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External ventricular drainage following aneurysmal subarachnoid

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Article  in  British Journal of Neurosurgery · December 2010

DOI: 10.3109/02688697.2010.505989 · Source: PubMed

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 British Journal of Neurosurgery, December 2010; 24(6): 625–632

INVITED REVIEW

External ventricular drainage following aneurysmal subarachnoid

haemorrhage

PAUL GIGANTE, BRIAN Y. HWANG, GEOFFREY APPELBOOM,

CHRISTOPHER P. KELLNER, MICHAEL A. KELLNER & E. SANDER CONNOLLY

College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, USA
Br J Neurosurg Downloaded from informahealthcare.com by Columbia University on 12/15/10

Abstract
External ventricular drain (EVD) placement is standard of care in the management of aneurysmal subarachnoid
haemorrhage-associated hydrocephalus (aSAH). However, there are no guidelines for EVD placement and management after
aSAH. Optimal EVD insertion conditions, techniques to reduce the risk of EVD-associated infection and aneurysmal
rebleeding, and methods of EVD removal are critical, yet incompletely answered management variables. The present
literature consists primarily of small studies with heterogeneous populations and variable outcome measures, and suggests
the following: EVDs may increase the risk of rebleeding; EVDs are increasingly placed by non-neurosurgeons with unclear
results; intraparenchymal ICP monitors may be safely considered (with or without spinal drainage) in the setting of difficult
EVD placement; the optimal timing and manner of EVD removal has yet to be defined; and the efficacy of prophylactic
systemic antibiotics and antibiotic-coated EVDs needs further investigation. Nevertheless, there are no definitive practice
guidelines for EVD placement and management techniques in aSAH patients. Large prospective randomised trials are
For personal use only.

needed to definitively address important gaps in our understanding of EVD management principles in the neurocritical care
setting.

Key words: Aneurysmal subarachnoid haemorrhage, cerebrospinal fluid drainage, hydrocephalus, ICP measurements,
infection.

pathophysiology of EVD-associated complications

Introduction
In 1973, Kusske et al. reported one of the earliest uses
of an external ventricular drain (EVD) in treating
aneurysmal subarachnoid haemorrhage (SAH)-related
hydrocephalus and demonstrated significantly im-
proved outcome.1 Since then, EVDs have become
the standard approach in treating SAH-associated
hydrocephalus.2 EVDs provide an accurate, reliable
and expeditious way to monitor and control intracra-
nial pressure (ICP).3 ICP management with an EVD
can prevent secondary cortical damage, improve
neurological status and facilitate operative exposure
during aneurysm surgery.4,5 EVDs can also be used to
evaluate for permanent shunt placement and to
introduce intraventricular pharmaceutical agents.1
The use of EVDs following aneurysmal subarachnoid
haemorrhage-associated hydrocephalus (aSAH), how-
ever, has been reportedly associated with increased risk
of re-haemorrhage,6,7 infection8 and shunt-depen-
dency.9 Incomplete understanding of Cerebrospinal
fluid (CSF) dynamics and the natural history and
may contribute to variations in clinical practice. Here,
we review present day literature to guide EVD
placement and management techniques in the critical
care setting.
External ventricular drain placement
Indications for EVD placement
Ventriculomegaly in the setting of Glasgow Coma
Scale (GCS) 12,6 Hunt-Hess grade 2,10 Hunt-
Hess grade 311 or inability to follow commands
have been used as thresholds for strong consideration
of EVD placement.5 Some authors recommend
routine EVD placement in all patients,1 while others
monitor and treat only those who demonstrate
clinical or radiologic deterioration, or have an
unreliable neurologic exam.7,10,12 Indications for an
EVD are less clear in patients who are asymptomatic
or have fluctuating level of consciousness.

Correspondence: Paul Gigante, MD, Columbia University, College of Physicians and Surgeons, Neurological Institute of New York, 710 West, 168th Street,
New York, NY 10032, USA. Tel: þ1-212-305-4679. E-mail: pg2223@columbia.edu

Received for publication 8 March 2010. Accepted 29 June 2010.

