The burden and risk factors of ventriculostomy occlusion in a high-volume cerebrovascular practice: results of an ongoing prospective database

An International, Multicenter Feasibility Study on Active and Continuous Irrigation With Cerebrospinal Fluid Exchange for Improving Outcomes in Cerebral Ventriculitis

BACKGROUND AND OBJECTIVES

Cerebral ventriculitis remains a challenging neurosurgical condition because of poor outcomes including mortality rates of nearly 80% and a prolonged course of treatment in survivors. Despite current conventional management, outcomes in some cases remain unsatisfactory, with no definitive therapeutic guidelines. This feasibility study aims to explore the use of a novel active, continuous irrigation and drainage system (IRRAflow [IRRAS AB]) combined with intraventricular drug delivery for patients with cerebral ventriculitis.

METHODS

We conducted a multicenter, international, retrospective study of patients with ventriculitis who were treated with use of the IRRAflow system. Data collected included patient demographics, comorbidities, admission Glasgow Coma Scale score, baseline modified Rankin Scale (mRS) score, and imaging findings. Catheter occlusions, infections, and shunt placement were recorded for outcome assessment, along with discharge mRS scores and in-hospital deaths.

RESULTS

Four centers contributed data for a total of 21 patients who had IRRAflow placement for treatment of ventriculitis. Thirteen (61.9%) were men (mean age = 49.8 ± 14.87 years). The median baseline mRS score was 1. The median Glasgow Coma Scale score at admission was 13. The etiology of ventriculitis was iatrogenic in 12 (57.1%) patients and secondary to an abscess in 9 (42.9%). No cases reported hemorrhage or failure of IRRAflow placement. Antibiotics were administered through the IRRAflow system in 13 (61.9%) cases in addition to systemic dosing. Sixteen (76.2%) patients had significant clinical improvement and resolution of ventriculitis. Seven (33.3%) patients required shunt placement after resolution because of persistent hydrocephalus. There were 6 (28.6%) in-hospital deaths.

CONCLUSION

The use of active irrigation with drainage for continuous delivery of intraventricular irrigation fluid with antibiotics led to dramatically low mortality. In our case series, it led to a marked improvement in neurological status, imaging findings, and cerebrospinal fluid profiles, making it a technically feasible and safe treatment for ventriculitis.

Descriptive registry study on outcome and complications of external ventricular drainage treatment of intraventricular haemorrhage in a Danish cohort: a study protocol

INTRODUCTION

Intraventricular haemorrhage (IVH) is associated with high morbidity and mortality. External ventricular drainage (EVD) has been shown to decrease mortality. Although EVD is widely used, outcome and complication rates in EVD-treated patients with IVH are not fully elucidated. This study aims to describe EVD complication rates and outcomes in patients with primary and secondary IVH at two university hospitals in Denmark. The study will provide a historical reference of relevant endpoints for use in future clinical trials involving patients with IVH.

METHODS AND ANALYSIS

This descriptive, multicentre registry study included adult patients (age 18+) with primary or secondary IVH and treated with at least one EVD between 2017 and 2021 at Aarhus University Hospital or Odense University Hospital. Patients are identified using the Danish National Patient Register. Data are collected and recorded from patient medical records. Relevant descriptive statistics and correlation analyses will be applied.

ETHICS AND DISSEMINATION

Ethical approval and authorisation to access, store and analyse data have been obtained (Central Denmark Region Committee on Health Research Ethics). The research lead will present the results of the study. Data will be reported according to the Strengthening the Reporting of Observational Studies in Epidemiology and results submitted for publication in peer-reviewed journals.

Treatment of cerebral ventriculitis with a new self-irrigating catheter system: narrative review and case series

Cerebral ventriculitis is a life-threatening condition that requires prompt and effective pharmacological intervention. The continuous irrigation of the cerebral ventricles with fluid and its drainage is a system to remove toxic substances and infectious residues in the ventricles; this system is called IRRAflow®. We used this kind of ventricular irrigation/drainage system to treat two patients with post-surgical cerebral ventriculitis and a patient with bacterial meningitis complicated with ventriculitis. In this case series, we discuss the management of these three cases of cerebral ventriculitis: we monitored cytochemical parameters and cultures of the cerebrospinal fluid of patients during their ICU stay and we observed a marked improvement after irrigation and drainage with IRRAflow® system. Irrigation/drainage catheter stay, mode settings, and antibiotic therapies were different among these three patients, and neurological outcomes were variable, according to their underlying pathologies. IRRAflow® system can be applied also in other types of brain injury, such as intraventricular hemorrhage, intracranial abscess, subdural hematomas, and intracerebral hemorrhage, with the aim to remove the hematic residues and enhance the functional recovery of the patients. IRRAflow® seems a promising and useful tool to treat infectious and hemorrhagic diseases in neuro-intensive care unit.

