External Ventricular Drainage in Intraventricular Hemorrhage

• Letter to the Editor. A viewpoint on external ventricular drainage in intraventricular hemorrhage
• Research Progress of External Ventricular Drainage Catheterization Techniques
• Active Cerebrospinal Fluid Exchange vs External Ventricular Drainage in the Neurocritical Care Unit: An International, Retrospective Cohort Study
• Risk factors for the development of hydrocephalus in traumatic brain injury: a systematic review and meta-analysis
• Triple sheath neuroendoscopic combination technique for managing complete intraventricular hemorrhage casting in patients with cerebral hemorrhage
• Minimally Invasive Surgery Versus Conventional Neurosurgical Treatments for Patients with Subcortical Supratentorial Intracerebral Hemorrhage: A Nationwide Study of Real-World Data from 2016 to 2022
• Preventing What Matters: A Fast and Reliable Technique to Secure External Ventricular Drains and Avoid Dislodgement
• Comparative efficacy of urokinase and recombinant tissue-type plasminogen activators in intraventricular hemorrhage

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).

EVD is used to:

• Relieve obstructive hydrocephalus
• Control intracranial pressure
• Enable drainage of intraventricular blood
• Facilitate intraventricular thrombolysis (e.g., rt-PA – investigational)

• Acute hydrocephalus due to IVH
• Refractory elevated ICP
• Large clot burden obstructing CSF flow
• Participation in protocols (e.g., CLEAR III Trial)

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

• The CLEAR III trial (NEJM 2016):
  1. Alteplase via EVD reduced clot burden and mortality
  2. No statistically significant improvement in functional outcome (mRS ≤ 3)
• EVD alone remains standard for hydrocephalus relief, not for clot resolution

• Infection (5–20%)
• Obstruction due to blood clots
• Overdrainage → subdural collections
• Catheter tract hemorrhage

• Endoscopic IVH evacuation (limited to specialized centers)
• Intraventricular thrombolysis (investigational)
• Lumbar drainage if no obstructive component (not in IVH)

• 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 Management
• Ventriculostomy Technique

External Ventricular Drainage in Intraventricular Hemorrhage Guideline

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 ¹⁾.

* 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.

* 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.

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