ISSN 0268-8697 print/ISSN 1360-046X online ª 2010 The Neurosurgical Foundation
DOI: 10.3109/02688697.2010.505989
 626 P. Gigante et al.
Aetiology of neurological impairment is often
unclear in SAH patients who are comatose or
severely lethargic at presentation. Immediate EVD
placement for ICP monitoring and control is almost
universally considered the appropriate first step in
management of these patients.2,13 Absence of im-
provement after EVD placement and normalisation
of ICP may indicate other treatable aetiologies such
as seizures, medication effect, metabolic derange-
ment or early vasospasm. Although EVD placement
prior to definitive aneurysm treatment can provide
improvement in neurological status,14 it is not always
associated with improved prognosis.15–17 Moreover,
many patients who do not respond to immediate
ventricular drainage may improve following surgical
intervention.18,19
Br J Neurosurg Downloaded from informahealthcare.com by Columbia University on 12/15/10
In a prospective series of 473 aSAH patients,
Hasan et al. reported that all 91 patients with acute
radiographic hydrocephalus were asymptomatic at
presentation and 42% had no or slight impairment
in level of consciousness.6 Approximately 70% of
these patients did not clinically deteriorate. Further-
more, 50% of patients with an impaired level of
consciousness on admission spontaneously im-
proved without drainage, with the majority of
recoveries occurring within 24 h after admission.6
For personal use only.
In the same study, 29% of patients who deteriorated
from acute hydrocephalus had fluctuations in level
of consciousness. Ventricular drainage was often
delayed in this group of patients, which was thought
to cause persistent impairment of consciousness in
some cases.6 The results suggest that a majority of
patients who are present with radiographic ventri-
culomegaly and headache but are otherwise alert
can be observed with the expectation of neurologic
stability or improvement within the first 24 h.
However, the natural history of patients with
fluctuating levels of consciousness is not well
defined. Although some pursue aggressive interven-
tion in an effort to prevent lasting neurologic
deterioration secondary to hydrocephalus, careful
risk-benefit analysis is still warranted in this subset
of patients.
Preoperative EVD placement and risk of rebleeding
Controversy exists regarding the relationship be-
tween EVD placement and the incidence of rebleed-
ing in patients with aSAH.6,20,21 EVD placement has
been suggested to increase the risk of rebleeding,6
particularly when ventricular drainage has been set
below 25 mmHg.22 Abrupt lowering of ICP by CSF
drainage and resultant increase in aneurysmal
transmural pressure are thought to precipitate
rebleeding.23 Displacement of the tamponading
aneurysm clot and re-rupture of aneurysm through
the original tear has also been suggested as causal.2
CSF drainage with lumbar puncture, however, has
not been associated with increased risk of rebleeding
because it may allow for gradual ICP lowering and
insignificant shifts in intracranial pressure dy-
namics.21,23
Data regarding the risk of rebleeding after EVD
placement remains conflicting (Table I). In a
prospective series of 473 aSAH patients, Hasan
et al. reported that the rebleeding rate within 12 days
of haemorrhage was significantly higher in patients
with EVDs compared to those without (43% vs.
15%, p ¼ 0.025). However, the authors did not
provide information on timing of EVD placement.6
Similarly, Pare et al. observed in a cohort of 128
aSAH patients that those with EVDs had a higher
incidence of rebleeding than those with no EVD
(30% vs. 8.3%, p 5 0.006).21 Van Gijn et al. con-
ducted a multi-institutional prospective study of 174
aSAH patients and also determined that EVD
placement was associated with increased incidence
of rebleeding rate in patients with acute hydrocepha-
lus (17.6% vs. 9%), with a majority of rebleeding
occurring within 2 weeks post-ictus and between 3
and 10 days of drainage.7 However, a retrospective
study of 304 aSAH patients demonstrated that there
was no difference in rebleeding rate among hydro-
cephalic patients with or without EVD (4.4% vs.
5.4%).20 All rebleeds in the study occurred within
8 h post-EVD placement. Other studies have also
concluded that EVD placement is not associated with
rebleeding in patients with acute hydrocephalus after
aSAH.24 More recently, in a study of 546 prospec-
tively recruited aSAH patients adjusted for exposure
time and the interval between SAH and EVD
placement, no difference was detected between the
incidence of rebleeding with preoperative EVD
placement and controls (21% and 21%, respectively;
95% CI: 0.4–2.7).
No study to date has conclusively established a
causal relationship between EVD placement and
rebleeding in aSAH patients. Patients requiring EVD
insertion tend to present with worse clinical
grade,5,20–21 which in turn, is associated with
independent factors for rebleeding, such as larger
aneurysm and more dense SAH.2 Conflicting results
may be attributed to failure to account for confound-
ing variables such as clinical grade and timing of
aneurysm treatment.2,25 Further, the majority of
studies did not account for the following: (1) the
duration of EVD placement, particularly during
which the aneurysm remained untreated (‘exposure
time’) and (2) the interval between onset of SAH and
EVD placement.2,25 The latter is critical because the
risk of rebleeding after aneurysm rupture is cumula-
tive over time irrespective of EVD placement, with
the highest incidence during the first few days after
SAH.2,20,25
EVD insertion: responsibility and environment
EVDs have traditionally been placed by neurosur-
geons trained to recognise and manage procedure-
associated complications, such as intracranial
 EVD following aSAH 627

