of Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage with Asymptomatic Angiographic Vasospasm on Admission

Risk of delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage (aSAH) with asymptomatic angiographic vasospasm on admission is unclear in the literature. The goal of this study is to identify predictors of clinical DCI in this group of patients. An exploratory subgroup analysis was conducted in the SAHIT (Subarachnoid Hemorrhage International Trialists) data repository to identify predictors of clinical DCI in patients with good-grade aSAH (World Federation of Neurological Surgeons grade I and II) with angiographic vasospasm on admission. Predictors considered include age, sex, systolic blood pressure at presentation, World Federation of Neurological Surgeon grade, Fisher grade, aneurysm size and location, treatment modality, hydrocephalus requiring external ventricular drain insertion, and severity of vasospasm. The predictors were ranked based on dominance analysis with R2 as fit statistics and assessed in a set of logistic regression analysis models. Four data sets out of 16 studies in the SAHIT database were analyzed, with a total of 4125 patients. One hundred and ninety-one patients (4.6%) had asymptomatic angiographic vasospasm at admission. Of those, 78 patients (40.8%) developed clinical DCI. Univariate analysis showed significant associations between severe vasospasm on admission and development of clinical DCI (odds ratio, 9.5, 95% confidence interval, 2.07-43.50; P= 0.004). None of the studied predictors was associated with the development of clinical DCI on multivariate analysis. Asymptomatic angiographic vasospasm in patients with good-grade aSAH on admission is uncommon. Further studies are needed to identify high-risk patients for the development of DCI in the context of asymptomatic early vasospasm.

The hemorrhage risk of prophylactic external ventricular drain insertion in aneurysmal subarachnoid hemorrhage patients requiring endovascular aneurysm treatment: a systematic review and meta-analysis.

Endovascular treatment of acutely ruptured aneurysms requires the administration of antiplatelet and/or anticoagulant medication to prevent thrombosis. For patients who require an external ventricular drain (EVD) insertion to treat hydrocephalus stemming from aneurysm subarachnoid hemorrhage (aSAH), the administration of the medication may increase risk of hemorrhage in patients. It has become a practice for neurosurgeons to insert EVDs in patients with aSAH before endovascular treatment. However, the benefits and risks of this practice have not been fully assessed. The aim of this study was to compare and quantify the hemorrhagic risks associated with endovascular treatment of patients with sSAH before and after EVD. This is a systematic review and meta-analysis. The literature was searched for studies with EVD and non-EVD patients with ruptured aneurysms undergoing endovascular treatment of aneurysms. A qualitative and quantitative assessment of EVD-related hemorrhage risk before and after endovascular treatment was undergone. There seemed to be a stronger correlation between EVD-related hemorrhage and EVD insertion after endovascular treatment (cumulative relative risk: 9.61; 95% CI: 2.29, 40.24) compared to EVD insertion before endovascular treatment (cumulative relative risk: 2.37; 95% CI: 0.57, 9.81). EVD-related hemorrhage risk may increase with administration of antiplatelet and/or anticoagulant medication for endovascular treatment of ruptured aneurysms in aSAH patients.

Role of routine repeat head imaging in paediatric traumatic brain injury

Paediatric traumatic brain injuries (TBI) remain a leading cause of morbidity and mortality in Australia. There are clear guidelines on head imaging for children with TBI, but there is conflicting evidence on the role of routine repeat head computed tomography (CT) scan. This study aims to determine whether routine repeat head CT scans in paediatric TBI alter surgical or medical management. A retrospective study was performed at a level 1 tertiary paediatric trauma centre between January 2002 and July 2012. Patients with TBI who were admitted with acute intracranial injury and at least one repeat head CT scan were included. Mechanism of injury, severity of TBI, Glasgow Coma Score, use of intracranial pressure monitoring and operative procedures were listed. The need for operative management was compared for routine and clinically indicated head scans. Routine head CT scan was done in 36 out of 71 patients (51%). None from this group required craniotomy, but two children (6%) needed delayed ICP monitoring. Three patients with moderate to severe TBI required intracranial pressure monitor or external ventricular drain insertion based on a clinically indicated repeat head CT. Repeat head imaging is more likely to alter management of children with moderate to severe TBI. There is no role for routine repeat CT scan on mild TBI. Results of repeat cranial imaging should be correlated with the clinical status of the patient.