Tunneled antibiotic-impregnated vs. bolt-connected, non-coated external ventricular drainage: a comparison of complications

Background

External ventricular drainage (EVD) is a common emergency neurosurgical procedure, but it is not free of adverse events. The aim of this study is to compare the complication rate of two frequently used EVD types, namely, tunneled antibiotic-impregnated catheters (Bactiseal©) and bolt-connected non-coated devices (Camino©).

Methods

All EVDs placed between 1 March 2015 and 31 December 2017 were registered. Procedures performed with any catheter different from Bactiseal© or Camino© EVD with incomplete follow-up and those EVDs placed due to infectious disease were excluded. Demographic and clinical variables, as well as the overall complication rate (infection, hemorrhage, obstruction, malposition of the catheter, and involuntary pull-out of the device) and the need for replacement of the EVD, were collected.

Results

A total of 77 EVDs were finally considered for analysis (40 Bactiseal® and 37 Camino®). There was a statistically significant difference in diagnosis and also in the location of the procedure, as more bolt-connected EVD was placed outside the operating room (97.3 vs. 23.5%, p < 0.001) due to emergent pathologies such as vascular diseases and spontaneous hemorrhages. In the univariate analysis, a statistically significantly higher rate of catheter involuntary pull-out (29.7 vs. 7.5%, p = 0.012) and the need for EVD replacement (32.4 vs. 12.5%, p = 0.035) was found in the Camino cohort. However, those differences could not be confirmed with multivariable analysis, which showed no association between the type of catheter and any of the studied complications. Ventriculostomy duration was identified as a risk factor for infection (OR 1.09, 95% CI 1.02-1.18).

Conclusion

No significant differences were observed regarding infection, hemorrhage, obstruction, malposition, involuntary catheter pull-out, and the need for EVD replacement when comparing non-impregnated bolt-connected EVDs (Camino®) with tunneled antibiotic-impregnated catheters (Bactiseal®). The duration of EVD was associated with an increased risk of infection.

Chronic subdural hematoma drainage using anti-thrombotic catheter technique

Background

Burr hole evacuation is a well-established treatment for symptomatic cases with chronic subdural hematoma (cSDH). Routinely postoperative catheter is left in the subdural space to drain the residual blood. Drainage obstruction is commonly seen, and it can be related to suboptimal treatment.

Methods

Two groups of patients submitted to cSDH surgery were evaluated in a retrospective non-randomized trial, one group that had conventional subdural drainage (CD group, n ​= ​20) and another group that used an anti-thrombotic catheter (AT group, n ​= ​14). We compared the obstruction rate, amount of drainage and complications. Statistical analyses were done using SPSS (v.28.0).

Results

For AT and CD groups respectively (median ​± ​IQR), the age was 68.23 ​± ​26.0 and 70.94 ​± ​21.5 (p ​> ​0.05); preoperative hematoma width was 18.3 ​± ​11.0 ​mm and 20.7 ​± ​11.7 ​mm and midline shift was 13.0 ​± ​9.2 and 5.2 ​± ​8.0 ​mm (p ​= ​0.49). Postoperative hematoma width was 12.7 ​± ​9.2 ​mm and 10.8 ​± ​9.0 ​mm (p ​< ​0.001 intra-groups compared to preoperative) and MLS was 5.2 ​± ​8.0 ​mm and 1.5 ​± ​4.3 ​mm (p ​< ​0.05 intra-groups). There were no complications related to the procedure including infection, bleed worsening and edema. No proximal obstruction was observed on the AT, but 8/20 (40%) presented proximal obstruction on the CD group (p ​= ​0.006). Daily drainage rates and length of drainage were higher in AT compared to CD: 4.0 ​± ​1.25 days vs. 3.0 ​± ​1.0 days (p ​< ​0.001) and 69.86 ​± ​106.54 vs. 35.00 ​± ​59.67 ​mL/day (p ​= ​0.074). Symptomatic recurrence demanding surgery occurred in two patients of CD group (10%) and none in AT group (p ​= ​0.230), after adjusting for MMA embolization, there was still no difference between groups (p ​= ​0.121).