Within the first 12 daysafter SAH

Within 8 h after EVD placement

haemorrhage. However, an increasing number of

3–10 days after EVD placement

EVDs and ICP monitors are being placed by

Within 20 days after SAH

Timing of rebleed
neurointensivists, and non-neurosurgeon insertion
has been suggested as a means to promote ICP-
guided management.26 Few studies demonstrate that
intensivists, nurse practitioners, physician assistants,
and general surgery residents may place ICP
monitors with acceptable results if provided appro-
NA priate training and supervision.26 Ehtisham et al.
retrospectively reviewed the results of 29 EVDs
placed by a single neurointensivist26 and determined
50.006
p-value

0.025

0.93
placement was both safe and efficacious.26 However,
NA

NA

no major studies have compared neurosurgeon to

non-neurosurgeon placement and its impact on
and no EVD (%)
rate in patients

successful placement location and incidence of

with aHCP
Rebleeding

complications.
8.3
5.4
TABLE I. Summary of major studies that examine the relationship between EVD and rebleeding rate in aneurysmal subarachnoid hemorrhage patients.
Br J Neurosurg Downloaded from informahealthcare.com by Columbia University on 12/15/10

9
15

21

While some place EVDs only in the operating

room (OR), others routinely perform the procedure
at the bedside.27,28 The OR provides a more
controlled and sterile environment but transporting
aHCP and EVD (%)
Rebleeding rate in

acutely, critically ill patients to the OR is accom-

patients with

panied by risks. Clark et al. retrospectively reviewed

17.6

4.4

175 cases of ICP monitor placement in 140 trauma

43
30

21

patients and reported that there was no significant

difference in the incidence of infection whether the
device was placed in the OR (N ¼ 143) or intensive
For personal use only.

care unit (ICU) (N ¼ 32) (18.8% vs. 8.4%,

6.3 + 6 days

aHCP, acute hydrocephalus; EVD, external ventricular drain; SAH, subarachnoid hemorrhage; NA, not assessed.

p 4 0.05).29 However, the authors found increased

Exposure
time*

NA
NA
NA
NA

severity of infection with ICU-placed devices and

recommended that ICP monitors be placed in the
OR.29 Likewise, in a series of 631 patients with
Within 24 h (38), 24–48 h (3),

different intracranial pathologies, Bekar et al. re-

Timing of EVD placement

and 448 h (4) after SAH

ported no significant difference in the infection rates

Within 2 weeks after SAH
(number of patients)

among monitors that were placed in the OR

Mean of 0.5 + 0.7 days

(N ¼ 374) compared to those placed in the ICU

(N ¼ 257) (5.34% versus 4.28%, p 4 0.05).27 Gard-
ner et al. retrospectively studied 188 EVD place-
Not reported
Not reported

after SAH

ments in patients with various intracranial conditions

and found that EVDs placed in the OR (N ¼ 66) and
*Duration of EVD placement during which aneurysm(s) is unprotected.

