Ventricular Drainage Research Articles

Mapping Inflammatory Markers in Cerebrospinal Fluid Following Aneurysmal Subarachnoid Hemorrhage: An Age- and Sex-Matched Analysis

Despite extensive research on aneurysm treatment and neurocritical care, aneurysmal subarachnoid hemorrhage (SAH) is still a life-threatening disease, often leaving survivors with lasting neurological and cognitive impairments. Early brain injury (EBI) and delayed cerebral ischemia (DCI) are the main contributors to brain damage, with neuroinflammation being a critical shared pathophysiological process. While numerous inflammatory markers and their temporal profiles in cerebrospinal fluid (CSF) have already been identified, comparisons with age- and sex-matched controls are limited. This study analyzed CSF from 17 SAH patients requiring an external ventricular drain (EVD) due to symptomatic hydrocephalus, sampled on days 4 and 10 post-ictus. An age- and sex-matched control group included 17 cerebrovascularly healthy patients requiring lumbar drains during aortic surgery. Chemokines and cytokines were quantified using immunoassays. Significantly elevated markers in SAH patients across both time points included MCP-1, CXCL-13, Eotaxin-1, CXCL-10, IL-8, and MIF. MIP-1α and MIP-1β showed significant differences at particular time points, indicating a distinct temporal profile for each parameter. These findings highlight neuroinflammation’s key role in intracranial and systemic pathophysiology following SAH, emphasizing its complexity and individual variability. Knowing demographic factors impact the specific manifestations of pathophysiological processes, the comparison with an age- and sex-matched control group is meaningful.

Management of incisional cerebrospinal fluid leak in open cranial surgeries and the "folding technique" in duraplasty.

The aim of this study was to review a series of patients who underwent open cranial surgeries to evaluate the incidence of iatrogenic incisional CSF leaks and discuss its prevention and management. The authors also discuss the utility of the "folding technique" used in duraplasty as an alternative to conventional dural reconstruction techniques. All patients undergoing open cranial surgery were reviewed, and those with incisional CSF leak were included in this study. CSF leakage was managed using either conservative nonsurgical methods or surgical interventions. When the conservative nonsurgical methods failed to curb the leak, surgical procedures such as lumbar external drainage (LED) using lumbar subarachnoid drainage, external ventricular drainage (EVD), a lumboperitoneal or ventriculoperitoneal shunt (VPS), and reexploration of the surgical site were considered. Between 2019 and 2024, 2149 patients underwent open cranial surgeries at our hospital for any cranial pathology; 39 (1.8%) of these patients experienced postoperative incisional CSF leakage. The majority of the pathologies requiring surgeries were located in the supratentorial region (76.9%). Patients were classified according to the type of dural closure technique used. Primary stitching, the patient's fascia, or synthetic dura (resorbable, nonresorbable, or both) were used for dural reconstruction. The median interval between the surgery and the start of the leakage was 19 (IQR 1-79) days in patients with no history of radiotherapy; however, this duration was longer in patients who received radiotherapy (median 45 [IQR 10-540] days). The surgical interventions for CSF leakage were classified as wound resuturing (combined with other conservative approaches such as tightened dressing and elevating the head end of the bed), LED or EVD, or surgical reexploration. The folding technique in duraplasty is a simple way to achieve watertight duraplasty even with autograft or synthetic material. Incisional CSF leakage is a potentially preventable complication with high morbidity. Such cases could be managed via conservative approaches including wound resuturing, LED or EVD, and surgical reexploration. However, the management strategy is beyond any strict algorithm. This folding technique for duraplasty is a worthy replacement for conventional primary suturing for dural repair or reconstruction in cranial and even spinal defects. This study highlights the importance of regaining the watertight nature of the dura in the primary surgery to prevent any further intervention and lower the overall morbidity.

Abstract WP32: Impact of External Ventricular Drain Placement Timing on Rerupture and Outcomes in Aneurysmal Subarachnoid Hemorrhage

Abstract WP32: Impact of External Ventricular Drain Placement Timing on Rerupture and Outcomes in Aneurysmal Subarachnoid Hemorrhage

Non-vascular structural-related intraventricular hemorrhage: Epidemiology and literature review.

