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External ventricular drainage

Placement of an external ventricular drainage (EVD) is a common neurosurgical procedure performed in both the intensive care unit (ICU) and operating room (OR).

Cerebrospinal fluid (CSF) external drainage devices are used to drain CSF and to monitor the flow of CSF from the ventricular system in order (1) to control intracranial pressure (ICP), (2) to evaluate CSF chemistry and cytology, and (3) to provide temporary egress for CSF in patients with infected or malfunctioning cerebrospinal fluid shunts.

The optimal setting for EVD placement in regards to safety and accuracy of placement is poorly defined.



External ventricular drains (EVD) are widely used to manage intracranial pressure (ICP) and hydrocephalus for aneurysmal subarachnoid hemorrhage (aSAH) patients. After days of use, a decision is made to remove the EVD or replace it with a shunt, involving EVD weaning and CT imaging to observe ventricular size and clinical status. This practice may lead to prolonged hospital stay, extra radiation exposure, and neurological insult due to ICP elevation.



Case series


In 155 patients Ortolano et al. studied the brain tissue surrounding the EVD by CT scan (all patients) and MRI (16 patients); 53 patients were studied at three time points (day 1-2, day 3-10, >10 days after EVD placement) to document the lesion time course. Small hemorrhages, with a hyperdense core surrounded by a hypodense area, were identified by CT scan in 33 patients. The initial average (hyper- + hypodense) lesion volume was 8.16 ml, increasing up to 15 ml by >10 days after EVD insertion. These lesions were not accompanied by neurologic deterioration or ICP elevation. History of arterial hypertension, coagulation abnormalities and multiple EVD insertions were significantly associated with hemorrhages. In 122 non-hemorrhagic patients, they detected very small hypodense areas (average volume 0.38 ml) surrounding the catheter. At later times these hypodensities slightly increased. MRI studies in 16 patients identified both intra- and extracellular edema around the catheters. The extracellular component increased with time.

EVD insertion, even when there are no clinically important complications, causes a tissue reaction with minimal bleedings and small areas of brain edema 1).


Arroyo-Palacios et al performed a retrospective study with 50 aSAH patients with reported weaning trial admitted to our institution between 03/2013 and 08/2014. By reviewing clinical notes and pre/post-brain imaging results, 32 patients were determined as having passed the weaning trial and 18 patients as having failed the trial. MOCAIP algorithm was applied to ICP signals to form a series of artifact-free dominant pulses. Finally, pulses with similar mean ICP were identified, and amplitude, Euclidean, and geodesic inter-pulse distances were calculated in a 4-h moving window.

While the traditional measure of mean ICP failed to differentiate the two groups of patients, the proposed amplitude and morphological inter-pulse measures presented significant differences (p ≤ 0.004). Moreover, receiver operating characteristic (ROC) analyses showed their usability to predict the outcome of the EVD weaning trial (AUC 0.85, p < 0.001).

Patients with an impaired CSF system showed a larger mean and variability of inter-pulse distances, indicating frequent changes on the morphology of pulses. This technique may provide a method to rapidly determine if patients will need placement of a shunt or can simply have the EVD removed 2).

Ortolano F, Carbonara M, Stanco A, Civelli V, Carrabba G, Zoerle T, Stocchetti N. External ventricular drain causes brain tissue damage: an imaging study. Acta Neurochir (Wien). 2017 Aug 8. doi: 10.1007/s00701-017-3291-0. [Epub ahead of print] PubMed PMID: 28791520.
Arroyo-Palacios J, Rudz M, Fidler R, Smith W, Ko N, Park S, Bai Y, Hu X. Characterization of Shape Differences Among ICP Pulses Predicts Outcome of External Ventricular Drainage Weaning Trial. Neurocrit Care. 2016 Apr 22. [Epub ahead of print] PubMed PMID: 27106888.
external_ventricular_drainage.txt · Last modified: 2018/05/07 13:59 by administrador