Long-tunneled versus short-tunneled external ventricular drainage: Prospective experience from a developing country

Modified ventriculoperitoneal shunt applied to temporary external ventricular drainage

External ventricular drainage (EVD) is a common procedure in neurosurgical practice. Presently, the three methods used most often include direct EVD (dEVD), long-tunneled external ventricular drains (LTEVDs), and EVD via the Ommaya reservoir (EVDvOR). But they possess drawbacks such as limited duration of retention, vulnerability to iatrogenic secondary infections, and challenges in regulating drainage flow. This study aimed to explore the use of a modified ventriculoperitoneal shunt (mVPS)-the abdominal end of the VPS device was placed externally-as a means of temporary EVD to address the aforementioned limitations. This retrospective cohort study, included 120 cases requiring EVD. dEVD was performed for 31 cases, EVDvOR for 54 cases (including 8 cases with previously performed dEVD), and mVPS for 35 cases (including 6 cases with previously performed EVDvOR). The one-time success rate (no need for further other EVD intervention) for dEVD, EVDvOR, and mVPS were 70.97%, 88.89%, and 91.42%, dEVD vs EVDvOR (P < 0.05), dEVD vs mVPS (P < 0.05), EVDvOR vs mVPS (P > 0.05). Puncture needle displacement or detachment was observed in nearly all cases of EVDvOR, while no such complications have been observed with mVPS. Apart from this complication, the incidence of postoperative complications was 35.48%, 14.81%, and 8.5%, dEVD vs EVDvOR (P < 0.05), dEVD vs mVPS (P < 0.05), EVDvOR vs mVPS (P > 0.05). Mean postoperative retention for EVD was 14.68 ± 9.50 days, 25.96 ± 15.14 days, and 82.43 ± 64.45 days, respectively (P < 0.001). In conclusion, mVPS significantly extends the duration of EVD, which is particularly beneficial for patients requiring long-term EVD.

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.

Effect of External Ventricular Drain Tunnel Length on Cerebrospinal Fluid Infection Rates-A Bayesian Network Meta-Analysis

BACKGROUND

External ventricular drain (EVD)-associated cerebrospinal fluid infection (EACI) remains a major complication associated with EVD. Length of EVD tunnel, an overlooked but modifiable factor, can be associated with increased risk of EACI. The aim of this study is to find the tunnel length associated with least chances of EACI by performing a network meta-analysis.

METHODS

A comprehensive search of different databases was performed to retrieve studies that studied the rates of EACI with different EVD tunnel lengths and a Bayesian network meta-analysis was performed.

RESULTS

Six studies met the inclusion criteria and were included in the network meta-analysis. With 0 cm tunnel length as reference, the odds ratio (OR) for developing EACI was minimum for tunnel length 5-10 cm (OR, 0.027). It was followed by tunnel length of 5 cm (OR, 0.060) and 10 cm (OR, 0.075). The surface under the cumulative ranking curve plot showed that the probability of the tunnel length 5-10 cm (ranked first), 5 cm (ranked second), and 10 cm (ranked third) for being the best EVD tunnel length was found to be 86%, 64%, and 61%, respectively.

CONCLUSIONS

The length for which an EVD is tunneled may have an impact on the rate of EACI. Our network meta-analyses showed that the tunnel length of 5-10 cm was associated with the lowest rates of EACI, with 86% probability of being the best EVD tunnel length. The probability of a patient with 5-10 cm EVD length developing EACI was 2.7% compared with zero tunnel length.

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).

Is External Ventricular Drain Infection Predictable in Neurosurgery Patients? A Following-up Study in Iran

Background: External ventricular drains (EVDs) infection is a life-threatening complication. Objectives: To investigate the rate of EVDs infection and its predictive factors in neurosurgery patients hospitalized at a tertiary teaching hospital in Iran. Methods: In this survey, all patients referred to a subspecialty hospital in Tehran (Iran) with an external ventricular drain (EVDs) from Jun 23, 2018, to Jun 23, 2019, are monitored within 30 days of EVDs placement for infection. Data on demographic information, underlying diseases, number of EVD replacements, length of hospital stay, type consumed antibiotic before neurosurgery, length of tunneling, type of airway, duration of mechanical ventilation, duration of surgery(hours), surgeon name, APACHE II score, length of intensive care unit stay are collected. The diagnosis was based on the Center for Diseases Control and Prevention criteria for meningitis/ventriculitis and clinical vision of infectious or critical care specialists. A logistic regression model was developed to identify factors that can predict the infection. Results: Of 81 patients with EVDs, 39 (48.1%) were infected. The mean age of patients was 44.33 ± 19.5 years, and 55.6% of them were male. According to the multiple logistic regression analysis, mechanical ventilation for more than 6 days (OR: 2.5, 95% CI: 1.6 - 3.56, P = 0.04) and length of tunneling > 5 cm (OR: 1.98, 95%CI: 1.87 - 4.76, P = 0.02) were identified as factors that could predict EVD infection. Also, consuming ceftazidime + vancomycin, as a prophylaxis agent, had a lower odds ratio for EVD infection (OR:0.4, 95% CI: 0.08 - 0.84, P = 0.04). Conclusions: Regarding the predictive factors of EVDs infection, either in the present study or other studies, there should be strategies to manage this life-threatening infection in neurosurgery patients.