Primary intraventricular hemorrhage (PIVH) is a rare type of hemorrhagic stroke typically associated with vascular structural abnormalities. However, little is known about the epidemiology and etiology of PIVH caused by non-vascular structural abnormalities. In this study, we aimed to clarify the etiology, clinical characteristics, and prognosis of non-vascular structural-related intraventricular hemorrhage (NVSRIVH). We retrospectively collected and analyzed data from 29 consecutive patients with NVSRIVH admitted to our hospital between January 2017 and May 2024. Outcomes were assessed using the modified Rankin Scale (mRS) at 90 days. A systematic review of the pertinent literature was performed and a pooled analysis of data from selected studies was performed. Among 2035 patients with spontaneous intracerebral hemorrhage, 40 (2 %) had PIVH. After excluding patients with vascular abnormalities and those without cerebrovascular examination results, data for 29 patients (13 males and 16 females, average age: 66.38 ± 2.76 years) were analyzed. The most common initial symptom was headache (65.5 %), with a median Glasgow Coma Scale (GCS) of 12 (7, 15) and modified Graeb score (mGS) of 15 (6, 18). Chronic hypertension was the most common clinical risk factor (79.3 %). Surgical intervention was performed in 24 patients, most commonly external ventricular drainage (62.1 %). At the 90-day follow-up, 22 patients (74.49 %) had good outcomes (mRS ≤ 3), and 7 patients (21.43 %) had poor outcomes (mRS > 3). Logistic regression analyses showed that GCS scores at admission, mGS, and hydrocephalus are associated with poor outcomes. NVSRIVH is a rare stroke subtype with a relatively good prognosis. NVSRIVH may be associated with long-term chronic disease, and chronic hypertension and age are the most relevant clinical risk factors.

P-1247. Cerebrospinal Fluid Penetration of Multiple Antibiotics in Patients With Intracranial Hemorrhage: A Prospective, Observational, Clinical Study

Abstract Background External ventricular drains (EVD) are used for acute hydrocephalus in intracranial hemorrhage(ICH), potentially causing ventriculostomy-associated cerebrospinal fluid infection (VAI). Variable meningeal inflammation in VAI can result in unpredictable antibiotic penetration in cerebrospinal fluid (CSF). This observational study aimed to assess CSF penetration of intravenous antibiotics for suspected VAI treatment in neurosurgical patients. Time to concentrations in CSF and plasma among the patients. The figure presented the concentrations of blood and cerebrospinal fluid (CSF) measured at different time points for each patient. REVD right-sided external ventricular drain. LEVD left-sided external ventricular drain. Methods Adults with EVD for ICH who were receiving antibiotics, including vancomycin, ceftazidime, cefepime and meropenem, for VAI from January 2023 to April 2024 in two north Taiwan medical centers were enrolled in this study. The primary outcome was the area under the concentration (AUC) ratio between CSF and plasma (AUCCSF/plasma). Factors influencing CSF concentration was also investigated. In addition, the probability of target attainment (PTA) of anti-Pseudomonal antibiotics were calculated. A summary of the permeability of vancomycin into the cerebrospinal fluid in this study. ARC augmentation renal clearance. L Left-side external ventricular drain R Right-side external ventricular drain. a. AUC was calculated from the first observation point to the last observation point. b. It was resistant to vancomycin. Results A total of 9 patients (6 male) with VAI were enrolled, and contributed 7 vancomycin, 3 ceftazidime, 2 cefepime and 2 meropenem treatment courses. One patient provided two courses. The ranges of AUCCSF/plasma for vancomycin, ceftazidime, cefepime, or meropenem were as follows 0.85-15.61%, 6.74-15.61%, 0.16-128.73%, and 0.09-13.24%, respectively. The CSF to plasma concentration ratio at the end of vancomycin infusion and at the middle of dosing interval showed good correlation with AUCCSF/plasma (Spearman's coefficient 0.8 and 0.783, p-value ≦0.01) For ceftazidime, both CSF and plasma achieved at least 98% fT >MIC=8 under 2 gram every 8 hours regimen. For meropenem, the fT >MIC=2 for CSF and plasma were 0-100 % and 95.7-99.8% under 2 gram every 8 hours regimen, respectively. For cefepime, the fT >MIC=16 for CSF and plasma were 0-100% and >97%, respectively. Conclusion This is the first study to report real-world data of antibiotic CSF penetration in neurosurgical population in Taiwan. Ceftazidime showed adequate penetration and achieved sufficient PTA in the CSF. Additionally, the single-point ratio of vancomycin at the end of infusion and during the mid-dosing interval may serve as a surrogate for AUCCSF/plasma. Disclosures All Authors: No reported disclosures

