Risk of Infection with Prolonged Ventricular Catheterization

Pathophysiology and Prevention of Ventriculostomy-Related Infections: A Review

This qualitative review aims to summarize current knowledge on ventriculostomy-related infection (VRI) pathophysiology and its prevention. VRI generally occurs at day 10, mainly because of Gram-positive cocci, after a cerebrospinal fluid leak. Skin microbiota and biofilm seem to play a major role in VRI pathogenesis. Colonization of external ventricular drain by biofilm is universal and occurs quickly after catheter insertion. However, pathogens from the skin are more often associated with VRI than commensal bacteria. A review of proposed preventive measures shows that none has proven to be fully efficient. Periprocedural and prolonged systemic prophylactic antimicrobials have not shown to prevent VRIs and may promote the emergence of more resistant or pathogenic strains. Antimicrobial and silver-impregnated external ventricular drains, although promising, have not demonstrated preventive effects and may modify bacterial ecology. These results are consistent with the proposed pathophysiology. Finally, we will present a few propositions for future research that may help in improving our knowledge and thus better prevent VRIs. Until then, given the available data, limiting the duration of ventricular drainage may be the most attainable option to prevent VRIs.

Usefulness of cerebrospinal fluid presepsin (soluble CD14 subtype) as a new marker in the diagnosis of neurosurgical postoperative meningitis

Objective

To determine the usefulness of cerebrospinal fluid (CSF) presepsin in the diagnosis of neurosurgical postoperative meningitis (POM).

Methods

The study included patients admitted to the Department of Neurosurgery, Toho University Medical Center Omori Hospital from May 1, 2020 to March 31, 2022 with suspected meningitis after neurosurgery who clinically required CSF sampling and patients who underwent CSF sampling for examination of idiopathic normal pressure hydrocephalus (iNPH). Participants were divided into a POM and a postoperative non meningitis (PONM) group based on the POM diagnostic criteria established for this study. The control group included patients from whom a CSF sample for iNPH was collected by tap test.

Results

A total of 238 CSF samples were collected from 90 patients. There were 39 samples in the POM, 180 samples in the PONM, and 19 samples in the control group. CSF presepsin levels in the POM were significantly higher than in the PONM group (1764.5 and 440.9 pg./mL, respectively; p < 0.0001). The control group had CSF presepsin levels of 95.5 pg./mL. A cutoff value of 669 pg./mL for CSF presepsin in POM and PONM groups had 76.9% sensitivity and 78.3% specificity for the diagnosis of POM. In analyzes including only subarachnoid hemorrhage (SAH) cases (123 samples), CSF presepsin (1251.2 pg./mL) in the POM was significantly higher than in the PONM subgroup (453.9 pg./mL; p < 0.0001). The cutoff value for presepsin in CSF among patients with SAH (669 pg./mL) had 87.5% sensitivity and 76.6% specificity, similar to that of all patients.

Conclusion

CSF presepsin is a useful marker in the diagnosis of neurosurgical POM even in patients with blood components, such as SAH. When POM is suspected, measurement of CSF presepsin may be recommended in addition to a general CSF examination.

The Neurosurgeon's Dilemma-Do Antiplatelet/Anticoagulant Medications Increase the Risk of Catheter-Associated Hemorrhage in External Ventricular Drain Placement?

OBJECTIVE

External ventricular drain (EVD) placement is a common neurosurgical procedure that can be performed at bedside. A frequent complication following EVD placement is catheter-associated hemorrhage (CAH). The hemorrhage itself is rarely clinically significant but may be complicated in patients taking anticoagulant or antiplatelet (AC/AP) medications.

METHODS

A total of 757 patients were who underwent EVD placement at bedside were included as part of a retrospective study at a large academic medical center. Demographic factors, use of AC/AP therapies, and several other clinical variables were recorded and assessed in univariate and multivariate regression analysis for association with CAH and mortality.

RESULTS

One hundred (13.2%) patients experienced CAH within 24 hours of the procedure. After univariate analysis, in 2 tandem-run multivariate regression analyses after stepwise variable selection, use of 2 or more AC/AP agents (odds ratio [OR] = 2.362, P = 0.020) and dual antiplatelet therapy with aspirin and clopidogrel (OR = 3.72, P = 0.009) were significantly associated with CAH. Use of noncoated catheters was a protective factor against CAH compared to use of antibiotic-coated catheters (OR = 0.55, P = 0.019). Multivariate analysis showed age, multiagent therapy, and thrombocytopenia were significantly associated with increased mortality.

CONCLUSIONS

There was increased risk of CAH after EVD placement in patients taking more than one AC/AP agent regardless of presenting pathology. In particular, use of aspirin and clopidogrel combined was associated with significantly higher odds of CAH, although it was not associated with higher mortality. In addition, there appears to be an association between use of antibiotic-coated catheters and CAH across univariate and multivariate analysis.

Significant Reduction in External Ventricular Drain-Related Infections After Introducing a Novel Bundle Protocol: A Before and After Trial

BACKGROUND

External ventricular drain (EVD)-related infection (ERI) is a serious complication in neurosurgical patients. The estimated ERI rates range from 5 to 20 cases per 1,000 EVD catheter days. The pathophysiology of ERI is similar to central line-associated bloodstream infections (CLABSIs) stemming from skin-derived bacterial colonization. The use of bundle management can reduce CLABSI rates. Due to the pathogenic similarities between infections related to the two devices, we developed and evaluated the effectiveness of an ERI-bundle protocol based on CLABSI bundles.

METHODS

From November 2016 to November 2021, we conducted a study to evaluate the effectiveness of an ERI-bundle protocol. This study adopted a before-and-after trial, comparing the ERI rates for the 2 years before and 3 years after the introduction of the newly developed ERI-bundle protocol. We also analyzed the contributing factors to ERI using logistic regression analysis.

RESULTS

A total of 183 patients with 2,381 days of catheter use were analyzed. The ERI rate decreased significantly after the ERI-bundle protocol from 16.7% (14 of 84; 14.35 per 1,000 catheter days) to 4.0% (4 of 99; 3.21 per 1,000 catheter days) (P = 0.004).

CONCLUSION

Introduction of the ERI-bundle protocol was very effective in reducing ERI.

Healthcare-Associated Ventriculitis in Children during COVID-19 Pandemic: Clinical Characteristics and Outcome of a First Infection

During the COVID-19 pandemic, patients in need of neurosurgical care suffered. Elective procedures were postponed, and emergency care visits decreased. Healthcare-associated ventriculitis (HAV) is a serious problem in children, with poor outcomes and frequent relapses. Our objective was to describe the clinical characteristics and the factors associated with a first HAV in children during two years of the pandemic. A retrospective cross-sectional study was performed from January 2021 to December 2022. The inclusion criteria were patients who developed a first HAV after a primary cerebrospinal fluid diversion procedure. The controls included patients without a first infection. Intraoperative and clinical data were extracted from medical records. A total of 199 CSF diversion surgeries were registered. A first infection occurred in 17 patients (8.5%), including 10 with external ventricular drain (EVD) and 6 with ventricular shunts. Gram-positive cocci were identified in 70.6%. Six patients recovered uneventfully, eight had relapse or superinfections, and three eventually died. Twenty patients were included as controls. Factors associated with a first infection were a younger age (median 9 vs. 102 months, p < 0.01), malnutrition (23.5% vs. 0%, p = 0.03), and an EVD placement (58.8% vs. 10%, p = 0.03). None of the intraoperative factors showed statistically significant differences. The rate of HAV was high. Most cases presented in children <1 year and with an EVD.

