Management of external ventricular drain after subarachnoid 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.
====== Management of external ventricular drain after subarachnoid hemorrhage ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1D9wCY_iV6sLl2umPr131cCP2F6Ef_deqN_xHqi-shkWKBcglZ/?limit=15&utm_campaign=pubmed-2&fc=20230909170153}}
----

----


Most institutions utilize a single predominant [[external ventricular drainage management]] approach, with a consensus toward a continuously open EVD to enhance CSF drainage in secured aneurysm patients coupled with a gradual weaning strategy. This finding is surprising given that the best available evidence suggests that the opposite approach is safe and can reduce ICU and hospital length of stay. Chung et al. recommend a critical reassessment of the approach to the management of EVDs. Given the potential impact on patient outcomes and length of stay, more research needs to be done to reach a threshold for practice change, ideally via multicenter and randomized trials
((Chung DY, Leslie-Mazwi TM, Patel AB, Rordorf GA. Management of External Ventricular Drains After Subarachnoid Hemorrhage: A Multi-Institutional Survey. Neurocrit Care. 2017 Jun;26(3):356-361. doi: 10.1007/s12028-016-0352-9. PMID: 28000129; PMCID: PMC5444979.)).
----
An early clamp trial and intermittent CSF drainage can be safe and result in fewer EVD complications and shorter length of stay. Given the discrepancy between the available evidence and current practice, more studies on the optimal management of EVDs are warranted with the greatest need for multicenter prospective studies
((Chung DY, Mayer SA, Rordorf GA. External Ventricular Drains After Subarachnoid Hemorrhage: Is Less More? Neurocrit Care. 2018 Apr;28(2):157-161. doi: 10.1007/s12028-017-0443-2. PMID: 28929378; PMCID: PMC5858985.))
----


The [[ventricular drainage placement]] is widely practiced in [[neurosurgery]] for various [[disease]]s and conditions accompanied by impaired [[cerebrospinal fluid circulation]], [[intracranial hypertension]] (ICHyp), [[intraventricular hemorrhage]] (IVH), and [[hydrocephalus]]. Specialists have been using this method in patients with [[acute]] [[aneurysmal subarachnoid hemorrhage]] (aSAH) for more than 50 years.
((Konovalov A, Shekhtman O, Pilipenko Y, Okishev D, Ershova O, Oshorov A, Abramyan A, Kurzakova I, Eliava S. External Ventricular Drainage in Patients With Acute Aneurysmal Subarachnoid Hemorrhage After Microsurgical Clipping: Our 2006-2018 Experience and a Literature Review. Cureus. 2021 Jan 27;13(1):e12951. doi: 10.7759/cureus.12951. PMID: 33643744; PMCID: PMC7885737.))
----
Once in place, [[External ventricular drainage management]] is thought to influence long-term patient outcomes, rates of ventriculitis, the incidence of delayed cerebral ischemia, need for a ventriculoperitoneal shunt, and intensive care unit (ICU), and hospital length of stay. The available evidence supports adopting early clamp trials and intermittent cerebrospinal fluid (CSF) drainage. However, a recent survey demonstrated that most neurological ICUs employ the opposite approach of continuously open EVDs and gradual weaning. In this article, we review the literature and arguments for and against the different EVD approaches. We conclude that an early clamp trial and intermittent CSF drainage can be safe and result in fewer EVD complications and a shorter length of stay. Given the discrepancy between the available evidence and current practice, more studies on the optimal management of EVDs are warranted with the greatest need for multicenter prospective studies
((Chung DY, Mayer SA, Rordorf GA. External Ventricular Drains After Subarachnoid Hemorrhage: Is Less More? Neurocrit Care. 2018 Apr;28(2):157-161. doi: 10.1007/s12028-017-0443-2. PMID: 28929378; PMCID: PMC5858985.))
----
External ventricular drain (EVD) placement is standard of care in the management of aneurysmal subarachnoid haemorrhage-associated hydrocephalus (aSAH). However, there are no guidelines for EVD placement and management after aSAH. Optimal EVD insertion conditions, techniques to reduce the risk of EVD-associated infection and [[intracranial aneurysm rebleeding]], and methods of EVD removal are critical, yet incompletely answered management variables. The present literature consists primarily of small studies with heterogeneous populations and variable outcome measures, and suggests the following: EVDs may increase the risk of [[rebleeding]]; EVDs are increasingly placed by non-neurosurgeons with unclear results; intraparenchymal ICP monitors may be safely considered (with or without spinal drainage) in the setting of difficult EVD placement; the optimal timing and manner of EVD removal has yet to be defined; and the efficacy of prophylactic systemic antibiotics and antibiotic-coated EVDs needs further investigation. Nevertheless, there are no definitive practice guidelines for EVD placement and management techniques in aSAH patients. Large prospective randomised trials are needed to definitively address important gaps in our understanding of EVD management principles in the neurocritical care setting
((Gigante P, Hwang BY, Appelboom G, Kellner CP, Kellner MA, Connolly ES. External ventricular drainage following aneurysmal subarachnoid haemorrhage. Br J Neurosurg. 2010 Dec;24(6):625-32. doi: 10.3109/02688697.2010.505989. Epub 2010 Sep 20. PMID: 20854058.)).