P-916. Use of BCID2 on CSF in nosocomial CNS surgical site infections

Abstract Background Nosocomial intracranial infections, arising from surgical procedures or neuroinvasive devices like ventricular drains or shunts, present distinct risk factors and microbiologic etiologies compared to community-acquired meningitides. Pathogens typically include Staphylococcus spp., Gram-negative bacilli, and multidrug-resistant bacteria. The current diagnostic standard for nosocomial central nervous system (CNS) infections is cerebrospinal fluid (CSF) Gram stain and culture, but rapid molecular diagnostics could improve diagnosis and treatment, enhancing patient outcomes. This pilot study aimed to assess the validity of the BioFire® Blood Culture Identification Panel 2 (BCID2) panel used for blood culture positivity detection on CSF samples in patients presenting with nosocomial meningitis/ ventriculitis. Sensitivity and specificity were calculated, and patient characteristics and co-morbidities were reviewed. Microbiologic data comparing gold standard Gram stain and culture of CSF to BCID2 result. Methods Patients over 18, admitted to Thomas Jefferson University Health System hospitals between 4/1/2017 to 4/1/2024, were included if meeting Centers for Disease Control (CDC) criteria for intracranial infection or meningitis/ventriculitis. Positive CSF samples (n=30) from 28 patients with nosocomial infections included Gram-positive bacteria (13), Gram-negative bacteria (13), and fungi (4). Positive CSF samples included those positive on culture, while control samples (n=26) had negative cultures or cultures positive for Cutibacterium acnes, an organism not detected by the BCID2 panel. Results Across all positive CSF specimens, sensitivity for organism detection was 76.7%. When culture-positive samples were classified based on Gram Stain, samples with organisms detected on Gram Stain had a sensitivity of 94.7% compared to 45.5% for samples with no organisms seen. For samples with organisms detected on Gram Stain, sensitivity for Gram-negative organisms was 100% and 88.9% for Gram-positive organisms. Among all control specimens, specificity was 100%. Conclusion The ability to rapidly identify a pathogen is crucial for managing nosocomial CNS infections effectively. Our study found that the BCID2 panel offers a promising utility in the detection of nosocomial CNS infections through CSF analysis. Disclosures Matthew Pettengill, PhD, Cepheid: Grant/Research Support

P-907. Burden of Hospitalization for Coccidioidal Meningitis: A National Cohort Study

Abstract Background Coccidioidal meningitis (CM) is a severe complication of an endemic fungal infection requiring life-long aggressive medical and often surgical management necessitating hospitalization. Few data evaluating the burden of CM on hospitals have been published. This report assesses inpatient healthcare utilization, total costs, and mortality in hospitalized CM patients.Table 1:Demographics, Comorbidities and Outcomes of Patients Admitted with Coccidioidal MeningitisCI=confidence intervals; CM=coccidioidal meningitis†Primary diagnosis code for a common meningitis complication including hydrocephalus, cerebral vascular accident, encephalitis, encephalopathy, cerebral vasculitis or vasospasm, cerebral abscess, shunt complication, infusion device failure.*Includes ventricular shunt, drain or infusion device placement, revision, or removal. Methods We used the National Inpatient Sample (NIS) to evaluate CM hospitalizations for the years 2019 t0 2021. The NIS is a 20% stratified systematic randomized sampling of all hospital discharges, drawn from States participating in the Healthcare Utilization Project (HCUP) (including all states in which coccidioidomycosis is endemic) and covering >97% of the US population. The sample weighted to reflect all hospitalizations in the US per year. CM was identified by the International Classification of Diseases-10th Revision (ICD-10) diagnosis code of B38.4 in any coding position. All analyses were performed on the weighted population using methods prescribed by HCUP. We estimated frequencies or mean/median values for demographics, comorbidities, need for CM-related procedures (i.e., ventricular shunt, drain or infusion device placement, revision, or removal), inpatient mortality, length-of-stay (LOS), and all cause total hospital costs (in 2023 US$) with 95% confidence intervals (CIs). Results We identified 2,305 CM hospitalizations (Table 1). The annual rates of CM hospitalizations ranged from 2.7-3.2 per million Americans for the three years studied. The mean age of CM patients was ∼48 years, most were men (73.3%) and occurred in the West census region (89.7%). Concurrent pulmonary coccidioidomycosis was present in 18.2% of patients. In total, 63.6% (59.3-67.6%) of patients required a CM-related procedure during the stay and 7.6% (5.6-10.3%) died prior to discharge. Mean LOS was 13.0 days (11.3-14.6) and mean hospital costs were $48,155 ($42,382-$53,929) per stay. Conclusion Hospitalization of CM patients in the US are associated with substantial medical and economic burden. The complex management and high costs associated with CM suggest a need for novel management approaches including novel antifungal treatments. Disclosures Craig I. Coleman, PharmD, F2G Ltd: Advisor/Consultant|F2G Ltd: Grant/Research Support Fariba Donovan, MD, PhD, F2G: Advisor/Consultant|F2G Ltd: Advisor/Consultant|F2G Ltd: Grant/Research Support|F2G Ltd: Honoraria Mark Bresnik, MD, F2G Ltd: Employee Belinda Lovelace, PharmD, MS, MJ, F2G, Inc.: Employee

