A nationwide prospective multicenter study of external ventricular drainage: accuracy, safety, and related complications

Abstract

OBJECTIVE External ventricular drainage (EVD) catheters are associated with complications such as EVD catheter infection (ECI), intracranial hemorrhage (ICH), and suboptimal placement. The aim of this study was to investigate the rates of EVD catheter complications and their associated risk factor profiles in order to optimize the safety and accuracy of catheter insertion. METHODS A total of 348 patients with urgently placed EVD catheters were included as a part of a prospective multicenter observational cohort. Strict definitions were applied for each complication category. RESULTS The rates of misplacement, ECI/ventriculitis, and ICH were 38.6%, 12.2%, and 9.2%, respectively. Catheter misplacement was associated with midline shift (p = 0.002), operator experience (p = 0.031), and intracranial length (p < 0.001). Although mostly asymptomatic, ICH occurred more often in patients receiving prophylactic low-molecular-weight heparin (LMWH) (p = 0.002) and those who required catheter replacement (p = 0.026). Infectious complications (ECI/ventriculitis and suspected ECI) occurred more commonly in patients whose catheters were inserted at the bedside (p = 0.004) and those with smaller incisions (≤ 1 cm) (p < 0.001). ECI/ventriculitis was not associated with preinsertion antibiotic prophylaxis (p = 0.421), catheter replacement (p = 0.118), and catheter tunneling length (p = 0.782). CONCLUSIONS EVD-associated complications are common. These results suggest that the operating room setting can help reduce the risk of infection, but not the use of preoperative antibiotic prophylaxis. Although EVD-related ICH was associated with LMWH prophylaxis for deep vein thrombosis, there were no significant clinical manifestations in the majority of patients. Catheter misplacement was associated with operator level of training and midline shift. Information from this multicenter prospective cohort can be utilized to increase the safety profile of this common neurosurgical procedure.

Supratentorial cerebrospinal fluid diversion using image-guided trigonal ventriculostomy during retrosigmoid craniotomy for cerebellopontine angle tumors

“…Feldkirchen, Germany) ( 11 ); affection of the fourth ventricle (open, distorted but patent or obstructed) and brainstem (normal, impressed, compressed or dislocated) ( 12 ); preoperative tonsillar transforaminal herniation (effacement of the CSF-cisterns surrounding the brainstem, inferior descent of the cerebellar tonsils below the level of the foramen magnum); Surgical outcome variables : relaxation of the surgical field upon durotomy: intraoperative assessment on successful ventricle puncture, CSF-diversion and a pulsatile dura prior durotomy ( Supplementary Video S1 ) without signs of cerebellar contusion, swelling or herniation through the dural incision. To reduce selection bias, a consecutive series of patients irrespective of the underlying pathology was included where the last author (VW) was involved in the surgical procedure; pre- or postoperative hydrocephalus (malresorptive or obstructive) based on clinical and radiological examination, pre- or postoperative permanent CSF-diversion; Radiographic outcome variables : Catheter malposition, defined as grade 1 (ipsilateral intraventricular), grade 2 (contralateral intraventricular), grade 3 (parenchymal or deep/eloquent areas) ( 13 , 14 ); ventriculostomy-related hemorrhage (VRH); intracerebral hemorrhage; intraventricular hemorrhage; cortical cortical scarring along the ventriculostomy canal; cortical atrophy and scaring caused by hemorrhage; signs of infarction; pre- and postoperative signs of upward transtentorial herniation (1. flattening or reversal of the smile-shaped quadrigeminal cistern; 2. obliteration of the quadrigeminal and superior cerebellar cistern; 3. “spinning top” appearance of midbrain due to bilateral compression of the posterior aspect of the midbrain) ( 15 , 16 ); posterior cerebral or superior cerebellar artery infarction.…”

“…“spinning top” appearance of midbrain due to bilateral compression of the posterior aspect of the midbrain) ( 15 , 16 ); posterior cerebral or superior cerebellar artery infarction. Clinical outcome variables : Ventriculostomy-related infections (VRI), ventriculostomy-related seizures and clinically relevant ventriculostomy-related visual field defects in the follow-up examinations ( 14 ).…”

Discontinuation of CSF drainage in acute hydrocephalus: a prospective cohort study and exploratory data analysis

“…In the UK, the EVD related infection rate was approximately 9.3%, with a higher risk if drainage was more than 8 days [15]. In Canada, the rate was 9.5%, occurring at a mean of 8.9 days [7]. In our study, there was no difference in the incidence of infection between weaning groups, although this may be a re ection of a more sensitive but less speci c classi cation of CNS infection with higher rates of infection in our cohort (29%).…”

Serial Diffusion Tensor Imaging and Rate of Ventricular Blood Clearance in Patients with Intraventricular Hemorrhage

“…EVD and VPS have been associated with infection, catheter clotting/shunt obstruction, suboptimal placement, shunt disconnection, ventriculitis, shunt malfunction, seizures, etc. 30,31 . Both rapid and gradual paradigm weaning to discontinue EVD has been used.…”