===== Case series =====
EVDs were placed in 31 of 56 (55.4%) patients and more often in women than men (66.7% vs 35.0%, p = 0.022) despite similar rates of hydrocephalus. Women had greater ICU [18 (13.5-25) vs 11.5 (6.5-18.5) days, p = 0.014] and hospital lengths of stay (LOS) [20.5 (16.5-34) vs 13.5 (10.5-27) days, p = 0.015] than men and greater mRS at discharge [4 (3-5) vs 3 (2-3.5), p = 0.011] although mRS at 6 months was similar. Patients with EVDs had longer ICU and hospital LOS and greater mRS at discharge [5 (3-6) vs 2 (2-3), p < 0.001] and at 6 months [4 (2-6) vs 1 (0-2), p = 0.001] than those without an EVD. In multivariable models, EVD use was associated with unfavorable 6-month outcome accounting for age, sex, and admission modified Fisher scale, but not in models adjusting for Hunt and Hess scale and World Federation of Neurological Surgeons scale.

Conclusion: In an aSAH cohort, the use of EVDs was associated with female sex and longer LOS, and may be linked to functional outcomes at discharge and at 6 months, although these associations warrant further investigation
((Nelson SE, Suarez JI, Sigmon A, Hua J, Weiner C, Sair HI, Stevens RD. External ventricular drain use is associated with functional outcome in aneurysmal subarachnoid hemorrhage. Neurol Res Pract. 2022 Jun 27;4(1):25. doi: 10.1186/s42466-022-00189-6. PMID: 35754049; PMCID: PMC9235272.)).
----
Extensive experience gained at the Burdenko Neurosurgical Center (BNC) in Moscow, the Russian Federation, in the surgical treatment of patients with acute aSAH enabled us to describe the results of using an EVD in patients after microsurgery. The objective of the research was to assess the effectiveness and safety of the EVD and clarify the indications for the microsurgical treatment of aneurysms in patients with acute SAH. Materials and methods From 2006 until the end of 2018, 645 patients registered in the BNC database underwent microsurgery for acute (0-21 days) aSAH. During the case study, we assessed the severity of hemorrhage according to the Fisher scale, the condition of patients on the Hunt-Hess (H-H) scale during surgery, the time of placement of EVD (before, during, and after surgery), and the duration of EVD. The number of patients with parenchymal intracranial pressure (ICP) transducers was assessed by the degree of correlation of ICP data through the EVD and parenchymal ICP transducer. One of the aims of the research was to compare the frequency of using EVD and decompressive craniectomy (DCH). The incidence of EVD-associated meningitis was analyzed. The need for a ventriculoperitoneal shunt (VPS) in patients after using EVD was also assessed. Overall outcomes were assessed using a modified Rankin scale (mRS) at the time of patient discharge. Exclusion criteria were as follows: patients aged less than 18 years and the lack of assessed data. Patients undergoing endovascular and conservative treatments also were excluded. Results Among the patients enrolled in the study, 22% (n=142) had EVD. Among these, 99 cases (69.7%) had EVD installed in the operating room just before the start of the surgical intervention. In some cases, ventriculostomy was performed on a delayed basis (16.3%). A satisfactory outcome (mRS scores of 1 and 2) was observed in 24.7% (n=35). Moderate and profound disability at the time of discharge was noted in 55.7% (n=79). Vegetative outcome at discharge was noted in 8.4% (n=12), and mortality occurred in 12.3% (n=15). Conclusion EVD ensures effective monitoring and reduction of ICP. EVD is associated with a relatively low risk of infectious, liquorodynamic, and hemorrhagic complications and does not worsen outcomes when used in patients with aSAH. We propose that all patients in the acute stage of SAH with H-H severity of III-V should receive EVD immediately before surgery
((Konovalov A, Shekhtman O, Pilipenko Y, Okishev D, Ershova O, Oshorov A, Abramyan A, Kurzakova I, Eliava S. External Ventricular Drainage in Patients With Acute Aneurysmal Subarachnoid Hemorrhage After Microsurgical Clipping: Our 2006-2018 Experience and a Literature Review. Cureus. 2021 Jan 27;13(1):e12951. doi: 10.7759/cureus.12951. PMID: 33643744; PMCID: PMC7885737.)).

===== Hydrocephalus after aneurysmal subarachnoid hemorrhage =====

[[Hydrocephalus after aneurysmal subarachnoid hemorrhage]]