Role of Subdural Antibiotic Therapy in the Management of Pediatric Bilateral Subdural Empyema

Introduction Use of intrathecal antibiotic therapy in the management of intracranial infections is a practice often required, usually administered through lumbar punctures or ventricular drains placement. Antibiotic administration through subdural drains is not a common practice in subdural empyemas treatment and limited evidence to date exists in the literature. To our best knowledge, this practice has not been previously reported in pediatric patient. Case report We present the case of a pediatric patient with bilateral subdural hematomas with posterior superinfection, who was treated by surgical evacuation and direct administration of Gentamicin through subdural drains. Resolution of the infection was achieved after institution of subdural antibiotic therapy. Conclusion Despite limited experience and evidence regarding administration of subdural antibiotic therapy as part of subdural empyema treatment, this practice may be beneficial in properly selected patients in addition to surgical management and intravenous antibiotic therapy.

Surgical treatment of patients with hypertensive intracerebral hematomas in the Republic of Tatarstan

Background. Over time as a result of improved surgical techniques, the emergence of new minimally invasive methods of intracerebral hematoma evacuation and more careful selection of patients potential for surgery, surgical treatment of hypertensive intracerebral hematoma has taken its niche in modern neurosurgery. Aim. To study the results of surgical treatment of patients with hypertensive intracerebral hematomas in the Republic of Tatarstan. Materials and methods. The retrospective multi-center study included data from 1127 patients with hypertensive intracerebral hemorrhages from 4 regional and 14 primary vascular centers in the Republic of Tatarstan for 2022, 87 patients were operated. Results. Among surgical methods the share of the open method was 64,4 %, endoscopic 32,2 %, external ventricular drainage / ventriculoperitoneal shunt implantation 3,4 %. Hospital mortality was 25,3 %. The highest mortality and incidence of recurrent hemorrhages were in patients operated on within the first 8 hours from the onset of symptoms. When comparing comparable groups (in terms of hematoma volume and severity of patients with intracerebral hemorrhage), in the surgical group hospital mortality was 2,9 times lower (22,6 %) than in the conservative group (65,6 %). Conclusion. Surgical removal of aggressive hypertensive intracerebral hematoma, at a patient’s severity of 8 points and above on the Glasgow coma helps reduce mortality. Endoscopic removal should be more widely used for deep aggressive haematomas. The optimal time to remove aggressive hypertensive intracerebral hematoma is 8 to 24 hours from the onset of a stroke.

Association of external ventricular drain duration and output with cerebral infarct risk in aneurysmal subarachnoid hemorrhage.

The optimal duration of external ventricular drain (EVD) in patients with aneurysmal subarachnoid hemorrhage (aSAH) is debatable. We sought to determine the association of EVD duration and output with outcomes, including cerebral infarct. We performed a retrospective study of a prospectively collected cohort of consecutive patients with aSAH who were admitted to an academic center from 2016 to 2023. Multivariable logistic regression was used to determine the association of EVD duration and output with outcomes, including cerebral infarct prior to discharge, poor outcome defined as 3-month modified Rankin Scale (mRS) 3-6 and ventriculoperitoneal (VP) shunt placement. We reviewed 429 cases of aSAH and included 306 patients who received EVD with mean age 57.9years (SD 13.9), 67% female and 69% white. Longer EVD duration was associated with higher odds of cerebral infarct (OR 1.04 for each day increase, 95% CI 1.01-1.07; p=0.003) independent of age, sex, Hunt and Hess grade and modified Fisher scale. Longer EVD duration was also associated with poor functional outcomes (OR 1.03 per each day increase, 95% CI 1.01-1.06; p=0.019) and VP shunt placement (OR 1.15 per each day increase, 95% CI 1.09-1.21; p<0.001) independent of other predictors. There was no independent association between daily EVD output and outcomes. Although longer EVD duration was associated with more cerebral infarcts and poor outcomes in patients with aSAH, no causal interferences can be drawn. Larger multicenter prospective studies are needed to better strategize the mode, duration, and amount of CSF drainage in aSAH patients.