Feasibility of Prompt Lumbar Drainage in Patients with Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Numerous studies have shown that continuous lumbar drainage (LD) reduces spontaneous subarachnoid hemorrhage (SAH)-related complications, decreasing the incidence of cerebral vasospasm, delayed cerebral ischemia , and hydrocephalus in patients treated with coiling or clipping, but performing LD before securing the aneurysm is still controversial. Our hospital has been implementing prompt LD for several years, and we present the results in this paper.

METHODS

Between January 2014 and December 2020, a total of 438 patients with SAH were included in this retrospective study. The indication for prompt LD was aneurysmal SAH of modified Fisher grade III or higher without dense intraventricular hemorrhage with obstructive hydrocephalus requiring extraventricular drainage or large intracranial hemorrhage requiring immediate decompression. Prompt LD was performed for 229 patients with SAH, and the control group included 209 patients. We compared in-hospital mortality and vasospasm or hydrocephalus occurrence and procedure-related complications between the two groups.

RESULTS

The in-hospital mortality rate was 7.4% for patients with prompt LD and 14.4% for patients without LD, and the difference was significant (P = 0.019). Vasospasm occurred in 10% of patients with prompt LD and 16.7% of controls (P = 0.039). Hydrocephalus requiring extraventricular drainage occurred in 10.9% of the LD group and 28.7% of the control group (P < 0.001). Rebleeding occurrence was 3.1% in the prompt LD group and 5.7% in the non-LD group (P = 0.168). Cerebrospinal fluid infection occurred in 0.4% of the prompt LD group and 1.4% of controls(P = 0.272).

CONCLUSIONS

Prompt LD is a feasible option for treating patients with selective aneurysmal SAH.

Ventriculosubgaleal shunting for spontaneous intraventricular haemorrhage: is it a good alternative to external ventricular drainage?

Background

Spontaneous intraventricular haemorrhage (IVH) is a life-threatening condition associated with high morbidity and mortality and is conventionally managed using external ventricular drain (EVD). However, EVD is commonly associated with a high rate of complications, which necessitates another alternative management with a comparable or better outcome. This study aims to compare the efficacy and safety of ventriculosubgaleal shunt (VSGS) compared to EVD for the management of adult patients with spontaneous IVH.

Results

A total of 48 patients were enrolled in this study. Twenty patients underwent EVD and 28 had VSGS. Postoperative complications were non-significantly more prevalent in the EVD than in the VSGS group (75 vs. 64.3%, p = 0.430), including non-CR (20 vs. 32.1%), infection (20 vs. 7.1%), blocked ventricular catheter (15 vs. 3.6%), and dislodged catheter (10 vs. 7.1%). Convulsions and CSF leaks occurred more frequently in the VSGS group (7.1 vs 5%, p = 1.000). Postoperative GCS and Graeb’s score were comparable between the groups (p > 0.05). The EVD group had a non-significantly higher rate of hydrocephalus after ventricular catheter removal (80 vs. 53.6%, p = 0.059) and a higher mean GOS 3 months postoperatively (mean score: 4 vs. 3).

Conclusions

VSGS is as effective and safe compared to EVD, with a lower rate of infection, blocked/dislodged catheters, as well as a reduced incidence of hydrocephalus. On the other hand, EVD showed better GOS at 3 months. However, these differences did not reach statistical significance.

Antibiotic-impregnated external ventricular drainage for the management of post-hemorrhagic hydrocephalus in low birth weight premature infants following intraventricular hemorrhage

PURPOSE

This study aims to evaluate the infection rates and catheterization duration of applying antibiotic-impregnated external ventricular drain (EVD) for the treatment of post-hemorrhagic hydrocephalus (PHH) in low birth weight infants (LBWI).

METHODS

This retrospective cohort study included 13 preterm LBWI with PHH. Data were collected from the patient's medical charts and included gender, gestational age, birth weight, intraventricular hemorrhage grade, ventriculostomy-associated infection (VAI), and the duration of catheterization. All patients were followed up for at least 6 months after EVD surgery.

RESULTS

The mean gestational age at birth was 27 ± 2.5 weeks, and the mean birth weight was 907 ± 220 g. Among all patients with IVH, two (6.7%) had grade 2 IVH, five (38.5%) had grade 3 IVH, and six (46.2%) had grade 4 IVH. EVD surgery was conducted once for six patients, twice for five patients, and three times for two patients. One patient (7.7%) had VAI post-EVD surgery at 14 days. Three patients (23%) expired due to sepsis, shock, and chylous ascites. Seven patients (53.8%) had hydrocephalus and needed a ventriculoperitoneal shunt over the following course. The longest EVD catheterization period was 57 days without sustained VAI.

CONCLUSIONS

Antibiotic-impregnated EVD has a similar infection rate with the ventricular access device and ventriculosubgaleal shunt. The risk of VAI was not increased even with the EVD catheterization day approaching 2 months. Our study supports the evidence that antibiotic-impregnated EVD is safe and effective for the management of PHH in LBWI. However, this research has a small sample sized and a retrospective design.

Challenges and Controversies in the Management of Tuberculous Meningitis with Hydrocephalus: A Systematic Review and Sarawak Institution's Experience

Introduction To date, there are no standard practice guidelines available and no universal consensus regarding treatment protocol in management of tuberculous meningitis (TBM) with hydrocephalus. Over the years, diverse views have existed in neurosurgical management of TBM with hydrocephalus. Some authors advocate ventriculo-peritoneal (VP) shunt, while others suggest that external ventricular drainage (EVD) may be the preferable neurosurgical procedure for a poor-grade patient.

Method We systematically reviewed published literature and presented our institution's experience. We performed a retrospective case study in our Sarawak neurosurgical center from 2018 to 2020. We tabulated the outcome according to preoperative classifications, which were Vellore Grading (VG), Modified Vellore Grading (MVG), British Medical Research Council Classification (MRC), and others: author-defined.

Result In our center, there were 20 cases of TBM with hydrocephalus treated by EVD and VP shunt from 2018 to 2020. We systematically searched published medical literature, and 23 articles were retrieved and analyzed. Poor outcomes were observed in poor-grade patients, especially VG/MVG 3/4 and MRC 3, from both institution and systemic review data. Shunt complication rate was lower in our center as compared with published literature.

Conclusion Unfortunately, morbidity and mortality were approximately twofold higher in poor-grade as compared with good-grade patients. However, about one-third of poor-grade patients achieved a good outcome. Cerebrospinal fluid (CSF) diversion would be an unavoidable treatment for hydrocephalus. Poor-grade patients tend to have cerebral infarcts in addition to hydrocephalus. An extended duration of EVD placement could be a potential measure to assess Glasgow coma scale recovery and monitor serial CSF samples.

Predictors of ventriculostomy-associated infections: A retrospective study of 243 patients

OBJECTIVE

Risk factors of ventriculostomy-associated infection (VAI) reported in the literature are variable due to heterogeneity of external ventricular drainage (EVD) procedures and management. This study aimed to assess the rate of VAI and its risk factors.

METHODS

The authors retrospectively reviewed the medical records of patients older than 18 years who received EVD catheterizations between January 2015 and December 2020.

