🧠 External Ventricular Drainage in Intraventricular Hemorrhage: Clinical Guideline

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

• 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)

• Uncorrected coagulopathy (INR > 1.5, platelets < 100k)
• Massive cerebral edema with midline shift
• Non-communicating hydrocephalus not accessible via lateral ventricles

• ☐ 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

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

• 🔄 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 CLEAR III protocol (investigational)

• Clamp EVD for 24 hours
• Monitor neurological status and ICP
• If stable → consider removal
• If hydrocephalus recurs → evaluate for ventriculoperitoneal shunt

• Connolly ES et al. *Guidelines for the Management of Spontaneous Intracerebral Hemorrhage*. Stroke. 2022.
• CLEAR III Trial — NEJM 2016
• Mayfrank L, et al. *Neurosurg Focus*. 2001;11(6):E9.

See also:

• Hydrocephalus Management
• Ventriculostomy Technique

External Ventricular Drainage Technique