IMAGINER 2-improving accuracy with augmented realIty navigation system during placement of external ventricular drains over Kaufman's, Keen's, Kocher's and Frazier's point.

External ventricular drain (EVD) placement is a routine neurosurgical procedure used to treat acute hydrocephalus and monitor intracranial pressure. Kocher's point is the most commonly used anatomical landmark, but other entry points can be challenging even for experienced neurosurgeons. Augmented reality (AR) may enhance the accuracy and safety of these procedures. Previous studies demonstrated improved ventriculostomy accuracy using AR among novices. This study evaluates AR's impact on EVD placement accuracy performed by experienced neurosurgeons. Eighteen neurosurgical experts performed ventriculostomies on a Styrofoam head model using Kaufman's, Keen's, Kocher's, and Frazier's points. Punctures were performed freehand (Freehand group) and with AR assistance (AR group). Post-procedure CT scans were used to compare the actual catheter tip positions with the ideal positions. Accuracy was assessed by the distance between real and ideal catheter tips and by Kakarla grading. The AR group had a mean tip distance of 16.93 ± 9.38 mm compared to 21.71 ± 9.69 mm in the Freehand group (p = 0.003). The AR group also showed better Kakarla grading outcomes (Grade 1: n = 26, Grade 3: n = 26) vs. the Freehand group (Grade 1: n = 7, Grade 3: n = 53; p < 0.0001). Neurosurgeons with ≥7 years of experience demonstrated higher accuracy across both methods (p = 0.040). AR significantly enhances the accuracy of EVD placement, particularly using Kaufman's, Keen's, Kocher's, and Frazier's points, with experienced neurosurgeons benefiting the most from AR assistance.

A prospective observational study on intracranial pressure management: A comparison of three ultrasound techniques.

This prospective observational study aimed to assess the effectiveness of B-mode ultrasound, color-coded Doppler, and shear-wave elastography in predicting intracranial pressure (ICP) and their capability to evaluate the efficacy of ICP lowering therapy. Forty-eight neuro-critical care patients were enrolled and categorized into 2 groups based on ICP measurements obtained through external ventricular drainage: the intracranial hypertension (IH) and normal ICP groups. The optic nerve (ON) sheath diameter (ONSD), end diastolic velocity, peak systolic velocity, resistance index of the central retinal artery (CRA), and Young's modulus (YM) of the ON were recorded after external ventricular drainage placement and following ICP lowering treatment in the IH group. The median values of ONSD (5.35mm [IQR 5.03, 5.80mm] vs. 4.38mm [IQR 4.25, 4.60mm]) and YM of the ON (23.69kPa [IQR 18.83, 30.90kPa] vs. 10.48kPa [IQR 9.84, 12.41kPa]) were remarkably higher in the IH group than in the normal ICP group (both P<0.001). However, no obvious differences were observed in end diastolic velocity, peak systolic velocity, or resistance index of the CRA between the two groups (all P>0.05). Additionally, analysis of the differences in ultrasound parameters before and after treatment revealed that ΔYM of the ON exhibited higher sensitivity and specificity in detecting successful treatment of IH compared to ΔONSD. ΔYM of the ON may serve as a more valuable parameter for reflecting changes in ICP and predicting the efficacy of treatment. In contrast, the color-coded Doppler indices of the CRA had limited values in evaluating ICP.

Iatrogenic pseudoaneurysm formation of the anterior cerebral artery following placement of an external ventricular drain: illustrative case.