RESULTS

Among 243 patients with 355 catheters, twenty-three VAIs were identified, yielding VIA rates of 9.5% per patient and 6.5% per catheter. VAI was associated with a longer total EVD duration (29.2 days vs. 15.8 days, P < 0.001), a longer procedural time (72 minutes vs. 40 minutes, P < 0.001), intraoperative ventriculostomy (39.1% vs. 9.1%, P < 0.001), craniotomy (87.0% vs. 60.9%, P = 0.014), and other systemic infections (30.4% vs. 8.2%, P = 0.004). On multivariate analysis, a longer total EVD duration (OR = 1.086, P < 0.001), intraoperative ventriculostomy (OR = 6.119, P = 0.001), and other systemic infections (OR = 4.620, P = 0.015) were associated with VAI. There was no statistical difference between the VAI rates of patients with and without prophylactic EVD exchanges at mean 12.6 days (7.1% vs. 2.2%, P = 0.401).

CONCLUSIONS

Intraoperative ventriculostomy was independently associated with VAI. Prophylactic EVD exchange at 12.6 days did not lower VAI rate.

Risk Factors Promoting External Ventricular Drain Infections in Adult Neurosurgical Patients at the Intensive Care Unit-A Retrospective Study

Objectives: Multiple risk factors have been described to be related to external ventricular drain (EVD) associated infections, with results varying between studies. Former studies were limited by a non-uniform definition of EVD associated infection, thus complicating a comparison between studies. In this regard, we assessed risk factors promoting EVD associated infections and propose a modified practice-oriented definition of EVD associated infections.

Methods: We performed a retrospective, single-center study on patients who were treated with an EVD, at the neurosurgical intensive care unit (ICU) at a tertiary center between 2008 and 2019. Based on microbiological findings and laboratory results, patients were assigned into an infection and a non-infection group. Patient characteristics and potential risk factors were compared between the two groups (p < 0.05). Receiver operating characteristics (ROC) for significant clinical, serum laboratory and cerebrospinal fluid (CSF) parameters were calculated.

Results: In total, 396 patients treated with an EVD were included into the study with a mean age of 54.3 (range: 18–89) years. EVD associated infections were observed in 32 (8.1%) patients. EVD insertion at another hospital (OR 3.86), and an increased CSF sampling frequency of more than every third day (OR 12.91) were detected as major risk factors for an EVD associated infection. The indication for EVD insertion, surgeon's experience, the setting of EVD insertion (ICU vs. operating room) and the operating time did not show any significant differences between the two groups. Furthermore, ROC analysis showed that clinical, serum laboratory and CSF parameters did not provide specific prediction of EVD associated infections (specificity 44.4%). This explains the high overtreatment rate in our cohort with the majority of our patients who received intrathecal vancomycin (63.3%), having either negative microbiological results (n = 12) or were defined as contaminations (n = 7).

Conclusions: Since clinical parameters and blood analyzes are not very predictive to detect EVD associated infections in neurosurgical patients, sequential but not too frequent microbiological and laboratory analysis of CSF are still necessary. Furthermore, we propose a uniform classification for EVD associated infections to allow comparability between studies and to sensitize the treating physician in determining the right treatment.

Escalation therapy in severe traumatic brain injury: how long is intracranial pressure monitoring necessary?

Traumatic brain injury frequently causes an elevation of intracranial pressure (ICP) that could lead to reduction of cerebral perfusion pressure and cause brain ischemia. Invasive ICP monitoring is recommended by international guidelines, in order to reduce the incidence of secondary brain injury; although rare, the complications related to ICP probes could be dependent on the duration of monitoring. The aim of this manuscript is to clarify the appropriate timing for removal and management of invasive ICP monitoring, in order to reduce the risk of related complications and guarantee adequate cerebral autoregulatory control. There is no universal consensus concerning the duration of invasive ICP monitoring and its related complications, although the pertinent literature seems to show that the longer is the monitoring maintenance, the higher is the risk of technical issues. Besides, upon 72 h of normal ICP values or less than 72 h if the first computed tomography scan is normal (none or minimal signs of injury) and the neurological exam is available (allowing to observe variations and possible occurrence of new-onset pathological response), the removal of invasive ICP monitoring can be justified. The availability of non-invasive monitoring systems should be considered to follow up patients' clinical course after invasive ICP probe removal or for substituting the invasive monitoring in case of contraindication to its placement. Recently, optic nerve sheath diameter and straight sinus systolic flow velocity evaluation through ultrasound methods showed a good correlation with ICP values, demonstrating their potential role in place of invasive monitoring or in the early weaning phase from the invasive ICP monitoring.

The effect of external ventricular drain tunneling length on CSF infection rate in pediatric patients: a randomized, double-blind, 3-arm controlled trial

OBJECTIVE

The role of tunneling an external ventricular drain (EVD) more than the standard 5 cm for controlling device-related infections remains controversial.

METHODS

This is a randomized, double-blind, 3-arm controlled trial done in the Children's Medical Center in Tehran, Iran. Pediatric patients (< 18 years old) with temporary hydrocephalus requiring an EVD and no evidence of CSF infection or prior EVD insertion were enrolled. Patients were randomly assigned (1:1:1) into the following arms: 5-cm (standard; group A); 10-cm (group B); or 15-cm (group C) EVD tunnel lengths. The investigators, parents, and person performing the analysis were masked. The surgeon was informed of the length of the EVD by the monitoring board just before operation. Patients were followed until the EVD's fate was established. Infection rate and other complications related to EVDs were assessed.

RESULTS

A total of 105 patients were enrolled in three random groups (group A = 36, group B = 35, and group C = 34). The EVD was removed because there was no further need in most cases (67.6%), followed by conversion to a new EVD or ventriculoperitoneal shunt (15.2%), infection (11.4%), and spontaneous discharge without further CSF diversion requirement (5.7%). No statistical difference was found in infection rate (p = 0.47) or EVD duration (p = 0.81) between the three groups. No group reached the efficacy point sooner than the standard group (group B: hazard ratio 1.21, 95% CI 0.75-1.94, p = 0.429; group C: hazard ratio 1.03, 95% CI 0.64-1.65, p = 0.91).

CONCLUSIONS

EVD tunnel lengths of 5 cm and longer did not show a difference in the infection rate in pediatric patients. Indeed, tunneling lengths of 5 cm and greater seem to be equally effective in preventing EVD infection. Clinical trial registration no.: IRCT20160430027680N2 (IRCT.ir).

Predictors of ventriculostomy infection in a large single-center cohort

OBJECTIVE

External ventricular drain (EVD) placement is a common neurosurgical procedure. While this procedure is simple and effective, infection is a major limiting factor. Factors predictive of infection reported in the literature are not conclusive. The aim of this retrospective, single-center large series was to assess the rate and independent predictors of ventriculostomy-associated infection (VAI).

METHODS

The authors performed a retrospective chart review of consecutive patients who underwent EVD placement between January 2012 and January 2018.

RESULTS

A total of 389 patients were included in the study. The infection rate was 3.1% (n = 12). Variables that were significantly associated with VAI were EVD replacement (OR 10, p = 0.001), bilateral EVDs (OR 9.2, p = 0.009), duration of EVD placement (OR 1.1, p = 0.011), increased CSF output/day (OR 1.0, p = 0.001), CSF leak (OR 12.9, p = 0.001), and increased length of hospital stay (OR 1.1, p = 0.002). Using multivariate logistic regression, independent predictors of VAI were female sex (OR 7.1, 95% CI 1.1-47.4; p = 0.043), EVD replacement (OR 8.5, 95% CI 1.44-50.72; p = 0.027), increased CSF output/day (OR 1.01, 95% CI 1.0-1.02; p = 0.023), and CSF leak (OR 15.1, 95% CI 2.6-87.1; p = 0.003).

CONCLUSIONS

The rate of VAI was 3.1%. Routine CSF collection (every other day or every 3 days) and CSF collection when needed were not associated with VAI. The authors recommend CSF collection when clinically needed rather than routinely.