Influence of Ward Environments on External Ventricular Drain Infections: A Retrospective Risk Factor Analysis

Background: Ventriculostomy-related infection (VRI) is one of the most severe and common complications of external ventricular drains (EVD). Ward environment is closely related to hospital-acquired infection, but its role in EVD infection is unclear. For some other recognized risk factors, clinical evidence also remains complicated and undetermined. We aimed to evaluate ward environment including multi-bed accommodation and intensive care unit (ICU) stay as potential risk factors for VRI, as well as to confirm those already known factors. Methods: We reviewed EVDs retrospectively in our center between January 2012 and January 2017. Univariable and logistic regression analysis were performed to identify risk factors for EVD-related infection. Results: A total of 284 patients who underwent EVD procedure were included. Thirty-six (12.7%) developed EVD-related infection. Univariable analysis revealed that the infection group had longer intensive care unit (ICU) stay (6.81 vs. 3.65 days, p = 0.045) but multi-bed accommodation showed no statistical difference between the two groups (p = 0.404). Univariable analysis also showed VRI patients had lower pre-operational Glasgow Coma Scale (6.89 vs. 9.32, p = 0.001), longer drainage placement duration (11.4 vs. 8.30 days, p < 0.001), greater numbers of cerebrospinal fluid (CSF) sampling (3.89 vs. 1.73, p < 0.001), higher percentage of pre-operational artificial airway status (50.0% vs. 18.1%, p < 0.001), and higher percentage of intracranial hemorrhage diagnosis (88.9% vs. 73.8%, p = 0.048). Logistic regression analysis demonstrated longer post-operational ICU stay (>5 days, odds ratio [OR] = 3.21, p = 0.026) as independent risk factor for EVD-related infection. Other independent risk factors included CSF sampling counts (>3, OR = 5.14, p <0.001), EVD duration (>7 days, OR = 3.85, p = 0.028), and pre-operational artificial airway status (OR = 2.85, p = 0.038). Conclusions: Longer post-operational ICU stay, frequent CSF sampling, longer duration of EVD placement, and pre-operational intubation are independent risk factors for EVD infection. Multi-bed accommodation and bilateral EVD placement have no substantial influence on VRI risk.

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.

The Aalborg Bolt-Connected Drain (ABCD) study: a prospective comparison of tunnelled and bolt-connected external ventricular drains

BACKGROUND

Acutely increased intracranial pressure (ICP) is frequently managed by external ventricular drainage (EVD). This procedure is life-saving but marred by a high incidence of complications. It has recently been indicated that bolt-connected external ventricular drainage (BC-EVD) compared to the standard technique of tunnelled EVD (T-EVD) may result in less complications.

AIM

To prospectively sample and compare two cohorts by consecutive allocation to either BC-EVD or T-EVD from the introduction of the BC-EVD technique in our department and 12 months onward.

METHODS

Patients undergoing ventriculostomy between the 1st of March 2017 and the 28th of February 2018 were considered for inclusion. The neurosurgeon on-call sovereignly set the indication and decided on EVD type (BC-EVD or T-EVD), consequently resulting in two cohorts as 3/7 senior neurosurgeons on call were open to the use of BC-EVD, while 4/7 were reluctant to use this technique. Data was continuously collected using patient records, including results of cerebrospinal fluid (CSF) culturing and available CT/MRI-scans. Recorded complications included CSF leakage, accidental discontinuation, placement-related intracranial haemorrhage, malfunction, migration, infection and revision.

RESULTS

Forty-nine EVDs (32 T-EVDs/17 BC-EVDs) were included; 19/32 (59.4%) T-EVDs and 3/17 (17.6%) BC-EVDs were found to have complications (p = 0.007). The relative risk of complications when using T-EVD was 3.4 times that of BC-EVD.

CONCLUSION

Ventriculostomy by BC-EVD compared to T-EVD reduces incidence and risk of complications and should be the first choice in EVD placement. That said, T-EVD has a role in paediatric patients and for intraoperatively and occipitally placed EVDs.

Population Pharmacokinetics and Dosing Regimen Optimization of Meropenem in Cerebrospinal Fluid and Plasma in Patients with Meningitis after Neurosurgery

Meropenem is used to manage postneurosurgical meningitis, but its population pharmacokinetics (PPK) in plasma and cerebrospinal fluid (CSF) in this patient group are not well-known. Our aims were to (i) characterize meropenem PPK in plasma and CSF and (ii) recommend favorable dosing regimens in postneurosurgical meningitis patients. Eighty-two patients were enrolled to receive meropenem infusions of 2 g every 8 h (q8h), 1 g q8h, or 1 g q6h for at least 3 days. Serial blood and CSF samples were collected, and concentrations were determined and analyzed via population modeling. Probabilities of target attainment (PTA) were predicted via Monte Carlo simulations, using the target of unbound meropenem concentrations above the MICs for at least 40% of dosing intervals in plasma and at least of 50% or 100% of dosing intervals in CSF. A two-compartment model plus another CSF compartment best described the data. The central, intercentral/peripheral, and intercentral/CSF compartment clearances were 22.2 liters/h, 1.79 liters/h, and 0.01 liter/h, respectively. Distribution volumes of the central and peripheral compartments were 17.9 liters and 3.84 liters, respectively. The CSF compartment volume was fixed at 0.13 liter, with its clearance calculated by the observed drainage amount. The multiplier for the transfer from the central to the CSF compartment was 0.172. Simulation results show that the PTAs increase as infusion is prolonged and as the daily CSF drainage volume decreases. A 4-hour infusion of 2 g q8h with CSF drainage of less than 150 ml/day, which provides a PTA of >90% for MICs of ≤8 mg/liter in blood and of ≤0.5 mg/liter or 0.25 mg/liter in CSF, is recommended. (This study has been registered at ClinicalTrials.gov under identifier NCT02506686.)