ICU (N ¼ 54) had no difference in haemorrhage rate

(34.8% versus 44.3%, p ¼ 0.21) or size (p ¼ 0.67).28
with aHCP
Number of

Most studies are retrospective case series, however,

and EVD
patients

and there are no conclusive data to determine the

45

34
9
32
20

Retrospective analysis of prospectively maintained database.

impact of EVD placement location on complication

rate and outcome.
Patients
number

304

546
174
473
128

External ventricular drain management

Retrospective

Retrospective

ICP monitoring
Prospective
Prospective
Prospective
Type of
study

No perfect ICP monitoring device exists.27 Accuracy

of ICP measurement is limited by device proximity to
pathology, intracranial compartmentalisation and
transducer drift and levelling. While EVD is the
van Gijn et al. (1985)7

McIver et al. (2002)20

Hasan et al. (1989)6
Pare et al. (1992)21

standard-of-care for ICP management in SAH-

Hellingman et al.

associated acute hydrocephalus,2,30 EVDs have been

Author (year)

associated with high rates of misplacement and

(2007)25

consequently inaccurate ICP measurement.31 More-

over, EVD insertion is difficult in the presence of
significant mass effect or collapsed ventricles.
 628 P. Gigante et al.
Assistance of electromagnetic neuronavigation in-
creases accuracy, particularly in undersized or slit
ventricles, and may reduce the rates of complication
and malfunction.32 If, however, an EVD cannot be
placed to drain CSF, spinal drainage can be used
instead. However, in such instances, a separate
intracranial monitoring device is often needed as
spinal drains do not offer reliable ICP monitoring. In
the event that an EVD cannot be placed for ICP
monitoring, the surgeon may consider surface or
parenchymal monitors for continuous ICP monitor-
ing. However, pressure varies significantly with
structure (e.g. parenchyma and CSF) and location
(e.g. supratentorial vs. infratentorial, right vs. left
hemispheres).33,34 Therefore, surface monitors such
as epidural catheters and subarachnoid bolts cannot
Br J Neurosurg Downloaded from informahealthcare.com by Columbia University on 12/15/10
accurately detect pressure changes in deeper parts of
the brain.35 Head movements can also affect
device calibration and compromise measurement
reliability.36
Intraparenchymal ICP monitors offer easy and
reliable placement and their fibre-optic or strain
gauge catheters allow accurate ICP monitoring.
EVDs and intraparenchymal devices are equally
sensitive in detecting ICP patterns, although intra-
parenchymal pressure can be as much as 2 to
For personal use only.
8 mmHg lower than ventricular pressure.37,38 Dis-
advantages of intraparenchymal devices include
mechanical failure, fragility and monitor malfunc-
tion. EVDs and intraparenchymal devices have been
associated with comparable rates haemorrhagic
complication, ranging between 2 and 10% and 0 to
10%, respectively.39 Some authors have recom-
mended simultaneous placement of EVD and
intraparenchymal ICP monitors.39 Dual insertion
can be particularly useful when the ventricles
collapses around a ventricular catheter, compromis-
ing CSF drainage and accuracy ICP measurement.
Timing of EVD removal
Although EVD weaning practices remain controver-
sial among neurointensivists and neurosurgeons,
there are few studies to conclusively address the
issue. EVDs are often discontinued gradually over