Population Pharmacokinetics of Intraventricular Vancomycin in Neonatal Ventriculitis, A Preterm Pilot Study

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Pharmacokinetics modelling of intraventricular vancomycin in a preterm pilot study.

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Intraventricular vancomycin follows a one compartment model in neonatal ventriculitis treatment.

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Ventricular Index, a dosing parameter, does not influence cerebrospinal fluid vancomycin levels.

Aim

Intraventricular vancomycin is an effective treatment for neonatal ventriculitis, as the cerebrospinal fluid (CSF) vancomycin levels reach adequate concentrations to achieve microbiological cure. There is no robust data on intraventricular vancomycin pharmacokinetics in the preterm population. This pilot population pharmacokinetic modelling study examines the pharmacokinetic behaviour of intraventricular vancomycin in the preterm population of < 28 weeks gestation, to inform the feasibility of future prospective studies.

Methods

The study comprised 8 preterm infants with neonatal ventriculitis (median gestation age 25.3 weeks; range 23.9 - 27.7). Population pharmacokinetics (non-linear mixed effects modelling) were described with one- and two-compartment models to fit plasma concentrations of vancomycin. A CSF compartment was added to the plasma modelling and mass transfer examined. Three covariates (serum creatinine, ventricular index (VI) and CSF protein) were tested on the final model. Area under the curve (AUC) and average CSF concentration (C average) predictions were generated from the final model and compared with time to microbiological cure.

Results

A one-compartment model provided the best fit to the data. There was no appreciable transfer between plasma and CSF. None of the covariates provided a significant reduction in the objective function value (OFV). Generally, time to sterilisation with higher CSF AUC (0-24) and C average tends to be shorter, however this should be interpreted with caution as data is erratic.

Conclusion

This pilot population pharmacokinetic analysis provides important information to warrant changes in the management of intraventricular vancomycin treatment in the preterm population, such as the current use of VI as a dosing parameter. Further study with a larger data pool is necessary to investigate the influence of VI on CSF vancomycin and ascertain dosing strategies.

Efficacy of translamina terminalis ventriculostomy tube in prevention of chronic hydrocephalus after aneurysmal subarachnoid hemorrhage

Background

Chronic shunt-dependent hydrocephalus is still a common complication after aneurysmal SAH (aSAH) and is associated with increased morbidity. Pathology of chronic shunt-dependent hydrocephalus after aSAH is complex and multifactorial which makes its prevention challenging. We thought to evaluate whether external ventricular drainage (EVD) through fenestrated lamina terminalis would decrease the rate of chronic shunt-dependent hydrocephalus after aSAH.

Methods

A retrospective analysis of 68 consecutive patients with aSAH who underwent microsurgical clipping of the ruptured aneurysm. Patients were divided into two groups: Group A included patients with lamina terminalis fenestration without insertion of ventriculostomy tube and Group B included patients with EVD through fenestrated lamina terminalis. Demographic, clinical, radiological, and outcome variables were compared between groups.

Results

Group A comprised 29 patients with mean age of 47.8 years and Group B comprised 39 patients with mean age of 46.6 years. Group B patients had statistically significant (P < 0.05) lower incidence of chronic shunt- dependent hydrocephalus than Group A patients (30.8% vs. 55.2%, respectively).

Conclusion

EVD through fenestrated lamina terminalis is safe and may be effective in decreasing the incidence of chronic shunt-dependent hydrocephalus after aSAH.

Cerebrospinal Fluid Collected by Lumbar Puncture Has a Higher Diagnostic Accuracy than Collected by Ventriculostomy

BACKGROUND

Patients harboring an external ventricular drain (EVD) who develop signs of infection require screening for infection in the central nervous system (CNS). The cerebrospinal fluid (CSF) can be collected by the EVD or by lumbar puncture (LP). If only one sample is analyzed, the diagnosis might be dubious or false-negative. The objective of this study was to compare the diagnosis accuracy of CNS infection of CSF samples collected from EVD and LP.

METHODS

We conducted a transversal study where data were prospectively collected from 2016 to 2019. Patients harboring EVD with signs of infection were submitted to the CSF analysis collected by LP and EVD. Diagnosis sensibility and results correlation were analyzed using the kappa index.

RESULTS

The 141 samples from LP and 141 samples from EVD were collected from 108 patients. Among the 282 samples, a total of 77 had infection. Seventy CSF samples from LP fulfilled infection criteria. However, only 32 EVD samples demonstrated infection. Among the 70 cases of infection based on the LP sample, 25 CSF samples collected from the EVD were also suggestive of infection; but in 45 patients only the CSF samples from LP met infection criteria. Seven patients had diagnosis of infection only in the EVD sample. The kappa correlation index of the results obtained from LP and EVD was 0.260 and the McNemar χ² test was <0.01.

CONCLUSIONS

The CSF analysis exclusive from the EVD has a low sensibility and negative predictive value. CSF collected from LP has a sensibility 2.18 times higher than EVD.

Ventricular Catheter Tract Hemorrhage as a Risk Factor for Ventriculostomy-Related Infection

BACKGROUND

Ventriculostomy-related infection (VRI) is a feared complication of external ventricular drain (EVD) placement. Although many contributing factors to VRI have been examined, little is known whether there is an association between ventriculostomy-related catheter tract hemorrhage (VCTH) and VRI.

OBJECTIVE

To evaluate risk factors for VRI and assess possible correlations with VCTH.

METHODS

We performed a retrospective analysis of patients with EVD placement in a neurocritical care unit between 2011 and 2015. VRI was defined as clinical signs of infection with a positive cerebrospinal fluid gram stain and isolation of cerebrospinal fluid culture. VCTH was diagnosed by computed tomography immediately after EVD insertion.

RESULTS

A total of 247 patients with EVD were identified during the 5-yr study period. An association between VCTH and gram-negative VRI was identified (P = .02). Ten percent (25 of 247 patients) developed a VRI, and 7% (18 of 247 patients) had a VCTH. Of the 25 patients with VRI, 20% (n = 5) had a VCTH, compared to 6% (n = 13) of 222 patients who had an EVD placed but did not develop VRI. There were no significant differences in demographic and clinical factors except for multiple EVD insertions (P < .00001), EVD duration (P < .001), and hospital length of stay (P < .001).

CONCLUSION

VCTH is a potentially significant risk factor for VRI. Further analysis will be needed to confirm the strength of this association, and to delineate the possible mechanisms by which tract hemorrhage may serve as a nidus for bacterial penetration into the central nervous system.

Risk Factors of External Ventricular Drainage-Related Infections: A Retrospective Study of 147 Pediatric Post-tumor Resection Patients in a Single Center

Background: External ventricular drainage (EVD) is common after brain surgery. However, the incidence of EVD-related infection (ERI) is still relatively high and can increase morbidity and mortality.

Objective: The objective of this study was to analyze ERI factors in pediatric population post-brain tumor surgery.

Methods: From January 2016 to December 2017, 147 patients <18 years old underwent tumor removal at Beijing Tiantan Hospital and had postoperative EVD. We recorded basic demographic data as well as several risk factors. We then analyzed whether these factors were related to ERI.

Results: Patients with a preoperative ventriculo-peritoneal (V-P) shunt, those with longer operation time, those who received blood transfusion, those with more frequent cerebrospinal fluid (CSF) sampling, and those with longer indwelling time of EVD had higher risks of infection (p < 0.05). Logistic regression analysis confirmed that a preoperative V-P shunt, operative duration, intraoperative blood transfusion, frequency of CSF sampling, and EVD duration were correlated with postoperative ERI (p < 0.05).