Conclusion

The anti-thrombotic catheter for cSDH drainage presented significant less proximal obstruction than the conventional one and higher daily drainage rates. Both methods demonstrated to safe and effective for draining cSDH.

External ventricular drains and risk of freehand placement: A systematic review and meta-analysis

OBJECTIVE

External ventricular drains (EVDs) are used to monitor and treat elevated intracranial pressure. EVDs are often placed blindly without the use of imaging guidance, and successful placement with respect to pass attempts and final catheter location may suffer as a result of this freehand technique.

METHODS

A systematic literature search was conducted in PubMed, Embase, Web of Science, and Cochrane databases to identify studies pertaining to freehand EVD placement through March 30, 2022. Studies were included if they reported percentage of EVDs placed successfully on the first pass attempt, or final catheter location as defined by the Kakarla Grading System. Pooled weighted incidence estimates and 95% confidence intervals (95%CI) were calculated using a random effects model.

RESULTS

Of the 2964 results returned from the literature search, 39 studies were included in this meta-analysis. These studies reported on 6313 EVDs placed via freehand technique in 6070 patients with the following respective incidence: successful EVD placement on the first attempt (78%, 95%CI: 67-86%); placement with a Kakarla Grade of 1 (optimal location) (72%, 95%CI: 66-77%); hemorrhage (7%, 95%CI: 6-10%), and infection (5%, 95%CI: 3-8%).

CONCLUSIONS

Only 78% of EVDs in this meta-analysis were placed successfully on the first pass, and only 72% of final placements were deemed optimal. This represents a relatively high rate of suboptimal outcomes with respect to EVD placement, which could potentially be avoided with the use of navigation-assisted placement techniques.

Use of Novel Automated Active Irrigation With Drainage Versus Passive Drainage Alone for Chronic Subdural Hematoma-A Propensity Score-Matched Comparative Study With Volumetric Analysis

BACKGROUND

Passive drainage post-surgical evacuation of symptomatic chronic subdural hematoma (cSDH) is currently standard of care. High rates of infection, drain occlusion, and recurrence are associated complications.

OBJECTIVE

To explore the use of a novel double-lumen active automated irrigation and aspiration system, IRRAflow (IRRAS), for patients with cSDH and compared procedural and clinical outcomes against passive drainage alone with propensity score matching (PSM) and volumetric analysis.

METHODS

A prospectively maintained database was retrospectively searched for consecutive patients presenting with cSDH. One-to-one PSM of covariates (including baseline comorbidities and presentation hematoma volume) in active and passive irrigation groups was performed to adjust for treatment selection bias. Rates of hematoma clearance, catheter-related occlusion, and infection; number of revisions; and length of hospital stay were recorded.

RESULTS

This study included 55 patients: active continuous irrigation-drainage-21 (21 post-PSM) and passive drainage-34 (21 post-PSM). For PSM groups, a significantly higher rate of hematoma clearance was obtained in the active irrigation-drainage group (0.5 ± 0.4 vs 0.4 ± 0.5 mL/day) and in the passive drainage group; odds ratio (OR) = 1.291 (CI: 1.062-1.570, P = .002) and a significantly lower rate of catheter-related infections (OR = 0.051; CI: 0.004-0.697, P = .039). A nonsignificantly lower hematoma expansion rate at discharge was noted in the active irrigation-drainage group (4.8% vs 23.8%; OR = 0.127; P = .186). No statistical difference in all-cause in-hospital mortality or discharge Glasgow Coma Scale score was observed between groups.

CONCLUSION

Active and automated continuous irrigation plus drainage after cSDH surgical evacuation resulted in faster hematoma clearance and led to favorable clinical outcomes and low complication and revision rates compared with passive irrigation.