External ventricular drains (EVDs) provide an invaluable diagnostic method for accessing cerebrospinal fluid and therapeutically treating elevated intracranial pressure. Although complications including hemorrhage and infection have been well documented, the formation of iatrogenic pseudoaneurysms following EVD placement has rarely been reported. The authors present a case of this exceedingly rare complication of iatrogenic pseudoaneurysm formation following EVD placement. In this report, the authors document the formation of a pseudoaneurysm within the A4 segment of the anterior cerebral artery in a 77-year-old female following frontal EVD placement, which was promptly recognized and successfully embolized endovascularly. They discuss the suspected pathophysiology, given the literature citing similar complications, and the differing management strategies following the discovery of iatrogenic pseudoaneurysms. Although rare, iatrogenic vascular injury following EVD placement or removal should not be overlooked. If hemorrhage following catheter placement or manipulation develops, suspicion for iatrogenic vascular injury should be high, and appropriate vascular imaging should be performed. As reported here, prompt treatment with endovascular embolization provides a safe and effective means to prevent future rupture and worsening hemorrhage. This case and the literature review emphasize the importance of rapid diagnosis of postprocedural pseudoaneurysm formation and treatment to prevent continued secondary brain injury. https://thejns.org/doi/10.3171/CASE24558.

A randomized trial comparing endovascular and surgical management of ruptured intracranial aneurysms excluded from previous trials.

Many patients with ruptured intracranial aneurysms (RIAs) underrepresented or excluded from previous randomized controlled trials (RCTs) comparing surgery with endovascular treatment (EVT) are still considered for surgical clipping, but the best management of these patients remains unknown. The International Subarachnoid Aneurysm Trial-2 was a randomized trial comparing surgical versus EVT of RIAs considered for surgical clipping, despite the results of previous RCTs, and also eligible for EVT. The primary endpoint was death or dependency according to the modified Rankin Scale score (mRS score > 2) at 1 year. Secondary endpoints included 1-year angiographic results and length of hospital stay. The primary hypothesis was that endovascular management would decrease the number of poor outcomes (mRS score > 2) from 30% to 23%, necessitating 1896 patients. The trial was interrupted after 10 years because of slow recruitment. Primary analysis was by intent-to-treat. There was no blinding. From November 2012 to December 2022, 270 patients were recruited at 6 North American and European centers. After exclusions, 263 patients were randomly allocated to receive surgery (n = 133) or EVT (n = 130). There were 12 crossovers (9 from surgery to EVT). The primary outcome was reached in 40 of 133 surgical patients (30%, 95% CI 23%-38%) compared with 35 of 130 EVT patients (27%, 95% CI 20%-35%) (p = 0.572). Residual aneurysms at 1 year were less frequent with surgery (10/118 [8%, 95% CI 5%-15%]) than EVT (22/109 [20%, 95% CI 14%-29%]) (p = 0.015). Additional procedures (ventricular drainage and decompressive craniotomy, p < 0.05) and hospitalization > 20 days were more frequent in the surgery group (69/133 [52%, 95% CI 43%-60%]) than in the EVT group (38/130 [29%, 95% CI 22%-38%]) (p < 0.001). This prematurely interrupted trial showed more frequent additional procedures and longer hospitalizations but better 1-year angiographic results with surgery. The primary clinical outcome, death or dependency at 1 year, was similar for EVT and surgery.

Ventriculitis incidence and outcomes in patients with aneurysmal subarachnoid hemorrhage: a prospective observational study.

To define the incidence of ventriculostomy-associated infections and their impact on the mortality and functional outcomes of patients with aneurysmal subarachnoid hemorrhage. We prospectively included all consecutive adult aneurysmal subarachnoid hemorrhage patients admitted to the neurological intensive care units of the Instituto Estadual do Cérebro Paulo Niemeyer (Rio de Janeiro, Brazil) and Hospital Cristo Redentor (Rio Grande do Sul, Brazil) who required external ventricular drains from July 2015 to December 2020. Daily clinical and laboratory variables were collected at admission and during the hospital stay. The presence of ventriculostomy-associated infections was evaluated daily, according to the Centers for Disease Control and Prevention and Infectious Diseases Society of America criteria. Hospital and 12-month outcomes were compared between patients with and without ventriculostomy-associated infections via both univariate and multivariate analyses. Out of the 676 patients screened, 271 received external ventricular drains (40%) and were included in the study. The mean age was 54 years (IQR 46-63), 198 were female (72%), 47% had poor grade status (World Federation of Neurological Surgeons scale 4 and 5), and 75% had modified Fisher 3 or 4. The mean time from admission to external ventricular drain placement was 8.8 days. Ventriculostomy-associated infections developed in 127 patients (47%), and the mean time from external ventricular drain to ventriculostomy-associated infection diagnosis was 4.4 days. Hospital and 12-month mortality rates did not differ between the ventriculostomy-associated infection group and the nonventriculostomy-associated infection group (36% versus 40% and 43% versus 49%, respectively). Poor functional outcomes, defined as modified Rankin scores of 4 to 6, showed no difference between groups at hospital discharge (ventriculostomy-associated infections 75% versus nonventriculostomy-associated infections 73%; p = NS) or at 12 months (ventriculostomy-associated infections 49% versus nonventriculostomy-associated infections 53%; p = NS). Ventriculostomy-associated infections are common complications after aneurysmal subarachnoid hemorrhage. Although it was not associated with hospital mortality or functional outcomes in our cohort, improving diagnostic accuracy and preventive measures is essential for better understanding the long-term impact of one of the most severe infectious complications after aneurysmal subarachnoid hemorrhage.