Conclusion: EVD should be removed as soon as possible and any unnecessary procedures should be avoided to reduce the infection rate. However, prophylactic treatment should be given in case patients do not meet the indication for EVD removal.

Logistic Regression Analysis of Risk Factors for Intracranial Infection After Multiple Traumatic Craniotomy and Preventive Measures

BACKGROUND AND OBJECTIVE

The aim of this study was to study the risk factors of intracranial infection after traumatic craniotomy in multiple trauma to provide references for clinical prevention and control of intracranial infection.

METHODS

A total of 34 multiple trauma patients treated with craniotomy and complicated with intracranial infection from February 2012 to December 2016 in the department of neurosurgery of our hospital were selected as infection group, and 60 multiple trauma patients who had not been infected after craniotomy during the same period were selected as control group. Related risk factors were screened by univariate analysis at first and analyzed by Logistic regression.

RESULTS

Of the 34 patients in the infection group, 13 cases were cured, 21 cases improved, whereas in the control group, 15 cases were cured and 45 cases improved. There was no significant difference in prognosis between the 2 groups (P > 0.05). Univariate analysis showed that surgical approach, surgical duration, postoperative cerebrospinal fluid leakage, and external drainage were important factors for intracranial infection after craniotomy (P < 0.05). Further Logistic regression analysis showed that postoperative external drainage, cerebrospinal fluid leakage, surgical time, and posterior fossa approaches were independent risk factors for intracranial infection after craniotomy.

CONCLUSION

High attention should be paid to the risk factors of intracranial infection after craniotomy such as postoperative cerebrospinal fluid leakage, external drainage, surgical duration and approach, and taking effective preventive measures to reduce the incidence of intracranial infection after craniotomy in patients with multiple traumatic injuries.

The Incidence of Catheter Tract Hemorrhage and Catheter Placement Accuracy in the CLEAR III Trial

BACKGROUND

Incidence of catheter tract hemorrhage (CTH) after initial ventriculostomy placement ranges from 10 to 34%. We investigated CTH incidence in the Clot Lysis: Evaluation of Accelerated Resolution of Intraventricular Hemorrhage Phase III trial.

METHODS

Prospective observational analysis of 1000 computer tomography (CT) scans from all 500 patients enrolled in the trial. All catheters were evaluated on first CT post-placement and on last CT prior to randomization for placement location and CTH size, location, and severity. Clinical variables were assessed for association with CTH with multivariable logistic regression.

RESULTS

Of 563 catheters, CTH was detected in 14 and 21% of patients on first and last CT (median 3.7 and 43.4 h after catheter placement, respectively). All, but one were asymptomatic. Majority of CTH (86%) occurred within 24 h after placement, were located within 1 cm of the skull, and had at least one diameter > 5 mm. Most catheters (71%) terminated in the third or lateral ventricle ipsilateral to insertion site. Factors significantly associated with CTH were pre-admission use of antiplatelet drugs, accuracy of catheter placement, non-operating room catheter placement, Asian race, and intraventricular hemorrhage expansion.

CONCLUSIONS

CTH incidence on initial catheter placement and during stabilization was relatively low, despite emergent placement in a high-risk population. Catheter placement accuracy was similar or better than convenience samples from the published literature. Decreasing risk of CTH may be achieved with attention to catheter placement accuracy and placement in the operating room. Antiplatelet agent use was an independent risk factor for CTH.

Antibiotic Distribution into Cerebrospinal Fluid: Can Dosing Safely Account for Drug and Disease Factors in the Treatment of Ventriculostomy-Associated Infections?

Ventriculostomy-associated infections, or ventriculitis, in critically ill patients are associated with considerable morbidity. Efficacious antibiotic dosing for the treatment of these infections may be complicated by altered antibiotic concentrations in the cerebrospinal fluid due to variable meningeal inflammation and antibiotic properties. Therefore, doses used to treat infections with a higher degree of meningeal inflammation (such as meningitis) may often fail to achieve equivalent exposures in patients with ventriculostomy-associated infections such as ventriculitis. This paper aims to review the disease burden, infection rates, and common pathogens associated with ventriculostomy-associated infections. This review also seeks to describe the disease- and drug-related factors that influence antibiotic distribution into cerebrospinal fluid and provide a critical appraisal of current dosing of antibiotics commonly used to treat these types of infections. A Medline search of relevant articles was conducted and used to support a review of cerebrospinal fluid penetration of vancomycin, including critical appraisal of the recent paper by Beach et al. recently published in this journal. We found that in the intensive care unit, ventriculostomy-associated infections are the most common and serious complication of external ventricular drain insertion and often result in prolonged patient stay and increased healthcare costs. Reported infection rates are extremely variable (between 0 and 45%), hindered by the inherent diagnostic difficulty. Both Gram-positive and Gram-negative organisms are associated with such infections and the rise of multi-drug-resistant pathogens means that effective treatment is an ongoing challenge. Disease factors that may need to be considered are reduced meningeal inflammation and the presence of critical illness; drug factors include physiochemical properties, degree of plasma-protein binding, and affinity to active transporter proteins present in the blood-cerebrospinal fluid barrier. The relationship between cerebrospinal fluid antibiotic exposures in the setting of ventriculostomy-associated infection and clinical response has not been fully elucidated for many of the antibiotics commonly used in its treatment. More thorough and clinically relevant investigations are needed to better define blood pharmacokinetic/pharmacodynamics targets and optimal therapeutic exposures for treatment of ventriculostomy-associated infections. It is hoped that this future research will be able to provide clearer recommendations for clinicians frequently faced with dosing-related dilemmas when treating patients with these challenging infections.

Risk Factors of External Ventricular Drain Infection: Proposing a Model for Future Studies

Background: External ventricular drain (EVD) has a major role in the management and monitoring of intracranial pressure (ICP) and its major complication is EVD infection. The risk factors for EVD infection are still a major topic of controversy, hence the need for further research.

Objective: The objective of this review was to identify risk factors that affect the incidence of EVD infection and create a model, which can be used in future studies in order to contribute to elaborations on guideline for EVD.

Methods: A PubMed and Google Scholar literature search was performed and data were extracted from studies published from 1966 through 2017. The search of the databases generated 604 articles and 28 articles of these were found to be relevant. A manual search of the 28 relevant papers generated 4 new articles. Of the 32 relevant articles, 20 articles that performed a multivariate analysis of the suspected risk factors of EVD infection and had a positive culture as a mandatory component in diagnosis were selected for data collection and analysis.

Results: Because reviewed papers investigated only a few influencing factors, and could not determine convincingly the real risk factors of EVD infection and their real strengths. A total of 15 supposed influencing factors which includes: age, age & sex interactions, coinfection, catheter insertion outside the hospital, catheter type, CSF leakage, CSF sampling frequency, diagnosis, duration of catheterization, ICP > 20 mmHg, irrigation, multiple catheter, neurosurgical operation, reduced CSF glucose at catheter insertion and sex were identified.

Conclusion: This review summarizes a set of variables which have to be covered by future clinical epidemiological investigations in order to describe the etiological background of EVD infection.