Thermal and Postural Effects on Fluid Mixing and Irrigation Patterns for Intraventricular Hemorrhage Treatment

Intraventricular hemorrhage is characterized by blood leaking into the cerebral ventricles and mixing with cerebrospinal fluid. A standard treatment method involves inserting a passive drainage catheter, known as an external ventricular drain (EVD), into the ventricle. EVDs have common adverse complications, including the occlusion of the catheter, that may lead to permanent neural damage or even mortality. In order to prevent such complications, a novel dual-lumen catheter (IRRAflow®) utilizing an active fluid exchange mechanism has been recently developed. However, the fluid dynamics of the exchange system have not been investigated. In this study, convective flow in a three-dimensional cerebral lateral ventricle with an inserted catheter is evaluated using an in-house lattice-Boltzmann-based fluid-solid interaction solver. Different treatment conditions are simulated, including injection temperature and patient position. Thermal and gravitational effects on medication distribution are studied using a dye simulator based on a recently-introduced (pseudo)spectral convection-diffusion equation solver. The effects of injection temperature and patient position on catheter performance are presented and discussed in terms of hematoma irrigation, vortical structures, mixing, and medication volume distribution. Results suggest that cold-temperature injections can increase catheter efficacy in terms of dye distribution and irrigation potential, both of which can be further guided by patient positioning.

Study protocol for ACTIVE study: safety and feasibility evaluation of external ventricular drainage with ACTIVE fluid exchange in intraventricular hemorrhage-a phase 2, multi-center, randomized controlled trial

BACKGROUND

Primary intraventricular hemorrhage (IVH) or IVH secondary to intracerebral (ICH) and subarachnoid hemorrhage (SAH) are known to have a very poor prognosis, with an expected mortality between 50 and 80% (Hinson et al. Current Neurology and Neuroscience Reports 10:73-82, 2010). Clearance of IVH might improve patient outcome.

METHODS

The study is designed as an investigator-initiated, comparative, prospective, multi-center, 1:1 randomized phase 2 trial evaluating the efficacy and safety of active irrigation in external ventricular drainage (intervention arm-IRRAflow) compared to passive external ventricular drainage (control arm-EVD). The trial will enroll 58 patients with primary or secondary IVH. Major eligibility criteria include age ≥18 years of age, IVH documented on head CT or MRI scan (Graeb score ≥3), need of cerebrospinal fluid drainage, deterioration of consciousness or medical sedation at the time of enrollment, and indication for active treatment evaluated by the treating physicians. Exclusion criteria included patients with fixed and dilated pupils and pregnant or nursing women. The primary endpoint of the study is catheter occlusion evaluated by time to first observed occlusion from VC placement. Secondary endpoints include clearance of ventricular blood as measured by head CT scan, rates of catheter-related infection and shunt dependency, length of intensive care unit stay, functional status-Extended Glascow Outcome Scale (eGOS) and modified Rankin scale (mRS) at discharge to rehabilitation and 90 days-and mortality rates at 30 days and 90 days.

DISCUSSION

With no standardized treatment for IVH and a poor prognosis, new treatments are needed. IVH patients often need CSF drainage to treat hydrocephalus and to decrease ICP. Standard treatment with passive external ventricular drainage is related to an increased risk of infections which is found in up to 22% of treated cases. The passive VC is known to have a risk of occlusion and is seen in 19-47% of the cases. We hypothesize that the use of active fluid change using the IRRAflow system will be safe and feasible and will reduce the occlusion and infection rates in patients with IVH.

TRIAL REGISTRATION

ClicalTrials.gov NCT05204849. Registered 15 December 2021. Updated 24 January 2022.

The application of augmented reality-based navigation for accurate target acquisition of deep brain sites: advances in neurosurgical guidance

OBJECTIVE

The objective of this study is to quantify the navigational accuracy of an advanced augmented reality (AR)-based guidance system for neurological surgery, biopsy, and/or other minimally invasive neurological surgical procedures.

