Drainage efficiency with dual versus single catheters in severe intraventricular hemorrhage

Continuous irrigation with thrombolytics for intraventricular hemorrhage: case-control study

Intraventricular hemorrhage (IVH) is a complication of a spontaneous intracerebral hemorrhage. Standard treatment is with external ventricular drain (EVD). Intraventricular thrombolysis may improve mortality but does not improve functional outcomes. We present our initial experience with a novel irrigating EVD (IRRAflow) that automates continuous irrigation with thrombolysis.Single-center case-control study including patients with IVH treated with EVD compared to IRRAflow. We compared standard demographics, treatment, and outcome parameters between groups. We developed a brain phantom injected with a human clot and assessed clot clearance using EVD/IRRAflow approaches with CT imaging.Twenty-one patients were treated with standard EVD and 9 patients with IRRAflow. Demographics were similar between groups. Thirty-three percent of patients with EVD also had at least one dose of t-PA and 89% of patients with IRRAflow received irrigation with t-PA (p = 0.01). Mean drain days were 8.8 for EVD versus 4.1 for IRRAflow (p = 0.02). Days-to-clearance of ventricular outflow was 5.8 for EVD versus 2.5 for IRRAflow (p = 0.02). Overall clearance was not different. Thirty-seven percent of EVD patients achieved good outcome (mRS ≥ 3) at 90 days versus 86% of IRRAflow patients (p = 0.03). Assessing only t-PA, reduction in mean days-to-clearance (p = 0.0004) and ICU days (p = 0.04) was observed. In the benchtop model, the clot treated with IRRAflow and t-PA showed a significant reduction of volume compared to control.Irrigation with IRRAflow and t-PA is feasible and safe for patients with IVH. Improving clot clearance with IRRAflow may result in improved clinical outcomes and should be incorporated into randomized trials.

Application of magnetically actuated self-clearing catheter for rapid in situ blood clot clearance in hemorrhagic stroke treatment

Maintaining the patency of indwelling drainage devices is critical in preventing further complications following an intraventricular hemorrhage (IVH) and other chronic disease management. Surgeons often use drainage devices to remove blood and cerebrospinal fluid but these catheters frequently become occluded with hematoma. Using an implantable magnetic microactuator, we created a self-clearing catheter that can generate large enough forces to break down obstructive blood clots by applying time-varying magnetic fields. In a blood-circulating model, our self-clearing catheters demonstrated a > 7x longer functionality than traditional catheters (211 vs. 27 min) and maintained a low pressure for longer periods (239 vs. 79 min). Using a porcine IVH model, the self-clearing catheters showed a greater survival rate than control catheters (86% vs. 0%) over the course of 6 weeks. The treated animals also had significantly smaller ventricle sizes 1 week after implantation compared to the control animals with traditional catheters. Our results suggest that these magnetic microactuator-embedded smart catheters can expedite the removal of blood from the ventricles and potentially improve the outcomes of critical patients suffering from often deadly IVH.

The pressure differential efflux technique - A novel approach for troubleshooting air-locked external ventricular drainage systems: A technical note and review of literature

External ventricular drainage (EVD) is carried out in many neurosurgical conditions for the diversion of cerebrospinal fluid. These EVD systems can, however, malfunction with potentially lethal consequences. Air bubbles within the EVD can result in air locking of the system with subsequent blockage of drainage, with blood clots and debris being the other causes. There are both non-invasive and invasive methods of rectifying such blockages, with invasive procedures having its associated risks. This is especially so for EVD revisions, with each surgery increasing the risk of ventriculitis. We describe a case of bilateral air locked EVD managed successfully with a novel non-invasive 'pressure differential efflux technique'. This method exploits the pressure gradient established by adjusting each EVD to a different height to evacuate the pneumoventricle. In addition, we present a sequential approach to the management of EVD malfunction, based on the current literature and our institutional protocol.

Intraventricular Tissue Plasminogen Activator and Shunt Dependency in Aneurysmal Subarachnoid Hemorrhage Patients With Cast Ventricles

BACKGROUND

Patients with intraventricular hemorrhage (IVH) are at higher risk of hydrocephalus requiring an external ventricular drain and long-term ventriculoperitoneal shunt placement.

