External Ventricular Drainage: A Practical Guide for Neuro-Anesthesiologists

Abstract

External ventricular drainage is often considered a life-saving treatment in acute hydrocephalus. Given the large number of discussion points, the ideal management of EVD has not been completely clarified. The objective of this study was to review the most relevant scientific evidence about the management of EVD in its main clinical scenarios. We reviewed the most recent and relevant articles about indications, timing, management, and complications of EVD in neurocritical care, with particular interest in patients with subarachnoid hemorrhage (SAH), severe traumatic brain injury (TBI), and intraventricular hemorrhage (IVH) using the following keywords alone or matching with one another: intracranial pressure, subarachnoid hemorrhage, traumatic brain injury, intraventricular hemorrhage, external ventricular drainage, cerebrospinal shunt, intracranial pressure monitoring, and ventriculoperitoneal shunt. In the management of EVD in SAH, the intermittent drainage strategy is burdened with an elevated risk of complications (e.g., clogged catheter, hemorrhage, and need for replacement). There seems to be more ventriculoperitoneal shunt dependency in rapid weaning approach-managed patients than in those treated with the gradual weaning approach. Although there is no evidence in favor of either strategy, it is conventionally accepted to adopt a continuous drainage approach in TBI patients. Less scientific evidence is available in the literature regarding the management of EVD in patients with severe TBI and intraparenchymal/intraventricular hemorrhage. EVD placement is a necessary treatment in several clinical scenarios. However, further randomized clinical trials are needed to clarify precisely how EVD should be managed in different clinical scenarios.

Intraventricular haemorrhage treated by extra ventricular drainage with catheter mistakenly penetrating the cisterna ambiens: A case report

“…15,16 The puncture point is called Kocher point, and is located 10.0-11.0 cm behind the nasal root, 3.0 cm near the midline and 1.0 cm before the coronal suture. 17 The catheter should be directed at an angle that is perpendicular to the intersection of lines drawn from the ipsilateral medial canthus and the ipsilateral external auditory meatus. The catheter should enter the skull vertically, to a depth approximately 6.0 cm away from the scalp.…”

Ventriculostomy-associated infection (VAI) in patients with acute brain injury—a retrospective study

“…Not surprisingly, this complex decision-making process is associated with a large variation in treatment between clinicians, hospitals, and countries [ 8 , 38 – 40 ], potentially leading to both under- and overtreatment. The exploratory VAI prediction score was conducted to simplify this process, enable early prescription of adequate antibiotics in patients with VAI, and avoid or minimize inadequate treatment in those without VAI.…”

Petroclival Clinoidal Folds and Arachnoidal Membranes of the Anteromedial Incisural Space: Clinical Anatomy for Neuro Critical Care

“…As described above, the anterior incisural space is situated anteriorly to the brainstem, whereas the middle incisural space is lateral to it. These regions are characterized by complex relationships between the bony structures of the skull base, dura mater, arachnoid membranes, cisternal spaces, cranial nerves and vascular structures [1][2][3]7,8,11,23,24,31,32].…”

“…In this area, comprising petrous bone, petrous apex, upper petro-clival region and encircled by the free edge of the tentorium, the insertion of the tentorium itself to the petrous apex and to the anterior and posterior clinoid processes gives rise to three distinct dural folds or ligaments: the anterior petroclinoid ligament, the posterior petroclinoid ligament and the interclinoid ligament [5][6][7][8][9][10][11]. These dural folds constitute the posterior portion of the roof of the cavernous sinus denominated "the oculomotor triangle" [1][2][3]12,13].…”