External Ventricular Drainage in Intraventricular Hemorrhage [Neurosurgery Wiki]

This page is read only. You can view the source, but not change it. Ask your administrator if you think this is wrong.
====== External Ventricular Drainage in Intraventricular Hemorrhage ======

{{pasted:20250705-090652.png}}

===== Latest related articles on PubMed =====


{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1D_UZwhO1I_BUzgBbbjMw9WNK58GPCJ5NMFrtahHmRnUg5mESM/?limit=15&utm_campaign=pubmed-2&fc=20250705025220}}
----


===== Definition =====

[[External ventricular drainage]] (EVD) is a core [[neurosurgical technique]] in the acute management of **[[intraventricular hemorrhage]] (IVH)**, especially when associated with [[hydrocephalus]] or elevated [[intracranial pressure]] (ICP).

===== 🧠 Purpose =====
EVD is used to:
  * Relieve **[[obstructive hydrocephalus]]**
  * Control **[[intracranial pressure]]**
  * Enable **[[drainage]] of [[intraventricular]] [[blood]]**
  * Facilitate **[[intraventricular thrombolysis]]** (e.g., [[rt-PA]] – investigational)

===== 🩺 Indications =====
  * Acute **[[hydrocephalus]]** due to IVH
  * Refractory **elevated [[ICP]]**
  * Large clot burden obstructing [[CSF]] [[flow]]
  * Participation in protocols (e.g., [[https://pubmed.ncbi.nlm.nih.gov/25762143/|CLEAR III Trial]])

===== 🛠️ Technical Steps =====
  - [[Position]] patient [[supine]], head elevated 20–30°
  - Identify **[[Kocher’s point]]**: 2.5 cm lateral to midline, 1 cm anterior to coronal suture
  - Drill [[burr hole]], open [[dura]]
  - Advance catheter ~5–6 cm toward [[foramen of Monro]]
  - Confirm **bloody CSF** return
  - Connect to [[drainage system]], level at **10–15 cmH₂O above [[tragus]]**
  - [[Monitor]] [[ICP]] and drainage
  - *Optional*: instill [[thrombolytic]]s (per protocol)

===== 📊 Evidence Summary =====
  * The [[https://pubmed.ncbi.nlm.nih.gov/25762143/|CLEAR III trial]] (NEJM 2016):
    - [[Alteplase]] via EVD reduced clot burden and mortality
    - No statistically significant improvement in functional outcome (mRS ≤ 3)
  * EVD alone remains standard for **hydrocephalus relief**, not for clot resolution

===== ⚠️ Complications =====
  * [[ventriculitis|Infection]] (5–20%)
  * Obstruction due to blood clots
  * Overdrainage → subdural collections
  * Catheter tract hemorrhage

===== 🔄 Alternatives / Adjuncts =====
  * Endoscopic IVH evacuation (limited to specialized centers)
  * Intraventricular [[thrombolysis]] (investigational)
  * Lumbar drainage if no obstructive component (not in IVH)

===== 🧾 Clinical Pearls =====
  * Always monitor **neurologic exam** and **ICP trends**
  * Avoid excessive CSF drainage
  * Reassess [[EVD]] need daily
  * Use **strict sterile technique** for CSF sampling

----

**See also:**  
  * [[hydrocephalus|Hydrocephalus Management]]  
  * [[ventriculostomy|Ventriculostomy Technique]]  

===== Guideline =====
[[External Ventricular Drainage in Intraventricular Hemorrhage Guideline]]





===== Letters to the Editor =====

In a [[Letter to the Editor]]
Leite et al.
in the *[[Journal of Neurosurgery]]*
comment on current practices and considerations regarding [[external ventricular drainage in intraventricular hemorrhage]].
The authors present their viewpoint on optimal EVD timing, placement technique, cerebrospinal fluid management strategies, and potential complications
((Leite PIF, Rabello PHM, Figueiredo EG. Letter to the Editor. A viewpoint on external ventricular drainage in intraventricular hemorrhage. J Neurosurg. 2025 Jul 4:1-2. doi: 10.3171/2025.3.JNS25426. Epub ahead of print. PMID: 40614284.)).

===== Critical Review =====

* **Strengths:**  
  * Raises important technical and clinical considerations not addressed in existing guidelines.  
  * Encourages neurosurgeons to think critically about EVD protocols within IVH management.

* **Weaknesses:**  
  * No original data or case series—purely anecdotal/opinion-based.  
  * Lacks explicit descriptions of technique or outcomes that could inform practice.  
  * Limited generalizability due to absence of evidence backing suggestions.

* **Verdict:**  
  * Opinion letters can spark discussion, but without empirical data, this piece remains speculative.  
  * Useful as a catalyst for more rigorous study, but should not alter clinical practice alone.

===== Score and Takeaway =====

* **Rating:** 4 / 10  
  * Points awarded for raising procedural nuances; significant deductions for absence of data.

* **Key takeaway for practicing neurosurgeons:**  
  * While the authors emphasize several technical considerations, it remains essential to rely on high‑quality evidence and institutional protocols when using EVD in IVH. This letter may prompt re‑evaluation of local practices, but should not replace data‑driven protocols.

===== Bottom Line =====  
An anecdotal commentary on EVD use in IVH—thought‑provoking but unsubstantiated. Use as a discussion starter, not as a guideline.

**Citation:** Leite PI, Rabello PH, Figueiredo EG. Letter to the Editor: A viewpoint on external ventricular drainage in intraventricular hemorrhage. *J Neurosurg.* 2025 Jul 4:1–2. doi:10.3171/2025.3.JNS25426.  


**Categories:** neurosurgery_letters, ivh_management, csf_diversion  
**Tags:** intraventricular hemorrhage, external ventricular drainage, EVD technique, opinion piece, commentary