days towards the end of a patient’s ICU stay.30
However, it is not clear whether gradual removal
provides any benefit over more rapid discontinua-
tion. In addition, it is not clear which subgroup of
patients would benefit most from prolonged EVD
placement.
Klopfenstein et al. conducted a prospective rando-
mised trial to compare rapid versus gradual weaning
from EVD in aSAH patients.30 After EVD place-
ment, patients were randomly assigned to either
rapidly weaned or gradually weaned group. Rapid
weaning occurred within 24 h with immediate
closure of the EVD, whereas gradual weaning took
place over a 96-h period with daily sequential level
elevations of the EVD system followed by drain
closure for 24 h. All patients who failed EVD
weaning underwent shunt placement. Although the
overall shunt placement rate was high (60%), there
was no difference in the rate of shunt-dependency
between the two groups. The gradually weaned
group spent a mean of 2.8 more days in the ICU
(p ¼ 0.0002) and 2.4 more days in the hospital
(p ¼ 0.0314) as compared to the rapidly weaned
group. Based on shorter hospital stay and similar
shunt placement rate, it was concluded that rapid
weaning is as safe and potentially more cost-effective
than gradual weaning. However, the study’s design
limitations may have affected the results. The most
significant bias of the study is related to the timing of
weaning initiation, which depended entirely on the
treating physician’s judgement. For instance, a
‘gradually’ weaned patient may not have begun
undergoing weaning until 10 days of drainage,
thereby have longer ICU stay. Additionally, power
of the study may have been inadequate to identify
subgroups that can benefit from different EVD
weaning methods. Lack of a control group and
strong preference for surgical clipping (95%) may
have also affected the results.
Chronic hydrocephalus and prediction of shunt
dependency
Many factors are associated with the development of
chronic hydrocephalus following aSAH.40,41 Ulti-
mately, an empiric challenge using an EVD or spinal
drainage is necessary to determine shunt depen-
dency.42 Chan et al. retrospectively reviewed 157
consecutive spontaneous SAH cases and reported
that CSF protein level at challenge was the most
predictive factor of EVD challenge failure (76.5 mg/
dl versus 40.3 mg/dl; p 5 0.0001).42 The following
variables were also significantly different between
patients who failed compared to those who passed
the EVD challenge: mean third ventricular diameter
at time of admission (7.0 mm vs. 5.4 mm; p ¼ 0.02);
mean third ventricular diameter at time of challenge
(6.6 mm vs. 5.2 mm; p ¼ 0.04); mean bicaudate
diameter at the time of challenge (31.9 mm vs.
30.2 mm; p ¼ 0.03); mean Hunt and Hess grade at
the time of admission (3 vs. 2; p ¼ 0.02); female sex
(63.5% vs. 34.5%; p ¼ 0.01); and posterior location
of the aneurysm (77.3% vs. 22.7%; p ¼ 0.01).
Additionally, increasing values of each risk factor
were associated with greater risk of EVD challenge
failure.42 A number of retrospective studies reported
that prolonged or continuous CSF drainage is
associated increased risk of chronic hydrocephalus
after aneurysm rupture.43,44 However, causality of
the association remains inconclusive.
EVD site versus shunt placement site
There are no clear guidelines on technique and
placement site when converting EVD to permanent

