🧠 External Ventricular Drainage in Intraventricular Hemorrhage: Clinical Guideline [Neurosurgery Wiki]

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====== 🧠 External Ventricular Drainage in Intraventricular Hemorrhage: Clinical Guideline ======

Standardized guideline for neurosurgeons and neurocritical care teams regarding the use of EVD in IVH.

===== ✅ 1. Indications =====
  * Obstructive **hydrocephalus** secondary to IVH
  * **Elevated intracranial pressure (ICP)** not responsive to medical therapy
  * Declining **level of consciousness** (e.g., ↓ GCS)
  * Access route for **intraventricular thrombolysis** (investigational)

===== ❌ 2. Contraindications =====
  * **Uncorrected coagulopathy** (INR > 1.5, platelets < 100k)
  * Massive **cerebral edema** with midline shift
  * Non-communicating hydrocephalus not accessible via lateral ventricles

===== 📋 3. Pre-Procedure Checklist =====
  * ☐ Confirm IVH and hydrocephalus on **CT scan**
  * ☐ Assess ventricle **size and symmetry**
  * ☐ Review **INR / platelets**
  * ☐ Obtain **informed consent**
  * ☐ Identify **Kocher's point**: 2.5 cm lateral to midline, 1 cm anterior to coronal suture
  * ☐ Set up **sterile drainage system**

===== 🛠️ 4. Technique Summary =====
  - Supine positioning, head elevated 20–30°
  - Local anesthesia ± light sedation
  - Burr hole at **Kocher's point**
  - Advance catheter ~5–6 cm toward foramen of Monro
  - Confirm **bloody CSF** return
  - Secure and tunnel catheter
  - Connect to external drainage & ICP monitor
  - Level at **+10–15 cmH₂O above tragus**

===== 📈 5. Post-Placement Management =====
  * 🔄 Repeat **CT** after placement (6–12 h)
  * 🔍 Monitor **ICP trends** and drainage volume
  * 🧪 CSF samples only when essential
  * ⏱️ Evaluate for **weaning** or **conversion to VP shunt**
  * 💉 *Optional*: rt-PA (1 mg q8–12h) per [[https://pubmed.ncbi.nlm.nih.gov/25762143/|CLEAR III protocol]] (investigational)

===== ⚠️ 6. Complications =====
^ Complication ^ Prevention/Management ^
| **Infection (ventriculitis)** | Aseptic technique, minimal manipulation |
| **Catheter obstruction** | Gentle saline irrigation if indicated |
| **Overdrainage** | Proper leveling; avoid excessive CSF removal |
| **Tract hemorrhage** | Avoid in uncorrected coagulopathy |

===== ⏳ 7. Weaning Protocol  =====
[[External Ventricular Drainage Weaning Protocol]].

===== 📚 8. References =====
  * Connolly ES et al. *Guidelines for the Management of Spontaneous Intracerebral Hemorrhage*. Stroke. 2022.
  * [[https://pubmed.ncbi.nlm.nih.gov/25762143/|CLEAR III Trial — NEJM 2016]]
  * Mayfrank L, et al. *Neurosurg Focus*. 2001;11(6):E9.

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

===== External Ventricular Drainage Technique =====

[[External Ventricular Drainage Technique]]