OBJECTIVE

To investigate whether intraventricular tissue plasminogen activator (tPA) administration in patients with ventricular casting due to IVH reduces shunt dependence.

METHODS

Patients from the Post-Barrow Ruptured Aneurysm Trial (PBRAT) database treated for aneurysmal subarachnoid hemorrhage (aSAH) from August 1, 2010, to July 31, 2019, were retrospectively reviewed. Patients with and without IVH were compared. A second analysis compared IVH patients with and without ventricular casting. A third analysis compared patients with ventricular casting with and without intraventricular tPA treatment. The primary outcome was chronic hydrocephalus requiring permanent shunt placement.

RESULTS

Of 806 patients hospitalized with aSAH, 561 (69.6%) had IVH. IVH was associated with a higher incidence of shunt placement (25.7% vs 4.1%, P < .001). In multivariable logistic regression analysis, IVH was independently associated with increased likelihood of shunt placement (odds ratio [OR]: 7.8, 95% CI: 3.8-16.2, P < .001). Generalized ventricular casting was present in 80 (14.3%) patients with IVH. In a propensity-score adjusted analysis, generalized ventricular casting was an independent predictor of shunt placement (OR: 3.0, 95% CI: 1.8-4.9, P < .001) in patients with IVH. Twenty-one patients with ventricular casting received intraventricular tPA. These patients were significantly less likely to require a shunt (OR: 0.30, 95% CI: 0.010-0.93, P = .04).

CONCLUSION

Ventricular casting in aSAH patients was associated with an increased risk of chronic hydrocephalus and shunt dependency. However, this risk decreased with the administration of intraventricular tPA.

Natural history and surgical management of spontaneous intracerebral hemorrhage: a systematic review

INTRODUCTION

Management of spontaneous intracerebral hemorrhage (ICH) remains controversial despite efforts to produce high level evidence in the past few years. We systematically examined the pooled literature data on the natural history and surgical management of ICH.

EVIDENCE ACQUISITION

A systematic review was performed using the PubMed and Embase databases, encompassing English, full-text articles, reporting treatment outcomes for the conservative and surgical management of ICH.

EVIDENCE SYNTHESIS

A total of 91 studies met the eligibility criteria (total of 16,411 ICH cases). The most common locations for an ICH were the basal ganglia for both the conservative (68.7%) and surgical cohorts (58.4%). Patients in the non-operative group (40.5%) were older (mean age 62.9 years; range 12.0-94.0), had a higher Glasgow Coma Scale (GCS) score at presentation (mean GCS 10.2; range 3-15) and lower ICH volume (mean 36.9 mL). When managed non-operatively, a favorable functional outcome was encountered in 25.7% (95% CI 16.9-34.5) of patients, with a 22.2% (95% CI 16.6-27.8) mortality rate. Patients who underwent surgery (59.5%) were younger (mean age 58.8 years; range 12.0-94.0), had a lower GCS at presentation (mean GCS 8.2; range 3-15) and larger ICH volume (mean 58.3 mL; range 8.2-140.0). Craniotomy with hematoma evacuation was the preferred surgical technique (38.6%). A favorable functional outcome was encountered in 29.8% (95% CI 23.8-35.8) of operated patients, with a 21.3% (95% CI 16.3-26.3) mortality rate.

CONCLUSIONS

For many ICH cases, the reviewed literature allows to define surgical and conservative candidates. However, there are still some ICH-cases where management remains controversial.

A novel surgical technique for spontaneous intracerebral hematoma evacuation

Stereotactic removal of intracerebral hematoma is a routine procedure for treating hypertensive intracerebral hemorrhage, but the complex sequence of operations limits its adoption. We explored the application of a novel surgical technique for the removal of spontaneous intracerebral hematomas. The surgical technique based on computed tomography (CT) images was used in hematoma projection and surgical planning. Markers placed on the scalp based on an Android smartphone app allowed the installation of a stereotactic head frame to facilitate the selection of the best trajectory to the hematoma center for removing the hematoma. Forty-two patients with spontaneous intracerebral hemorrhage were included in the study, including 33 cases of supratentorial hemorrhage, 5 cases of cerebellum hemorrhage, and 4 cases of brain stem hemorrhage. The surgical technique combined with the stereotactic head frame helped the tip of the drainage tube achieve the desired position. The median surgical time was 45 (range 25-75) min. The actual head frame operating time was 10 (range 5-15) min. Target alignment performed by the surgical technique was accurate to ≤ 10.0 mm in all 42 cases. No patient experienced postoperative rebleeding. In 33 cases of supratentorial intracerebral hemorrhage, an average evacuation rate of 77.5% was achieved at postoperative 3.1 ± 1.4 days, and 29 (87.9%) cases had a residual hematoma of < 15 ml. The novel surgical technique helped to quickly and effortlessly localize hematomas and achieve satisfactory hematoma removal. Clinical application of the stereotactic head frame was feasible for intracerebral hemorrhage in various locations.