Hydrocephalus in primary brainstem hemorrhage risk predictors and management

This study explored the risk factors associated with hydrocephalus incidence and evaluated the effectiveness of surgical treatments in managing this condition. Patients with PBSH were retrospectively evaluated, identifying clinical and radiological characteristics. A multivariate logistic regression model was used for analyses. Of the 169 patients studied, 77 developed hydrocephalus. Midbrain hemorrhage, tegmental pons hemorrhage, disappearance of annular cisterna, combined cerebellar and intraventricular hematoma increased the risk of hydrocephalus (p < 0.05). A linear relationship was found between hematoma volume and hydrocephalus, with a volume > 6.1 mL associated with a higher risk. Patients with ≥ 2 the following factors: multiple hematoma sites, intraventricular hematoma, or hematoma volume > 6.1 mL, had a significantly increased risk of hydrocephalus. Forty-seven patients received surgical treatments including stereotactic puncture drainage of hematoma (SPDH) or external ventricular drainage (EVD). Both SPDH and EVD were effective in treating hydrocephalus (p < 0.001). The combination of SPDH and EVD showed the greatest benefit (p < 0.001); 30-day mortality and de-ventilator rates in the surgical group were significantly different from the non-surgical group. This finding provides valuable insights for early surgical intervention in patients with PBSH.

Neurosurgical Intervention in Primary Intraventricular Hemorrhage : Experience from a Center in China.

Primary intraventricular hemorrhage (PIVH) is a rare type of neurologic disorder and remains a challenge for cerebrovascular surgeons. This study intended to investigate the factors associated with neurosurgical intervention and its impact on outcome after PIVH. We retrospectively included consecutive patients with PIVH admitted to at a single tertiary academic medical center in China. Conservative treatment or neurosurgical intervention options (including endovascular therapy, craniotomy, stereotactic radiotherapy, endoscopic surgery or external ventricular drain) were assessed. Multivariable logistic regression was applied to determine associations. In total, 174 patients with PIVH were included in our analysis. There were 79 (45.4%) patients underwent surgery, which was associated with younger age (P = 0.004), higher Baseline Graeb score (P = 0.001), acute hydrocephalus (P = 0.02) and underlying cerebrovascular diseases (P < 0.001) in an adjusted model. In multivariable logistic regression analysis, significant predictors of external ventricular drain after PIVH were higher Baseline Graeb score (P = 0.04), and acute hydrocephalus (P< 0.001). Furthermore, after adjustment for confounders, our analysis showed that neurosurgical intervention could decrease 90-day mortality after PIVH (P = 0.04). After PIVH, younger patients with higher Baseline Graeb score, acute hydrocephalus and underlying cerebrovascular diseases were more likely to undergo neurosurgical intervention. Surgical treatment of PVIH patients should be optimized to decrease mortality. However, further clinical trials are still needed to determine which patients would benefit from neurosurgical intervention.

Safety and efficacy of endovascular embolization combined with external drainage for poor-grade ruptured cerebral aneurysms.

To investigate the safety and efficacy of endovascular embolization combined with external drainage for poor-grade ruptured cerebral aneurysms and risk factors. Forty-six patients with poor-grade ruptured cerebral aneurysms treated with endovascular embolization combined with decompressive craniectomy and drainage were retrospectively enrolled. Coil embolization alone was performed in 29 (63.0%) patients, stent-assisted coiling in 14 (30.4%), and coiling with the assistance of two microcatheters in three (6.5%). Immediately after embolization, aneurysm occlusion degree was Raymond-Roy grade I in 88% (44/50), II in 8% (4/50), and III in 4% (2/50). Periprocedural complications occurred in four (8.7%) patients. Forty-two (91.3%) patients had lumbar cistern drainage (n = 29 or 63.0%), extraventricular drainage (n = 11 or 23.9%), or decompressive craniectomy (n = 2 or 4.3%). At discharge, six (13.0%) patients died, and hydrocephalus took place in 16 (34.8%) patients. Better outcomes (mRS 0-2) were achieved in 31 (67.4%), including 23 (50.0%) patients below 60 years and eight (17.4%) over 60 years. Better clinical outcomes were achieved in patients below 60 years and with lumbar cistern drainage, and age was the only significant independent risk factor for better clinical outcomes. Receiver characteristics curve analysis of age for better clinical outcomes revealed that the cutoff value was 61 years, with the AUC 0.73, sensitivity 0.69, and specificity 0.73. Endovascular embolization combined with decompressive craniectomy and drainage may be safe and efficient for poor-grade ruptured cerebral aneurysms, and older age and drainage modality may significantly affect the clinical outcomes.