Transfer Function Between Intracranial Pressure and Aortic Blood Pressure and Carotid Blood Flow

The compliance of the intracranial space is such that the intracranial pressure (ICP) waveform is approximately the aortic blood pressure (BP) waveform minus the dominant harmonic (heart rate (HR)) of that waveform. This has been tested across species of different resting HR. Whether this filter characteristic holds true for large changes in HR, or under changed ICP, has not been examined. This study tested these changes in 11 anesthetized rats instrumented to measure and change ICP, HR, aortic BP, and carotid blood flow. The aortic BP to ICP and carotid blood flow to ICP transfer function was determined for normal ICP at paced HRs of 300, 400 and 500 bpm, and at raised ICP at HRs of 400 and 500 bpm. The aortic BP to ICP transfer function magnitude showed a dependency on HR HR (-0.15±0.04 ×10^-3 bpm^-1, p<0.001) and mean ICP (4.4±0.6 ×10^-3 mmHg^-1). The carotid blood flow to ICP transfer function magnitude showed a dependency on mean ICP (11.1±1.8 ×10^-3 mmHg/ml/min/mmHg, p<0.001) but not on HR. The changes with different HRs indicates a degree of non-linearity in the system. Though small, this may need to be accounted for in understanding the relationship between systemic BP and flow and ICP. This data is useful in understanding the relationship between cardiovascular signals and ICP, valuable in advancing the ability to estimate ICP non-invasively.

Complications of invasive intracranial pressure monitoring devices in neurocritical care

Intracranial pressure monitoring devices have become the standard of care for the management of patients with pathologies associated with intracranial hypertension. Given the importance of invasive intracranial monitoring devices in the modern neurointensive care setting, gaining a thorough understanding of the potential complications related to device placement-and misplacement-is crucial. The increased prevalence of intracranial pressure monitoring as a management tool for neurosurgical patients has led to the publication of a plethora of papers regarding their indications and complications. The authors aim to provide a concise review of key contemporary articles in the literature concerning important complications with the hope of elucidating practices that improve outcomes for neurocritically ill patients.

Cerebrospinal Fluid Presepsin As a Marker of Nosocomial Infections of the Central Nervous System: A Prospective Observational Study

Background

Nosocomial CNS infection (NI-CNS) is a common and serious complication in neurocritical care patients. Timely, accurate diagnosis of NI-CNS is crucial, yet current infection markers lack specificity and/or sensitivity. Presepsin (PSP) is a novel biomarker of macrophage activation. Its utility in NI-CNS has not been explored. We first determined the normal range of cerebrospinal fluid (CSF) PSP in a control group without brain injury before collecting data on CSF PSP levels in neurocritical care patients. Samples were analyzed in four groups defined by systemic and neurological infection status.

Results

CSF PSP levels in 15 control patients without neurological injury were 50–100 pg/ml. Ninety-seven CSF samples were collected from 21 neurocritical care patients. In patients without NI-CNS or systemic infection, CSF PSP was 340.4 ± 201.1 pg/ml. Isolated NI-CNS was associated with CSF PSP levels of 640.8 ± 235.5 pg/ml, while levels in systemic infection without NI-CNS were 580.1 ± 329.7 pg/ml. Patients with both NI-CNS and systemic infection had CSF PSP levels of 1,047.7 ± 166.2 pg/ml. In neurocritical care patients without systemic infection, a cut-off value of 321 pg/ml gives sensitivity and specificity for NI-CNS of 100 and 58.3%, respectively.

Conclusion

CSF PSP may prove useful in diagnosing NI-CNS, but its current utility is as an additional marker only.

2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis

The Infectious Diseases Society of America (IDSA) Standards and Practice Guidelines Committee collaborated with partner organizations to convene a panel of 10 experts on healthcare-associated ventriculitis and meningitis. The panel represented pediatric and adult specialists in the field of infectious diseases and represented other organizations whose members care for patients with healthcare-associated ventriculitis and meningitis (American Academy of Neurology, American Association of Neurological Surgeons, and Neurocritical Care Society). The panel reviewed articles based on literature reviews, review articles and book chapters, evaluated the evidence and drafted recommendations. Questions were reviewed and approved by panel members. Subcategories were included for some questions based on specific populations of patients who may develop healthcare-associated ventriculitis and meningitis after the following procedures or situations: cerebrospinal fluid shunts, cerebrospinal fluid drains, implantation of intrathecal infusion pumps, implantation of deep brain stimulation hardware, and general neurosurgery and head trauma. Recommendations were followed by the strength of the recommendation and the quality of the evidence supporting the recommendation. Many recommendations, however, were based on expert opinion because rigorous clinical data are not available. These guidelines represent a practical and useful approach to assist practicing clinicians in the management of these challenging infections.

Analysis on the risk factors of intracranial infection secondary to traumatic brain injury

OBJECTIVE

To discuss the characteristics and risk factors for intracranial infection post traumatic brain injury to prevent and better the clinical care.

METHODS

Retrospective study of 520 patients with traumatic brain injury were included, 308 male and 212 female. The risky factors of intracranial infection were identified.

RESULTS

Thirty two cases (6.54%, 32/520) of intracranial infection were diagnosed. Intracranial infection most likely happened 4-10 days after injury. Cerebrospinal fluid leakage, drainage, multiple craniotomies were significant related to intracranial infection. Logistic regression predicted cerebrospinal fluid leakage and drainage as independent factors.

CONCLUSION

Intracranial infection is a serious complication after traumatic brain injury. Patients with drainage or cerebrospinal fluid leakage are more risky for intracranial infection. Aggressive precaution should be taken to better outcome.

External ventricular drain practice variations: results from a nationwide survey

OBJECTIVE While guidelines exist for many neurosurgical procedures, external ventricular drain (EVD) insertion has yet to be standardized. The goal of this study was to survey the neurosurgical community and determine the most frequent EVD insertion practices. The hypothesis was that there would be no standard practices identified for EVD insertion or methods to avoid EVD-associated infections. METHODS The American Association of Neurological Surgeons membership database was queried for all eligible neurosurgeons. A 16-question, multiple-choice format survey was created and sent to 7217 recipients. The responses were collected electronically, and the descriptive results were tabulated. Data were analyzed using the chi-square test. RESULTS In total, 1143 respondents (15.8%) completed the survey, and 705 respondents (61.6%) reported tracking EVD infections at their institution. The most common self-reported infection rate ranged from 1% to 3% (56.1% of participants), and 19.7% of respondents reported a 0% infection rate. In total, 451 respondents (42.7%) indicated that their institution utilizes a formal protocol for EVD placement. If a respondent's institution had a protocol, only 258 respondents (36.1%) always complied with the protocol. Protocol utilization for EVD insertion was significantly more frequent among residents, in academic/hybrid centers, in ICU settings, and if the institution tracked EVD-associated infection rates (p < 0.05). A self-reported 0% infection rate was significantly more commonly associated with a higher level of training (e.g., attending physicians), private center settings, a clinician performing 6 to 10 EVD insertions within the previous 12 months, and prophylactic continuous antibiotic utilization (p < 0.05). CONCLUSIONS This survey demonstrated heterogeneity in the practices for EVD insertion. No standard practices have been proposed or adopted by the neurosurgical community for EVD insertion or complication avoidance. These results highlight the need for the nationwide standardization of technique and complication prevention measures.

External Ventricular Drain-Related Infection in Spontaneous Intracerebral Hemorrhage

OBJECTIVE

We aimed to analyze infection rates in patients with spontaneous intracranial hemorrhage who underwent surgical external ventricular drain (EVD) placement.

METHODS

This prospective study included 94 consecutive patients who required an EVD for spontaneous intracranial hemorrhage at the Neurosurgery Department of Hospital Cristo Redentor, Porto Alegre, Rio Grande do Sul, Brazil.

RESULTS

The mean duration of EVD use was 7 days. Overall sample mortality was 45%, and overall infection rate was 36%. Patients who had an EVD in place >10 days had higher odds of infection than patients who had an EVD in place ≤10 days (odds ratio = 3.1, 95% confidence interval, 1.1-8.7). Culture positivity rate was 5.3%.