METHODS

Five burr holes were drilled through a plastic cranium, and 5 optical fiducials (AprilTags) printed with CT-visible ink were placed on the frontal, temporal, and parietal bones of a human skull model. Three 0.5-mm-diameter targets were mounted in the interior of the skull on nylon posts near the level of the tentorium cerebelli and the pituitary fossa. The skull was filled with ballistic gelatin to simulate brain tissue. A CT scan was taken and virtual needle tracts were annotated on the preoperative 3D workstation for the combination of 3 targets and 5 access holes (15 target tracts). The resulting annotated study was uploaded to and launched by VisAR software operating on the HoloLens 2 holographic visor by viewing an encrypted, printed QR code assigned to the study by the preoperative workstation. The DICOM images were converted to 3D holograms and registered to the skull by alignment of the holographic fiducials with the AprilTags attached to the skull. Five volunteers, familiar with the VisAR, used the software/visor combination to navigate an 18-gauge needle/trocar through the series of burr holes to the target, resulting in 70 data points (15 for 4 users and 10 for 1 user). After each attempt the needle was left in the skull, supported by the ballistic gelatin, and a high-resolution CT was taken. Radial error and angle of error were determined using vector coordinates. Summary statistics were calculated individually and collectively.

RESULTS

The combined angle of error of was 2.30° ± 1.28°. The mean radial error for users was 3.62 ± 1.71 mm. The mean target depth was 85.41 mm.

CONCLUSIONS

The mean radial error and angle of error with the associated variance measures demonstrates that VisAR navigation may have utility for guiding a small needle to neural lesions, or targets within an accuracy of 3.62 mm. These values are sufficiently accurate for the navigation of many neurological procedures such as ventriculostomy.

Factors which influence the complications of external ventricular cerebrospinal fluid drainage

BACKGROUND

External ventricular drainage (EVD) is one of the most common neurosurgical procedures in emergencies. This study aims to find out which factors influence the occurrence of EVD-related complications in a comparative investigation of metal needles and polyurethane catheters. This is the first clinical study comparing these two systems.

METHODS

Adult patients undergoing pre-coronal EVD placement via freehand burr hole trepanation were included in this prospective study. The exclusion criteria were the open EVD insertion and/or a pre-existing infectious disease of the central nervous system.

RESULTS

Two hundred consecutive patients were enrolled. Of these, 100 patients were treated by using metal EVD (group 1) and 100 patients with polyurethane catheters (group 2). The overall complication rate was 26% (misplacement 13.5%, hemorrhage 12.5%, infection 2.5%, and dislocation 1%) without statistically significant differences between both groups. Generalized brain edema and midline shift had a significant influence on misplacements (generalized brain edema: p = 0.0002, Cramer-V: 0.307, OR = 7.364, 95% CI: 2.691-20.148; all patients: p = 0.001, Cramer-V: 0.48, OR = 43.5, 95% CI: 4.327-437.295; group 1: p = 0.047, Cramer-V: 0.216, OR = 3.75, 95% CI: 1.064-13.221; group 2: midline shift: p = 0.038, Cramer-V: 0.195, OR = 3.626, 95% CI: 1.389-9.464) all patients: p = 0.053, Cramer-V: 0.231, OR = 5.533, 95% CI 1.131-27.081; group 1: p = 0.138, Cramer-V: 0.168, OR = 2.769, 95% CI: 0.813-9.429 group 2. Hemorrhages were associated with the use of oral anticoagulants or antiplatelet therapy (p = 0.002; Cramer-V: 0.220, OR = 3.798, 95% CI: 1.572-9.175) with a statistically similar influence in both groups.

CONCLUSION

Generalized brain edema has a significant influence on misplacements in both groups. Midline shift lost its significance when considering only the patients in group 2. Patients under oral anticoagulation and antiplatelet therapy have increased odds of EVD-associated hemorrhage. Metal needles and polyurethane catheters are equivalent in terms of patient safety when there are no midline shift and generalized brain edema.