Impact of Country Income Level on Outcomes in Patients with Acute Brain Injury Requiring Invasive Mechanical Ventilation: A Secondary Analysis of the ENIO Study.

Invasive mechanical ventilation can present complex challenges for patients with acute brain injury (ABI) in middle-income countries (MICs). We characterized the impact of country income level on weaning strategies and outcomes in patients with ABI. A secondary analysis was performed on a registry of critically ill patients with ABI admitted to 73 intensive care units (ICUs) in 18 countries from 2018 to 2020. Patients were classified as high-income country (HIC) or MIC. The primary outcome was ICU mortality. Secondary outcomes were days to first extubation, tracheostomy, extubation failure, ICU length of stay, and hospital mortality. Multivariable analyses were adjusted for clinically preselected covariates such as age, sex, body mass index, neurological severity, comorbidities, and ICU management. Extubation and tracheostomy outcomes were also adjusted for arterial blood gas values and ventilatory settings. Of 1512 patients (median age = 54years, 66% male), 1170 (77%) were from HICs, and 342 (23%) were from MICs. Median age was significantly lower in MICs [35 (range 26-52) vs. 58 (range 45-68) years in HICs]. Neurosurgical procedures (47.7% vs. 38.2%) and decompressive craniectomy (30.7% vs. 15.9%) were more common in MICs, whereas intracranial pressure monitoring (12.0% vs. 51.5%) and external ventricular drain (7.6% vs. 35.6%) were less common. Compared with HICs, patients from MICs had 2.27 times the odds of ICU mortality [p = 0.009, 95% confidence interval (CI) 1.22-4.21]. Frequency of extubation failure was lower in MICs but not significant after adjustment. Patients from MICs had 3.38 times the odds of tracheostomy (p ≤ 0.001, 95% CI 2.28-5.01), 5.59days shorter mean ICU stay (p < 0.001, 95% CI - 7.82 to - 3.36), and 1.96 times the odds of hospital mortality (p = 0.011, 95% CI 1.17-3.30). In an international registry of patients with ABI requiring invasive mechanical ventilation, MICs had higher odds of ICU mortality, tracheostomy placement, and hospital mortality compared with HICs, which may be due to difference in neurocritical care resources and management.

Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: Investigation of Prognostic Variables and Creation of a Stronger Predictive Model.

Aneurysmal subarachnoid hemorrhage (aSAH) is frequently complicated by permanent shunt-dependent hydrocephalus, but it is difficult to predict which patients are at highest risk. This study seeks to identify novel variables associated with shunt dependency after aSAH and to create a predictive algorithm that improves upon existing models. Retrospective case control design was used. Patients who presented with aSAH and external ventricular drain (EVD) placement were included. Those who successfully weaned off their EVD were compared with those who required shunt placement. Demographic and treatment data were analyzed using univariate and multivariable logistic regression. Receiver operating characteristic (ROC) was used to compare the proposed model's performance against existing ones (BNI, CHESS, and SDASH). 100 patients were included: 50 No Shunt and 50 Shunt. Advanced age, elevated modified Graeb score, intraventricular hemorrhage, increased clot thickness, acute hydrocephalus, and CSF protein >110mg/dL prior to wean attempt were all found to be significantly associated with progression to shunt-dependency (p = .0351, .0022, .0407, .0274, .0014, and .0064, respectively). Multivariate regression demonstrated an area under the curve of 0.7852 (p < .0001), outperforming those of the other models. Our study suggests that elevated modified Graeb score on initial CT and high CSF protein levels prior to EVD wean are important prognostic indicators for development of shunt dependency after aSAH. Integrating these findings into clinical practice may aid in earlier and more targeted decision-making.