Doing More with less
Applicability, Safety, and Cost-Effectiveness of Improvised External Ventricular Drainage:
An Observational Study of Tunisian Neurosurgery Inpatients
Brahim Kammoun1, Fatma Kolsi1, Mehdi Borni1, Anis Abdelhedi1, Souhir Abdelmouleh1, Firas Jarraya1,
Oussama Bouhamed3, Omar Kammoun2, Emna Elleuch4, Mohamed Zaher Boudawara1
- OBJECTIVE: External ventricular drainage (EVD) is an
emergent neurosurgical procedure. Many commercial sets
are available for EVD that are not always obtainable in all
hospitals. The aim of our study was to describe new
techniques to perform EVD using simple improvised mate-
rials to check the real-world applicability of the same
device in the management of acute hydrocephalus and its
effectiveness and safety.
- METHODS: We illustrated 2 techniques for a “do it
yourself” improvised EVD device using materials available
even in non-neurosurgery-dedicated operating rooms. We
performed an observational study in our institution (April
2015 to December 2016). We included all patients pre-
senting with acute hydrocephalus and requiring EVD.
- RESULTS: During a 20-month period, the new EVD device
was used as a lifesaving solution for 33 patients. Good
outcomes were noted in 11 of the 33 patients (33%). The
EVD was complicated by fatal meningitis in 4 of the pa-
tients (12%). Malfunction occurred in 6 patients. The new
EVD device costs less than US$20 for the first technique
and less than US$10 for the second technique. In contrast,
the cost of a standard EVD set ranges from US$170 to
US$380 in Tunisia.
- CONCLUSIONS: The new EVD device has the potential
to improve the quality of efficiency of care in difficult
economic times that have changed the medical landscape,
because it is both easy to make and cost-effective.
Key words
- Acute hydrocephalus
- CSF drainage device
- External ventricular drainage
- Technique
Abbreviations and Acronyms
CSF: Cerebrospinal fluid
EVD: External ventricular drainage
ICP: Intracranial pressure
From the Departments of 1Neurosurgery and 2Radiology, Habib Bourguiba University
Hospital, Sfax University, Sfax; 3Department of Anesthesiology, Habib Bourguiba Hospital of
428 www.SCIENCEDIRECT.com
Because it is an inexpensive technique, it could also be
suitable for low-income countries, where neurosurgery is
not yet the first and foremost health priority.
INTRODUCTION
T he placement of an external ventricular drainage (EVD)
device is one of the most elementary and most common
neurosurgical procedures worldwide.1-3 It is used as an
emergency treatment for acute hydrocephalus, increased intra-
cranial pressure (ICP), and temporary cerebrospinal fluid (CSF)
diversion in patients with craniocerebral infection.4-8
EVD must be emergently performed when acute hydrocephalus
or increased ICP has been diagnosed. EVD consists in placing an
intraventricular catheter connected to an external drainage device.
Many commercial sets are available to perform this procedure.
However, these sets are not obtainable in all hospitals, especially
those lacking neurosurgical departments. In addition, the clinical
condition of patients waiting for transfer to a specialized center
can deteriorate. As a rescue solution, we have described 2 tech-
niques of a “do it yourself” improvised EVD device using materials
available even in non-neurosurgeryededicated operating rooms.
The EVD device can also be used at the bedside in intensive care
units.
This new EVD device is effective and less expensive than
commercial sets. Therefore, it could be suitable for low-income
countries, where cost pressures have necessitated such creative
approaches and where neurosurgery is not yet a health priority.
Mednine, Sfax University, Mednine; and 4Department of Infectious Diseases, Hedi Chaker
University Hospital, Sfax University, Sfax, Tunisia
To whom correspondence should be addressed: Brahim Kammoun, M.D.
[E-mail: kammoun.brahim28@gmail.com]
Supplementary digital content available online.
Citation: World Neurosurg. (2018) 119:428-436.
https://doi.org/10.1016/j.wneu.2018.07.261
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.07.261