Surgery for spontaneous intracerebral hemorrhage

Spontaneous intracerebral hemorrhage is a devastating disease, accounting for 10 to 15% of all types of stroke; however, it is associated with disproportionally higher rates of mortality and disability. Despite significant progress in the acute management of these patients, the ideal surgical management is still to be determined. Surgical hematoma drainage has many theoretical benefits, such as the prevention of mass effect and cerebral herniation, reduction in intracranial pressure, and the decrease of excitotoxicity and neurotoxicity of blood products.

Several surgical techniques have been considered, such as open craniotomy, decompressive craniectomy, neuroendoscopy, and minimally invasive catheter evacuation followed by thrombolysis. Open craniotomy is the most studied approach in this clinical scenario, the first randomized controlled trial dating from the early 1960s. Since then, a large number of studies have been published, which included two large, well-designed, well-powered, multicenter, multinational, randomized clinical trials. These studies, The International Surgical Trial in Intracerebral Hemorrhage (STICH), and the STICH II have shown no clinical benefit for early surgical evacuation of intraparenchymal hematoma in patients with spontaneous supratentorial hemorrhage when compared with best medical management plus delayed surgery if necessary. However, the results of STICH trials may not be generalizable, because of the high rates of patients’ crossover from medical management to the surgical group. Without these high crossover percentages, the rates of unfavorable outcome and death with conservative management would have been higher. Additionally, comatose patients and patients at risk of cerebral herniation were not included. In these cases, surgery may be lifesaving, which prevented those patients of being enrolled in such trials. This article reviews the clinical evidence of surgical hematoma evacuation, and its role to decrease mortality and improve long-term functional outcome after spontaneous intracerebral hemorrhage.

Minimally invasive approaches for the management of intraventricular hemorrhage

Adult-onset intraventricular hemorrhage is a potentially life-threatening condition associated with a high morbidity and mortality rates. Intraventricular hemorrhage remains one of the most challenging entities for neurosurgeons to treat. Various medical and surgical modalities have been employed for the management of this entity with variable success and complications rates. In this paper, we review the neurosurgical interventions for the management of intraventricular hemorrhage and describe new approaches and potential therapeutic modalities for the management of this devastating condition.

Major publications in the critical care pharmacotherapy literature: January-December 2017

PURPOSE

To summarize selected meta-analyses and trials related to critical care pharmacotherapy published in 2017. The Critical Care Pharmacotherapy Literature Update (CCPLU) Group screened 32 journals monthly for impactful articles and reviewed 115 during 2017. Two meta-analyses and eight original research trials were reviewed here from those included in the monthly CCPLU. Meta-analyses on early, goal-directed therapy for septic shock and statin therapy for acute respiratory distress syndrome were summarized. Original research trials that were included evaluate thrombolytic therapy in severe stroke, hyperoxia and hypertonic saline in septic shock, intraoperative ketamine for prevention of post-operative delirium, intravenous ketorolac dosing regimens for acute pain, angiotensin II for vasodilatory shock, dabigatran reversal with idarucizumab, bivalirudin versus heparin monotherapy for myocardial infarction, and balanced crystalloids versus saline fluid resuscitation.

CONCLUSION

This clinical review provides perspectives on impactful critical care pharmacotherapy publications in 2017.

Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial

BACKGROUND

Intraventricular haemorrhage is a subtype of intracerebral haemorrhage, with 50% mortality and serious disability for survivors. We aimed to test whether attempting to remove intraventricular haemorrhage with alteplase versus saline irrigation improved functional outcome.