CONCLUSIONS

Our findings suggest that EVD infection is a very common complication, occurring in 36.2% of cases. We adopted ventriculitis as the standard diagnosis, as advocated by the U.S. Centers for Disease Control and Prevention. Considering the high lethality associated with intracranial hemorrhage, use of a more aggressive treatment protocol for this patient population might improve morbidity and mortality rates.

Post-neurosurgical meningitis: Management of cerebrospinal fluid drainage catheters influences the evolution of infection

BACKGROUND

In order to better define the pathogenic role of cerebrospinal fluid (CSF) drainage catheters in postoperative patients, we comparatively analyze the clinical course of device and non-device-related meningitis.

METHODS

This is an observational, partially prospective, study on consecutive adult patients who developed meningitis after undergoing neurosurgical procedures at the Neurosurgery and Neurointensive care Departments, Spedali Civili, Brescia, Italy, between January 1999 and August 2007.

RESULTS

All 77 consecutive post-neurosurgical meningitis events in 65 patients were included in the analysis. Most were classified as external ventricular drainage (EVD)-related meningitis (23 cases, group A), external spinal drainage (ESD)-related meningitis (12 cases, group B), and non-device-related post-neurosurgical meningitis (30 cases, group C). Proven meningitis was identified in 78.3%, 91.7% and 56.7% of the events, respectively. ESD-related meningitis had a shorter onset time vs EVD and non-device-associated meningitis (3 days versus 6 and 7 days, respectively). Median antibiotic treatment duration was 20, 17, and 22.5 days in groups A, B, and C, respectively. Overall, 8 patients (34.8%) in group A, 3 (25.0%) in group B, and 3 (10.0%) in group C died. Median time to become afebrile was shorter in group C than in group A (10 days versus 12 days, P = 0.04). Removal of the device later than 48 hours after meningitis onset, as well as implantation of a second device were associated with a slower time of meningitis resolution.

CONCLUSIONS

Early device removal and avoiding implantation of a second device were associated with short illness duration. Larger studies are warranted to confirm the conclusions of this study.

Endoscopic Third Ventriculostomy in 250 Adults With Hydrocephalus

BACKGROUND:

Endoscopic third ventriculostomy (ETV) has been used predominantly in the pediatric population in the past. Application in the adult population has been less extensive, even in large neurosurgical centers. To our knowledge, this report is one of the largest adult ETV series reported and has the consistency of being performed at 1 center.

OBJECTIVE:

To determine the efficacy, safety, and outcome of ETV in a large adult hydrocephalus patient series at a single neurosurgical center. In addition, to analyze patient selection criteria and clinical subgroups (including those with ventriculoperitoneal shunt [VPS] malfunction or obstruction and neurointensive care unit patients with extended ventricular drainage before ETV) to optimize surgical results in the future.

METHODS:

We conducted a retrospective review of adult ETV procedures performed at our center between 2000 and 2014.

RESULTS:

The overall rate of success (no further cerebrospinal fluid diversion procedure performed plus clinical improvement) of 243 completed ETVs was 72.8%. Following is the number of procedures with the success rate in parentheses: aqueduct stenosis, 56 (91%); communicating hydrocephalus including normal pressure hydrocephalus, nonnormal pressure hydrocephalus, and remote head trauma, 57 (43.8%); communicating hydrocephalus in postoperative posterior fossa tumor without residual tumor, 14 (85.7%); communicating hydrocephalus in subarachnoid hemorrhage without intraventricular hemorrhage, 23 (69.6%); obstruction from tumor/cyst, 42 (85.7%); VPS obstruction (diagnosis unknown), 23 (65.2%); intraventricular hemorrhage, 20 (90%); and miscellaneous (obstructive), 8 (50%). There were 9 complications in 250 intended procedures (3.6%); 5 (2%) were serious.

CONCLUSION:

Use of ETV in adult hydrocephalus has broad application with a low complication rate and reasonably good efficacy in selected patients.

Ventriculostomy-associated infection: a new, standardized reporting definition and institutional experience

OBJECTIVE

Shortcomings created by the lack of both a uniform definition of ventriculostomy-associated infection (VAI) and reporting standards have led to widely ranging infections rates (2-24%) whose significance is uncertain. We propose a standardized definition of VAI and a consistent reporting format compliant with Centers for Disease Control and Prevention (CDC) for device-related infections. Using those parameters to establish an infection-control surveillance program, we report our 4-year institutional VAI rates.

METHODS

In this prospective study covering ventriculostomy utilization (October 2006-December 2010), 498 patients had a total of 4,673 ventriculostomy days. By review of the literature and our institutional analysis, we defined VAI as a positive CSF culture in a patient with ventriculostomy catheter, plus one or more of the following (1) fever recorded >101.5 °F or (2) cerebrospinal fluid (CSF) glucose level, either <50 mg/dL or <50% of a serum glucose level drawn within 24 h of the CSF glucose. In a report format that is CDC compliant, rates of VAI are reported.

RESULTS

Among our patients, the CDC-compliant infection rate was 2.14 per 1,000 ventriculostomy days. Of the 10 VAIs occurring in 498 patients during 4,673 ventriculostomy days, this 2.0% infection rate was lower than the previously reported 8.8% composite rates of VAI. Average duration of ventriculostomy was 9.4 days. Neither antibiotic-impregnated catheters nor periprocedural or prophylactic antibiotics were used.

CONCLUSIONS

Our standardized VAI definition and CDC format seems promising toward facilitating future study and guideline development. Given our strict protocol of sterile catheter placement and care, and our institution's low 2.0% infection rates, we propose an infection-rate target of ≤5 per 1,000 device days. Our results suggest that the use of antibiotics or antibiotic-impregnated catheters is unwarranted--a positive given concerns of evolving anti-microbial resistance.

Bleeding and infection with external ventricular drainage: a systematic review in comparison with adjudicated adverse events in the ongoing Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR-III IHV) trial

BACKGROUND

Retrospective series report varied rates of bleeding and infection with external ventricular drainage (EVD). There have been no prospective studies of these risks with systematic surveillance, threshold definitions, or independent adjudication.

OBJECTIVE

To analyze the rate of complications in the ongoing Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR III) trial, providing a comparison with a systematic review of complications of EVD in the literature.

METHODS

Patients were prospectively enrolled in the CLEAR III trial after placement of an EVD for obstructive intraventricular hemorrhage and randomized to receive recombinant tissue-type plasminogen activator or placebo. We counted any detected new hemorrhage (catheter tract hemorrhage or any other distant hemorrhage) on computed tomography scan within 30 days from the randomization. Meta-analysis of published series of EVD placement was compiled with STATA software.

RESULTS

Growing or unstable hemorrhage was reported as a cause of exclusion from the trial in 74 of 5707 cases (1.3%) screened for CLEAR III. The first 250 patients enrolled have completed adjudication of adverse events. Forty-two subjects (16.8%) experienced ≥1 new bleeds or expansions, and 6 of 250 subjects (2.4%) suffered symptomatic hemorrhages. Eleven cases (4.4%) had culture-proven bacterial meningitis or ventriculitis.

CONCLUSION

Risks of bleeding and infection in the ongoing CLEAR III trial are comparable to those previously reported in EVD case series. In the present study, rates of new bleeds and bacterial meningitis/ventriculitis are very low despite multiple daily injections, blood in the ventricles, the use of thrombolysis in half the cases, and generalization to >60 trial sites.