Development and validation of a rapidly deployable CT-guided stereotactic system for external ventricular drainage: preclinical study

External ventricular drainage (EVD) is an emergency neurosurgical procedure to decrease intracranial pressure through a catheter mediated drainage of cerebrospinal fluid. Most EVD catheters are placed using free hands without direct visualization of the target and catheter trajectory, leading to a high rate of complications- hemorrhage, brain injury and suboptimal catheter placement. Use of stereotactic systems can prevent these complications. However, they have found limited application for this procedure due to their long set-up time and expensive hardware. Therefore, we have developed and pre-clinically validated a novel 3D printed stereotactic system for rapid and accurate implantation of EVD catheters. Its mechanical and imaging accuracies were found to be at par with clinical stereotactic systems. Preclinical trial in human cadaver specimens revealed improved targeting accuracy achieved within an acceptable time frame compared to the free hand technique. CT angiography emulated using cadaver specimen with radio-opaque vascular contrast showed vessel free catheter trajectory. This could potentially translate to reduced hemorrhage rate. Thus, our 3D printed stereotactic system offers the potential to improve the accuracy and safety of EVD catheter placement for patients without significantly increasing the procedure time.

External ventricular drain management in subarachnoid haemorrhage: a systematic review and meta-analysis

External ventricular drainage (EVD) is one of the most commonly performed neurosurgical procedures. Despite this, the optimal drainage and weaning strategies are still unknown. This PRISMA-compliant systematic review and meta-analysis analysed the outcomes of patients undergoing EVD procedures, comparing continuous versus intermittent drainage and rapid versus gradual weaning. Four databases were searched from inception to 01/10/2020. Articles reporting at least 10 patients treated for hydrocephalus secondary to subarachnoid haemorrhage were included. Other inclusion criteria were the description of the EVD drainage and weaning strategies used and a comparison of continuous versus intermittent drainage or rapid versus gradual weaning within the study. Random effect meta-analyses were used to compare functional outcomes, incidence of complications and hospital length of stay. Intermittent external CSF drainage was associated with lower incidence of EVD-related infections (RR = 0.20, 95% CI 0.05-0.72, I-squared = 0%) and EVD blockages compared to continuous CSF drainage (RR = 0.45, 95% CI 0.27-0.74, I-squared = 0%). There was no clear advantage in using gradual EVD weaning strategies compared to rapid EVD weaning; however, patients who underwent rapid EVD weaning had a shorter hospital length of stay (SMD = 0.34, 95% CI 0.22-0.47, I-squared = 0%). Intermittent external CSF drainage after SAH is associated with lower incidence of EVD-related infections and EVD blockages compared to continuous CSF drainage. Patients who underwent rapid EVD weaning had a shorter hospital length of stay and there was no clear clinical advantage in using gradual weaning.

Use of emerging technologies to enhance the treatment paradigm for spontaneous intraventricular hemorrhage

The presence of intraventricular hemorrhage (IVH) portends a worse prognosis in patients presenting with spontaneous intracerebral hemorrhage (ICH). Intraventricular hemorrhage increases the rates of hydrocephalus, ventriculitis, and long-term shunt dependence. Over the past decade, novel medical devices and protocols have emerged to directly treat IVH. Presently, we review new technological adaptations to treating intraventricular hemorrhage in an effort to focus further innovation in treating this morbid neurosurgical pathology. We summarize current and historical treatments as well as innovations in IVH including novel procedural techniques, use of the Integra Surgiscope, use of the Artemis evacuator, use of BrainPath, novel catheter technology, large bore external ventricular drains, the IRRAflow, the CerebroFlo, and the future directions of the field. Technology and medical devices for both surgical and nonsurgical methods are advancing the treatment of IVH. With many promising new technologies on the horizon, prospects for improved clinical care for IVH and its etiologies remain hopeful.

Drainage, Irrigation, and Fibrinolytic Therapy (DRIFT) for Adult Intraventricular Hemorrhage Using IRRAflow® Self-Irrigating Catheter

Intraventricular hemorrhage (IVH) is a devastating neurosurgical condition associated with high rates of morbidity and mortality. It can occur as the result of several pathologies and typically presents with mental status changes, neurologic deficits, seizures, headaches, and decreased Glasgow Coma Scale score. These patients are often treated with placement of an external ventricular drain, which helps decrease the clot burden; however, they commonly clot off leading to multiple exchanges. We present a case in which drainage, irrigation, and fibrinolytic (DRIFT) therapy using IRRAflow® (IRRAS) irrigating catheter was used to treat a patient with severe IVH secondary to aneurysmal subarachnoid hemorrhage.

Determinants of accuracy of freehand external ventricular drain placement by neurosurgical trainees

BACKGROUND

The external ventricular drain (EVD) placement is one of the most common neurosurgical procedures. This operation is performed by freehand technique in the majority of cases; therefore, the operator's experience plays an important role in success and possible morbidity of this procedure.