METHODS

In this randomised, double-blinded, placebo-controlled, multiregional trial (CLEAR III), participants with a routinely placed extraventricular drain, in the intensive care unit with stable, non-traumatic intracerebral haemorrhage volume less than 30 mL, intraventricular haemorrhage obstructing the 3rd or 4th ventricles, and no underlying pathology were adaptively randomly assigned (1:1), via a web-based system to receive up to 12 doses, 8 h apart of 1 mg of alteplase or 0·9% saline via the extraventricular drain. The treating physician, clinical research staff, and participants were masked to treatment assignment. CT scans were obtained every 24 h throughout dosing. The primary efficacy outcome was good functional outcome, defined as a modified Rankin Scale score (mRS) of 3 or less at 180 days per central adjudication by blinded evaluators. This study is registered with ClinicalTrials.gov, NCT00784134.

FINDINGS

Between Sept 18, 2009, and Jan 13, 2015, 500 patients were randomised: 249 to the alteplase group and 251 to the saline group. 180-day follow-up data were available for analysis from 246 of 249 participants in the alteplase group and 245 of 251 participants in the placebo group. The primary efficacy outcome was similar in each group (good outcome in alteplase group 48% vs saline 45%; risk ratio [RR] 1·06 [95% CI 0·88-1·28; p=0·554]). A difference of 3·5% (RR 1·08 [95% CI 0·90-1·29], p=0·420) was found after adjustment for intraventricular haemorrhage size and thalamic intracerebral haemorrhage. At 180 days, the treatment group had lower case fatality (46 [18%] vs saline 73 [29%], hazard ratio 0·60 [95% CI 0·41-0·86], p=0·006), but a greater proportion with mRS 5 (42 [17%] vs 21 [9%]; RR 1·99 [95% CI 1·22-3·26], p=0·007). Ventriculitis (17 [7%] alteplase vs 31 [12%] saline; RR 0·55 [95% CI 0·31-0·97], p=0·048) and serious adverse events (114 [46%] alteplase vs 151 [60%] saline; RR 0·76 [95% CI 0·64-0·90], p=0·002) were less frequent with alteplase treatment. Symptomatic bleeding (six [2%] in the alteplase group vs five [2%] in the saline group; RR 1·21 [95% CI 0·37-3·91], p=0·771) was similar.

INTERPRETATION

In patients with intraventricular haemorrhage and a routine extraventricular drain, irrigation with alteplase did not substantially improve functional outcomes at the mRS 3 cutoff compared with irrigation with saline. Protocol-based use of alteplase with extraventricular drain seems safe. Future investigation is needed to determine whether a greater frequency of complete intraventricular haemorrhage removal via alteplase produces gains in functional status.

FUNDING

National Institute of Neurological Disorders and Stroke.

Early Quantification of Hematoma Hounsfield Units on Noncontrast CT in Acute Intraventricular Hemorrhage Predicts Ventricular Clearance after Intraventricular Thrombolysis

BACKGROUND AND PURPOSE

Thrombolytic efficacy of intraventricular rtPA for acute intraventricular hemorrhage may depend on hematoma composition. We assessed whether hematoma Hounsfield unit quantification informs intraventricular hemorrhage clearance after intraventricular rtPA.

MATERIALS AND METHODS

Serial NCCT was performed on 52 patients who received intraventricular rtPA as part of the Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage trial and 12 controls with intraventricular hemorrhage, but no rtPA treatment. A blinded investigator calculated Hounsfield unit values for intraventricular hemorrhage volumes on admission (t0), days 3-4 (t1), and days 6-9 (t2). Controls were matched uniquely to 12 rtPA-treated patients for comparison.

RESULTS

Median intraventricular hemorrhage volume on admission for patients treated with intraventricular rtPA was 31.9 mL (interquartile range, 34.1 mL), and it decreased to 4.9 mL (interquartile range, 14.5 mL) (t2). Mean (±standard error of the mean) Hounsfield unit for intraventricular hemorrhage was 52.1 (0.59) at t0 and decreased significantly to 50.1 (0.63) (t1), and to 45.1 (0.71) (t2). Total intraventricular hemorrhage Hounsfield unit count was significantly correlated with intraventricular hemorrhage volume at all time points (t0: P = .002; t1: P < .001; t2: P < .001). On serologic and CSF analysis at t0, only higher CSF protein was positively correlated with intraventricular hemorrhage Hounsfield units (P = .03). In 24 matched patients treated with rtPA and controls, total intraventricular hemorrhage Hounsfield units were significantly lower in patients treated with rtPA at t2 (P = .02). Higher Hounsfield unit quantification of fourth ventricle hematomas independently predicted slower clearance of this ventricle (95% CI, 0.02-0.14; P = .02), along with higher intraventricular hemorrhage volume (95% CI, 0.02-0.41; P = .03) and lower CSF protein levels (95% CI, -0.003 to -0.002; P < .001).