Diagnostic accuracy of presepsin (sCD14-ST) for prediction of bacterial infection in cerebrospinal fluid samples from children with suspected bacterial meningitis or ventriculitis

Children with temporary external ventricular drains (EVD) are prone to nosocomial infections. Diagnosis of bacterial meningitis and ventriculitis in these children is challenging due to frequent blood contamination of cerebrospinal fluid (CSF) and the presence of chemical ventriculitis. The aim of this study was to compare diagnostic accuracy of presepsin (sCD14-ST), a novel biomarker of bacterial infection in CSF, to predict bacterial infection in comparison to the accuracy of established biomarkers like those demonstrated in biochemical analysis of CSF. We conducted a prospective study with 18 children with suspected bacterial meningitis or ventriculitis who had 66 episodes of disease. CSF samples were taken from external ventricular drainage. We measured presepsin in CSF, as well as CSF leukocyte count, glucose, and proteins. CSF was also taken to prove bacterial infection with culture methods or with 16S rRNA gene broad-range PCR (SepsiTest; Molzym, Germany). Infection was clinically confirmed in 57 (86%) episodes of suspected meningitis or ventriculitis. Chemical ventriculitis was diagnosed in 9 (14%) episodes of suspected meningitis or ventriculitis. Diagnostic accuracies presented as area under the curve (AUC) for sCD14-ST, leukocytes, and proteins measured in CSF were 0.877 (95% confidence interval [CI], 0.793 to 0.961), 0.798 (95% CI, 0.677 to 0.920), and 0.857 (95% CI, 0.749 to 0.964), respectively. With CSF culture, we detected bacteria in 17 samples, compared to 37 detected with broad-range PCR. It was found that presepsin was present at a significantly higher level in children with clinically proven ventriculitis than in those without meningitis or ventriculitis. Diagnostic accuracies of presepsin were superior to those of leukocytes or proteins in CSF. Presepsin-guided 16S rRNA gene PCR could be used in everyday clinical practice to improve etiological diagnosis of meningitis and ventriculitis and to prescribe more appropriate antibiotics.

A meta-analysis of ventriculostomy-associated cerebrospinal fluid infections

BACKGROUND

Ventriculostomy insertion is a common neurosurgical intervention and can be complicated by ventriculostomy-associated cerebrospinal fluid infection (VAI) which is associated with increased morbidity and mortality. This meta-analysis was aimed at determining the pooled incidence rate (number per 1000 catheter-days) of VAI.

METHODS

Relevant studies were identified from MEDLINE and EMBASE and from reference searching of included studies and recent review articles on relevant topics. The Newcastle-Ottawa Scale was used to assess quality and risk of bias. A random effects model was used to pool individual study estimates and 95% confidence intervals (CI) were calculated using the exact Poisson method. Heterogeneity was assessed using the heterogeneity χ2 and I-squared tests. Subgroup analyses were performed and a funnel plot constructed to assess publication bias.

RESULTS

There were a total of 35 studies which yielded 752 infections from 66,706 catheter-days of observation. The overall pooled incidence rate of VAI was 11.4 per 1000 catheter days (95% CI 9.3 to 13.5), for high quality studies the rate was 10.6 (95% CI 8.3 to 13) and 13.5 (95% CI 8.9 to 18.1) for low quality studies. Studies which had mean duration of EVD treatment of less than 7 days had a pooled VAI rate of 19.6 per 1000 catheter-days, those with mean duration of 7-10 days had VAI rate of 12.8 per 1000 catheter-days and those with mean duration greater than 10 days had VAI rate of 8 per 1000 catheter-days. There was significant heterogeneity for the primary outcome (p = 0.004, I-squared = 44%) and most subgroups. The funnel plot did not show evidence for publication bias.

CONCLUSIONS

The incidence rate of VAI is 11.4 per 1000 catheter-days. Further research should focus on analysis of risk factors for VAI and techniques for reducing the rate of VAI.

Use of a cyanoacrylate skin adhesive to reduce external ventricular drain infection rates

Object

Ventriculitis related to external ventricular drain (EVD) placement is a significant source of morbidity in neurological intensive care patients. Current rates of EVD-related infections range from 2% to 45% in the literature. The authors sought to determine if a 2-octyl cyanoacrylate adhesive would result in lower infection rate than standard semiocclusive dressings.

Methods

The authors tracked ventriculitis rates via CSF cultures among 259 patients whose EVD sites were dressed with sterile semiocclusive dressings and underwent routine sterile dressing exchanges every 48 hours. They analyzed data obtained in an additional 113 patients whose EVD sites were dressed one time with a surgical adhesive, 2-octyl cyanoacrylate.

Results

Ventriculitis rate in patients with standard bioocclusive dressings and wound care was 15.1%, whereas that in patients with a 2-octyl cyanoacrylate dressing was 3.54% (p = 0.002). Staphylococcus genus accounted for 79.5% of instances of ventriculitis among patients with bioocclusive dressings and routine wound care, whereas it accounted for 25.0% of the instances of ventriculitis among patients with a liquid polymer sealant dressing. A 90% reduction in Staphylococcus infection completely accounts for the observed effect (p = 0.04).

Conclusions

The one-time application of 2-octyl cyanoacrylate to EVD wounds and exit sites provided superior protection against EVD-related ventriculitis compared to conventional EVD-site wound care. Likely this protection results from a barrier to the entry of gram-positive skin flora along the EVD exit tract. The results should be validated in a randomized trial.

Monoblock external ventricular drainage system in the treatment of patients with acute hydrocephalus: a pilot study

Background

Infection is a major complication in patients undergoing external ventricular drainage (EVD). Our study aimed to evaluate the incidence of infection in a series with the monoblock EVD system.

Material/Methods

46 patients treated with EVD at our emergency department were analyzed prospectively to research the incidence of infections with a new EVD system.

Results

The average rate of infection was 8.7%. When we stratified the patients according to the exclusive use of EVD without craniotomies, we identified a reduction in the overall incidence of ventriculitis from 8.7% to 2.3%. Age, etiology, and the presence of ventricular bleeding were not statistically significant risk factors.

Conclusions

Despite the small sample examined in this study, we believe that the monoblock system is a simple, inexpensive device that reduces accidental disconnection of the system.

Factors associated with external ventricular drain placement accuracy: data from an electronic health record repository

BACKGROUND

We evaluated external ventricular drain placement for factors associated with placement accuracy. Data were acquired using an electronic health record data requisition tool.

METHOD

Medical records of all patients who underwent ventriculostomy from 2003 to 2010 were identified and evaluated. Patient demographics, diagnosis, type of guidance and number of catheter passes were searched for and recorded. Post-procedural hemorrhage and/or infection were identified. A grading scale was used to classify accuracy of catheter placements. A multiple logistic regression model was developed to assess features associated with accurate catheter placement.

RESULTS

One hundred nine patients who underwent 111 ventriculostomies from 2003 to 2010 were identified. Patient diagnoses were classified into vascular (63 %), tumor (21 %), trauma (14 %), and cyst (2 %). Procedures were performed freehand in 90 (81 %), with the Ghajar guide in 17 (15 %), and with image guidance in 4 (4 %) patients. Eighty-eight (79 %) catheters were placed in the correct location. Trauma patients were more likely to have catheters misplaced (p = 0.007) whereas patients in other diagnostic categories were not significantly associated with misplaced catheters. Post-procedural hemorrhage was noted in 2 (1.8 %) patients on post-procedural imaging studies. Five (4.5 %) definite and 6 (5.4 %) suspected infections were identified.

CONCLUSIONS

External ventricular drain placement can be performed accurately in most patients. Patients with trauma are more likely to have catheters misplaced. Further development is required to identify and evaluate procedure outcomes using an electronic health record repository.