OBJECTIVE

To evaluate the accuracy and safety of EVD placement by junior neurosurgery residents and factors predicting accuracy of EVD placement.

METHODS

This is a prospective cohort study conducted at our academic medical center, between September 2017 and August 2018. All patients 18 years or older who required EVD placement were included. The accuracy and complications of EVD placement were assessed in the first and second year resident cohorts as well as by their level of experience, using descriptive statistics. Univariate and multivariate models were used to assess predictive factors for optimal EVD.

RESULTS

A total of 100 EVDs were placed in 100 patients during the study period. According to Kakarla classification, the catheter was optimally placed in 80% of cases. The first year residents had a significantly higher rate of suboptimal burr hole placement compared to the second year residents (66.7% versus 27.1%, p = 0.004). The trainees with less than 10 EVD placement experience also had a significantly higher rate of suboptimal burr hole placement (55.2% vs. 23.9%, p = 0.003), significantly longer duration of operation (43.1 min ± 14.9SD vs 34.2 min ± 9.6 p = 0.005), and significantly lower rate of optimal EVD location (85.9% versus 65.5%, p = 0.023). Optimal location of the burr hole was the only significant predictor of optimal EVD placement in multivariate analysis (OR 11.9, 95% CI 3.2-44.6, p < 0.001).

CONCLUSIONS

Neurosurgery residents experience and optimal burr hole placement are the main predicators of accurate EVD placement.

Complications of external cerebrospinal fluid drainage in aneurysmal subarachnoid haemorrhage

Background

The need for external cerebrospinal fluid (CSF) drains in aneurysmal subarachnoid haemorrhage (aSAH) patients is common and might lead to additional complications.

Objective

A relation between the presence of an external CSF drain and complication risk is investigated.

Methods

A prospective complication registry was analysed retrospectively. We included all adult aSAH patients admitted to our academic hospital between January 2016 and January 2018, treated with an external CSF drain. Demographic data, type of external drain used, the severity of the aSAH and complications, up to 30 days after drain placement, were registered. Complications were divided into (1) complications with a direct relation to the external CSF drain and (2) complications that could not be directly related to the use of an external CSF drain referred to as medical complications

Results

One hundred and forty drains were implanted in 100 aSAH patients. In total, 112 complications occurred in 59 patients. Thirty-six complications were drain related and 76 were medical complications. The most common complication was infection (n = 34). Drain dislodgement occurred 16 times, followed by meningitis (n = 11) and occlusion (n = 9). A Poisson model showed that the mean number of complications raised by 2.9% for each additional day of drainage (95% CI: 0.6–5.3% p = 0.01).

Conclusion

Complications are common in patients with aneurysmal subarachnoid haemorrhage of which 32% are drain-related. A correlation is present between drainage period and the number of complications. Therefore, reducing drainage period could be a target for further improvement of care.

Minimally Invasive Approach to Subdural Hematoma Treatment Using IRRAflow Catheter and Middle Meningeal Artery Embolization

Chronic subdural hematoma (cSDH) is a common neurosurgical pathology that usually occurs in the seventh decade of life. Patients can present with mental status changes, focal neurologic deficits, seizures, headaches, or may be asymptomatic. Recurrence is common. In order to address this problem with the treatment of cSDH, many studies exist that compare the effectiveness of various treatment modalities. Two recently developed treatment options of cSDH include middle meningeal artery (MMA) embolization and use of self-irrigating catheter systems. To our knowledge there have been no reported cases of combining the use of these new treatments. What follows is a case report of a 72-year-old patient with recurrent cSDH following MMA embolization who underwent minimally invasive surgical drainage of his hematoma using an IRRAflow catheter (IRRAS, San Diego, CA, USA).

Accuracy and complication rates of external ventricular drain placement with twist drill and bolt system versus standard trephine and tunnelation: a retrospective population-based study

Background

An external ventricular drain (EVD) is typically indicated in the presence of hydrocephalus and increased intracranial pressure (ICP). Procedural challenges have prompted the development of different methods to improve accuracy, safety, and logistics.