CONCLUSIONS

Intraventricular hemorrhage Hounsfield unit counts decrease significantly in the acute phase and to a greater extent with intraventricular rtPA treatment. Intraventricular hemorrhage Hounsfield units are correlated significantly with CSF protein and not with serum erythrocyte or platelet concentrations. Hounsfield unit counts may reflect intraventricular hemorrhage clot composition and rtPA sensitivity.

[News and perspectives in neurocritical care]

Neurocritical care is an ever-evolving discipline and its implementation in intensive care leads to reduction in mortality and to improvement of functional outcome in patients with devastating injuries to the nervous system. However, the decisive elements of the complete field of neurocritical care remain relatively unclear, as well as the exact ways to optimize them. During recent years new insights have been gained and new exciting studies have been initiated from which results are soon to be expected. This review focuses on the following management aspects: neuromonitoring, airway and ventilation, endovascular therapy, cerebrospinal fluid drainage, decompressive craniectomy, hematoma evacuation, blood pressure, and targeted temperature management. The application of these measures to brain diseases and injuries frequently treated in neurointensive care units will be addressed in the context of current studies.

Spontaneous intracerebral and intraventricular hemorrhage: advances in minimally invasive surgery and thrombolytic evacuation, and lessons learned in recent trials

Optimal management of spontaneous intracerebral hemorrhage (ICH) remains one of the highly debated areas in the field of neurosurgery. Earlier studies comparing open surgical intervention with best medical management failed to show a clear benefit. More recent experience with minimally invasive techniques has shown greater promise. Well-designed phase II trials have confirmed the safety and preliminary treatment effect of thrombolytic aspiration and clearance of spontaneous ICH and associated intraventricular obstructive hemorrhage. Those trials are reviewed, including respective protocols and technical nuances, and lessons learned regarding patient selection, the concept of hemorrhage stabilization, optimization of the surgical procedure, and thrombolytic dosing decisions. These concepts have been incorporated in the design of ongoing definite phase III randomized trials (MISTIE and CLEAR) funded by the National Institutes of Health. These are presented including the role of surgical leadership in the training and monitoring of the surgical task and quality assurance. The impact of these techniques on neurosurgical practice is discussed.

Clearing bloody cerebrospinal fluid: clot lysis, neuroendoscopy and lumbar drainage

PURPOSE OF REVIEW

Bloody cerebrospinal fluid (CSF) is a major cause of morbidity and mortality in intraventricular hemorrhage (IVH) and subarachnoid hemorrhage (SAH). Different treatment strategies aiming at faster clearance of bloody CSF have emerged. The present review focuses on recent developments in the investigation of those treatments.

RECENT FINDINGS

Intraventricular fibrinolysis (IVF) for accelerated IVH-resolution has been clinically tested since the early 1990s. The lately summarized evidence from smaller studies indicates that IVF may result in a benefit in mortality and outcome. Recent investigations have elucidated different aspects of IVF, mainly related to safety. Neuroendoscopy has also emerged as a minimally invasive technique allowing fast removal of IVH. The capability of lumbar drainage to reduce vasospasm after SAH has been tested in a large trial.

SUMMARY

IVF is relatively well tolerated and accelerates clot clearance after IVH. The effect of IVF on clinical outcome and mortality is currently being investigated in a large-scale phase III clinical trial. Neuroendoscopy is feasible for the treatment of IVH, however, larger trials are lacking. Lumbar drainage reduces the incidence of vasospasm after SAH. An ongoing phase III trial has been designed to test its influence on outcome. Lumbar drainage may also reduce shunt-dependency after IVH.