shunt in aSAH patients. A new site is routinely
established for shunt placement in order to avoid the
theoretical risk of infection from the previous incision
and EVD. Rammos et al. conducted a retrospective
analysis of 80 aSAH patients who underwent EVD-
ventriculoperitoneal (VP) shunt conversion at the
existing EVD site.45 Antibiotic-coated catheters were
used for both EVD and VP shunt and all patients
received prophylactic intravenous antibiotic treat-
ment 30–60 min before conversion. No shunt-
related infection was seen at a mean follow-up
duration of 24 months (range 2–53 months).
Although further investigation is warranted, these
data suggest that EVDs can be safely converted to a
permanent shunt using as existing EVD site.
Br J Neurosurg Downloaded from informahealthcare.com by Columbia University on 12/15/10
External ventricular drain-associated infection
Inconsistency in the definition of ventriculostomy-
related infection (VRI) across studies makes general-
isation and comparison of results difficult.46–48
Moreover, few studies on VRI are specific to aSAH.
Studies presented in this section pertain to the
general EVD population.
For personal use only.
Routine CSF sampling for infection
CSF profile (i.e. cell count, protein and glucose
level) and cultures are routinely tested. A few studies
have suggested that routine CSF cell count correlates
with positive CSF culture.9,49 However, there cur-
rently is no consensus that infection can be accu-
rately and reliably diagnosed based on CSF profile
changes alone. It is also not clear whether definitive
culture growth should be required to diagnose VRI.
Some has hypothesised that CSF sampling increases
the risk of infection and that CSF samples should
only be taken when there is clinical suspicion of
infection.50 However, a meta-analysis of 160 patients
in seven studies concluded that randomly acquired
daily cultures do not detect bacterial colonisation/
infection more than cultures acquired due to clinical
symptoms.51
Prophylactic systemic antibiotics
Although administration of prophylactic systemic
antibiotics (PSA) for EVD placement is common
practice at many institutions, its efficacy in prevent-
ing VRI remains to be elucidated.47,50,52 Despite
numerous studies to address the issue, a consensus
determination has been complicated by inconsistency
in study design, antibiotic regimens and criteria for
determining VRI (Table 2).47 Two randomised
controlled trials have sought to evaluate the efficacy
of PSA in preventing VRI. In 1985, Blomstedt et al.
examined the incidence of VRI in 52 patients
randomised to receive timethprim-sulfamethoxazole
or placebo given immediately preoperatively, fol-
lowed by dosing every 12 h up to 36 h after EVD
EVD following aSAH 629
removal.53 No significant difference in infection rates
between the two groups was demonstrated. In 1998,
Poon et al. examined the incidence of VRI associated
with EVD placement by randomising patients to one
of two groups.54 Group I received only perioperative
antibiotics consisting of ampicillin/sulbactam IV, and
Group II received prolonged antibiotic prophylaxis
consisting of ampicillin/sulbactam and aztreonam IV.
The authors reported a significantly decreased
infection rate in patients receiving prolonged PSA
(3% vs. 11%, p 5 0.05). When infections did occur,
however, they were more severe in the prolonged
PSA treatment group. More recently, two other
retrospective observational studies were com-
pleted.46–47 Alleyne et al. examined perioperative
cefuroxime (3 doses every 8 h before, during and
after the procedure) versus cefuroxime given peri-
procedurally and for the duration of EVD drainage.47
The authors reported no difference in the incidence
of VRI between the groups. Arabi et al., however,
reported a significant difference between periopera-
tive PSA-treated patients (PSA given at the time of
insertion) and non-PSA treated patients (no anti-
biotics given at insertion) (OR 2.82 95%, CI:
1.45–5.46).46
Antibiotic-coated catheters
Antibiotic-coated EVD catheters have been devel-
oped in an attempt to reduce EVD associated-VRI.
Two studies have been performed to evaluate the
potential benefit of these catheters. The use of EVD
catheters coated with both minocycline and rifampin
were shown to significantly reduce the risk of CSF
infection in a prospective, randomised trial. Positive
CSF cultures were seven times less frequent in
patients with antibiotic-impregnated catheters as
compared to those in the control group (1.3
compared with 9.4%, respectively, p ¼ 0.002).55 In
a historical case controlled comparison study, Tam-
burrini et al. compared catheters impregnated with
clindamycin and rifampicin to uncoated catheters in
47 paediatric patients and observed that CSF
cultures were positive in 2.1% of coated-catheter
patients and 31.8% of control patients. No patients
showed clinical signs of infection and all patients with
positive CSF culture were treated with 10 days of
antibiotic therapy with no clinical consequences.48
There is currently an ongoing clinical trial comparing
the usage of perioperative PSA (ampicillin/sulbactam
and ceftriaxone) with an EVD coated with antibiotics
versus prolonged PSA with a standard EVD. An
interim report including analysis of a total of 110
patients reported no incidence of VRIs in both
groups.
The incidence of VRI has been reported in
catheters impregnated with substances other than
antibiotics. Heparin-coated surface was hypothesised
to reduce the frequency of infection. However, a
recent study reported no difference in the frequency
 Br J Neurosurg Downloaded from informahealthcare.com by Columbia University on 12/15/10
For personal use only.