Objectives

EVD placement and complications rates were compared using two surgical techniques; the standard method (using a 14-mm trephine burrhole with the EVD tunnelated through the skin) was compared to a less invasive method (EVD placed through a 2.7–3.3-mm twist drill burrhole and fixed to the bone with a bolt system).

Methods

Retrospective observational study in a single-centre setting between 2008 and 2018. EVD placement was assessed using the Kakarla scoring system. We registered postoperative complications, surgery duration and number of attempts to place the EVD.

Results

Two hundred seventy-two patients received an EVD (61 bolt EVDs, 211 standard EVDs) in the study period. Significant differences between the bolt system and the standard method were observed in terms of revision surgeries (8.2% vs. 21.5%, p = 0.020), surgery duration (mean 16.5 vs. 28.8 min, 95% CI 7.64, 16.8, p < 0.001) and number of attempts to successfully place the first EVD (mean 1.72 ± 1.2 vs. 1.32 ± 0.8, p = 0.017). There were no differences in accuracy of placement or complication rates.

Conclusions

The two methods show similar accuracy and postoperative complication rates. Observed differences in both need for revisions and surgery duration favoured the bolt group. Slightly, more attempts were needed to place the initial EVD in the bolt group, perhaps reflecting lower flexibility for angle correction with a twist drill approach.

The Evolution of the Role of External Ventricular Drainage in Traumatic Brain Injury

External ventricular drains (EVDs) are commonly used in neurosurgery in different conditions but frequently in the management of traumatic brain injury (TBI) to monitor and/or control intracranial pressure (ICP) by diverting cerebrospinal fluid (CSF). Their clinical effectiveness, when used as a therapeutic ICP-lowering procedure in contemporary practice, remains unclear. No consensus has been reached regarding the drainage strategy and optimal timing of insertion. We review the literature on EVDs in the setting of TBI, discussing its clinical indications, surgical technique, complications, clinical outcomes, and economic considerations.

Intracerebral Hemorrhage

PURPOSE OF REVIEW

This article describes the advances in the management of spontaneous intracerebral hemorrhage in adults.

RECENT FINDINGS

Therapeutic intervention in intracerebral hemorrhage has continued to focus on arresting hemorrhage expansion, with large randomized controlled trials addressing the effectiveness of rapidly lowering blood pressure, hemostatic therapy with platelet transfusion, and other clotting complexes and clot volume reduction both of intraventricular and parenchymal hematomas using minimally invasive techniques. Smaller studies targeting perihematomal edema and inflammation may also show promise.

SUMMARY

The management of spontaneous intracerebral hemorrhage, long relegated to the management and prevention of complications, is undergoing a recent evolution in large part owing to stereotactically guided clot evacuation techniques that have been shown to be safe and that may potentially improve outcomes.

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.

Small versus Large Catheters for Ventriculostomy in the Management of Intraventricular Hemorrhage

OBJECTIVE

Intraventricular hemorrhage (IVH) often requires the insertion of an external ventricular drain (EVD), but blood clots could occlude the catheters. Large EVD catheters may help to reduce the risk of catheter occlusion. Here, we compared small catheters with large catheters for ventriculostomy in patients suffering from IVH.

METHODS

We conducted a retrospective cohort study. Patients were included if they had IVH requiring EVD insertion. We then compared baseline characteristics and outcomes of patients treated with large catheters with patients treated with small catheters.

RESULTS

Between 2011 and 2015, 227 IVH patients were admitted to our 2 hospitals. Among the patients, 28 were treated in first intention with large catheters, and 46 controls were identified. Insertion of large catheter decreased the risk of temporary and permanent catheter occlusion without impact on the occurrence of intracerebral hemorrhage (ICH) related to catheter insertion. There was 38.5% more catheter-related infections in the small catheter group when compared with the large catheter group, but this result was not significant. There was no impact on functional outcomes. Surprisingly, the rate of death was higher in the large catheter group.

CONCLUSIONS

In patients suffering from IVH, the use of large catheters for EVD reduced the risk of catheter occlusion without increasing the risk of ICH related to catheter insertion. The risk of catheter-related infection may subsequently be decreased by using large catheters. A prospective randomized trial would be necessary to seek out any benefits that large catheters may provide for the risk of death and functional outcome.