Thrombolytic evacuation of intracerebral and intraventricular hemorrhage

Intracranial hemorrhage (ICH) accounts for 10-15 % of all strokes, however it causes 30-50 % of stroke related mortality, disability and cost. The prevalence increases with age with only two cases/100,000/year for age less than 40 years to almost 350 cases/100,000/year for age more than 80 years. Several trials of open surgical evacuation of ICH have failed to show clear benefit over medical management. However, some small trials of minimal invasive hematoma evacuation in combination with thrombolytics have shown encouraging results. Based on these findings larger clinical trials are being undertaken to optimize and define therapeutic benefit of minimally invasive surgery in combination with thrombolytic clearance of hematoma. In this article we will review some of the background of minimally invasive surgery and the use of thrombolytics in the setting of ICH and intraventricular hemorrhage (IVH) and will highlight the early findings of MISTIE and CLEAR trials for these two entities respectively.

Ventricular catheter location and the clearance of intraventricular hemorrhage

BACKGROUND

There is no consensus regarding optimal position of an external ventricular drain (EVD) with regard to clearance of intraventricular hemorrhage (IVH).

OBJECTIVE

To assess the hypothesis that EVD laterality may influence the clearance of blood from the ventricular system with and without administration of thrombolytic agent.

METHODS

The EVD location was assessed in 100 patients in 2 Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR IVH) phase II trials assessing the safety and dose optimization of thrombolysis through the EVD to accelerate the clearance of obstructive IVH. Laterality of catheter was correlated with clearance rates.

RESULTS

Clearance of IVH over the first 3 days was significantly greater when thrombolytic compared with placebo was administered regardless of catheter laterality (P < .005; 95% confidence interval, -14.0 to -4.14 for contralateral EVD and -24.7 to -5.44 for ipsilateral EVD). When thrombolytic was administered, there was a trend toward more rapid clearance of total IVH through an EVD placed on the side of dominant intraventricular blood compared with an EVD on the side with less blood (P = .09; 95% confidence interval, -9.62 to 0.69). This was not true when placebo was administered. Clearance of third and fourth ventricular blood was unrelated to EVD laterality.

CONCLUSION

It is possible that placement of EVD may be optimized to enhance the clearance of total IVH if lytic agents are used. Catheters on either side can clear the third and fourth ventricles with equal efficiency.

Management of non-traumatic intraventricular hemorrhage

Intraventricular hemorrhage (IVH) is defined as the eruption of blood in the cerebral ventricular system and is mostly secondary to spontaneous intracerebral hemorrhage and aneurysmal and arteriovenous malformation rupture. IVH is a proven risk factor of increased mortality and poor functional outcome. Its seriousness is correlated not only with the amount of blood but also with the involvement of the third and fourth ventricles. There are four mechanisms that explain the pathophysiology of this event: acute obstructive hydrocephalus, the mass effect exerted by the blood clot, the toxicity of blood-breaking products on the adjacent brain parenchyma, and, lastly, the development of a chronic hydrocephalus. It is thus obvious that the clearance of blood from the ventricles should be a therapeutic goal. In cases of acute hydrocephalus, external ventricular drainage is a mandatory step, but proven often insufficient. The concomitant use of intraventricular fibrinolytics such as recombinant tissue plasminogen activator or urokinase seems to be beneficial at least in the context of spontaneous intracerebral hemorrhage, in which their use is now accepted but not yet validated by a randomized trial. Given the potential neurotoxicity of these agents, further research is needed in order to identify the best treatment for intraventricular fibrinolysis (IVF). The endoscopic retrieval of intraventricular blood was also described recently and seems to be as efficient as IVF, but its use is limited to specialized centers. IVH represents a therapeutic challenge for neurosurgeons, neurologists, and intensivists. Thus, a better understanding of this dramatic event will help in better tailoring the treatment strategies.

External ventricular drainage for intraventricular hemorrhage

Hemorrhagic stroke accounts for only 10% to 15% of all strokes; however, it is associated with devastating outcomes. Extension of intracranial hemorrhage (ICH) into the ventricles or intraventricular hemorrhage (IVH) has been consistently demonstrated as an independent predictor of poor outcome. In most circumstances the increased intracranial pressure and acute hydrocephalus caused by ICH is managed by placement of an external ventricular drain (EVD). We present a systematic review of the literature on the topic of EVD in the setting of IVH hemorrhage, articulating the scope of the problem and prognostic factors, clinical indications, surgical adjuncts, and other management issues.