630

TABLE II. Summary of major studies that examine the relationship between prophylactic antibiotic therapy and rate of EVD associated infection in aneurysmal subarachnoid hemorrhage patients.

Number of Duration of variable Infection rate Infection rate

P. Gigante et al.

Author (year) Type of study patients Variable tested tested without variable (%) with variable (%) p-value

Blomstedt (1985)51
Poon et al. (1998)52
Alleyne et al. (2000)46
Lundberg et al. (2000)54
Zabramski et al. (2003)53
Arabi et al. (2005)45
Lackner et al. (2008)55
Tamburrini et al. (2008)47
Wong et al. (2008)51
Keong et al. (2010)57
Retrospective 122 Placebo vs. prolonged, Drainage duration 6.5 23.3 50.001
trimethoprim-sulfamethoxazole
Retrospective 228 Perioperative ampicillin and Perioperative vs 3 11 0.01
sulbactam vs. prolonged drainage duration
ampicillin, sulbactam,
aztreonam
Retrospective 308 Perioperative cefuroxime vs. Perioperative vs. 4 3.8 NA
prolonged cefuroxime drainage duration
Prospective, randomised, 198 Standard EVD vs. EVD coated Drainage duration 10.3 6.3 0.81
controlled with heparin
Prospective, randomised, 288 Standard EVD vs. EVD coated Drainage duration 36.7 17.9 50.0012
controlled with minocycline, rifampin
Retrospective 99 No antibiotics vs. prolonged Drainage duration 29.3 12.1 0.03*
cefazolin (49%), ceftriaxone
(8%). Cefuroxime (1%)
Retrospective 40 Standard EVD vs. EVD coated Drainage duration 0 25 50.05
with silver nano-particles
Prospective, randomised, 47 Standard EVD vs. EVD coated Drainage duration 31.8 2.1 0.003
controlled with clindamycin, rifampicin
Prospective, randomised, 110 Perioperative unasyn, rocephin Drainage duration 0 0 1
controlled (ongoing) with EVD coated with
clindamycin, rifampicin vs.
prolonged unasyn and rocephin
with standard EVD catheter
Prospective, randomised, 278 Standard EVD vs. EVD coated Drainage duration 21.4 or 12.3{ 21.4 or 12.3{ 50.05
controlled with silver

EVD, external ventricular drain.

*Not significant in multivariate analysis; {Awaiting unblinding.

of bacterial colonisation (evaluated by catheter tip
culture) or the incidence of VRI (evaluated by CSF
culture) between heparin-coated catheters and con-
trols.56 CSF culture was positive in 10.3% of the 98
patients with heparin-coated catheters and 6.3% of
the 100 patients with standard catheters (p ¼ 0.18). A
recent historical case controlled study was performed
to evaluate silver nanoparticle-impregnated EVDs.
Of 20 patients who received silver-coated EVDs,
none was found to have positive CSF cultures
(evaluated by daily CSF sampling) whereas the
control group had an infection rate of 25%
(p 5 0.05).57 Recently, results of the SILVER trial
(silver impregnated line versus EVD randomised), a
randomised, double-blinded, controlled trial com-
paring silver-impregnated EVDs with non-impreg-
Br J Neurosurg Downloaded from informahealthcare.com by Columbia University on 12/15/10
nated EVDs in 278 patients, were presented in
abstract format. The authors suggest that silver-
impregnated catheters can reduce the incidence of
CSF infection, reporting a 12.3% CSF infection rate
in the silver-impregnated catheters versus 21.4% in
the non-impregnated catheters (p 5 0.05), with an
overall infection rate of 16.9%. Although the
SILVER trial is yet to formally conclude, it repre-
sents a significant advance towards defining optimal
EVD management strategies.58
For personal use only.
Conclusion
EVD placement is standard of care for managing
aSAH. However, there are no definitive practice
guidelines for EVD placement and management in
the setting of aSAH. At present, the literature
consists primarily of small studies with heteroge-
neous populations and variable outcome measures.
Nevertheless, it suggests the following: EVDs may
increase the risk of rebleeding; EVDs are increasingly
placed by non-neurosurgeons with unclear results;
intraparenchymal ICP monitors may be safely
considered (with or without spinal drainage) in the
setting of difficult EVD placement; the optimal
timing and manner of EVD removal has yet to be
defined; the efficacy of PSA and antibiotic-coated
EVDs is unclear. There is an urgent need for a
randomised controlled trial to better define the
aforementioned issues and other uncertainties. Ulti-
mately, evidence-based guidelines will help improve
both research and clinical outcome in aSAH.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the article.
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