BRAHIM KAMMOUN ET AL.
METHODS
To demonstrate the effectiveness and safety of the new EVD
device, we conducted a prospective observational study during a
20-month period (April 2015 to December 2016). During this
period, we experienced a shortage of standard EVD commercial
sets in our hospital. The patients who presented with acute hy-
drocephalus were included after obtaining the patients’ or their
relatives’ informed consent. EVD was performed using the new
device. A data form was completed for all the patients and
included the underlying disease, complications (tearing,
dysfunction, or infection), and outcomes. The ethics committee
reviewed and approved the utility of the described EVD device as a
life-saving solution in the case of lack of standard commercial sets
(approval number, CCP Sud 00 47/2017).
Device Description
Here, we report the technique for 2 “homemade” EVD devices.
The trademarked equipment shown in the photographs were only
included for demonstration (similar products could also be used
and we used other trademarked equipment in our series).
First Technique. For the new EVD device, we needed the following
materials: a 14-gauge central venous catheterization set (Figure 1A
Figure 1. Material required for the drainage device using the first technique.
(A, B) A 14-guage central venous catheterization set; (CeE) urimeter; (F)
WORLD NEUROSURGERY 119: 428-436, NOVEMBER 2018
DOING MORE WITH LESS
EVD: APPLICABLE, SAFE, AND COST-EFFECTIVE IMPROVISED DEVICE
and B); a urimeter (Figure 1CeE); a 3-way stopcock (Figure 1F); a
connector tube (coiled or not; Figure 1G); and a Foley catheter. All
the required materials are shown together in Figure 1H.
For the placement of the EVD using the 14-gauge central
catheter (Figure 2AeK), the patient’s position and the cranial
approach used were the same as those for a standard EVD. The
patient was placed supine on a standard table. The head rested
on a horseshoe headrest, exposing the ventricular puncture area.
We marked the midline, coronal suture, and midpupillary line,
which was 2e3 cm from the midline. The entry point was
located on the midpupillary line, 10 cm from the orbital rim.
The frontal incision was 1 cm anterior of the coronal suture and
2e3 cm from the midline. Next, we drilled a right frontal burr
hole and opened the dura mater. The ventricle puncture was
performed the same as for the usual procedure using the same
anatomical reference marks (i.e., the nasion and homolateral
tragus) and the central venous catheter. The central venous
catheter was assembled on a metal guide (Figure 3A) to act as a
ventricular catheter. High-pressure CSF poured through the
drainage device (Figure 2A). The catheter was tunneled under the
scalp (Figure 2BeD) and fixed using the “wings” present in the
proximal part of the catheter. The central catheter set included a
suitable patch for fixing the catheter (Figure 2EeK).
3-way stopcock; (G) connector tube; and (H) all the needed materials (with
the metal guide and nonabsorbable suture).
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 DOING MORE WITH LESS

BRAHIM KAMMOUN ET AL. EVD: APPLICABLE, SAFE, AND COST-EFFECTIVE IMPROVISED DEVICE

Figure 2. (A) Placement of the external ventricular drainage device using (EeJ) Fixation of the catheter using specific parts (yellow and blue) and the
the 14-guage central catheter for cerebrospinal fluid drainage after proximal “wings.” (K, L) Connection of the catheter to the drainage device.
ventricular puncture. (BeD) Tunneling of the catheter under the scalp.

To make the drainage device (Figure 3B and arrow, where there was a hydrophobic filter
Supplemental Video 1), we first mounted the (Figure 3D), which allowed for a balance with the
proximal end of the connector tube to the catheter. atmospheric pressure without allowing fluid to pass
Its distal end was mounted to the 3-way stopcock. through. Thus, the filter was the reference level; the
The Foley catheter was mounted on the urimeter and Video available at desired H2O cm pressure was determined by the
then cut proximally. This part was then connected to WORLDNEUROSURGERY.org difference in the level between this filter and the
the stopcock and consolidated with nonabsorbable external acoustic meatus. We could adjust the
suture. Supplemental Video 1 shows this in more detail. pressure by raising or lowering the filter level.
For connection and suspension of the drainage device
(Figure 3C and D), the urimeter (now called the CSF meter) was Second Technique. For the second technique, we needed the
attached to the bed frame. The proximal connection was fixed following materials: a 14-gauge central venous catheterization set
vertically. The reference level of the EVD was indicated by an (the same used with the first technique; Figure 4A); a vacuum

Figure 3. Fixation of the assembled drainage device. (A) The catheter was fixation of proximal end of the cerebrospinal fluid meter. Red arrow
assembled on a metal guide. (B) Photograph of the prepared drainage indicates the reference level.
device. (C) Cerebrospinal fluid meter attached to the bed frame. (D) Vertical

430 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.07.261


BRAHIM KAMMOUN ET AL.
Figure 4. Material needed for the drainage device using the second
technique: (A) a 14-gauge central venous catheterization set; (B) a Redon
bottle with vacuum removed by putting a needle in the green compressed
Redon bottle (with the vacuum removed by putting a needle in the
green compressed part) and tubing (Figure 4B and C); a coiled
connector tube (Figure 4D); disposable transfusion sets
(Figure 4E); and a flat scale ruler to adjust the level of the EVD
(Figure 4F). To place the EVD using the 14-guage central cath-
eter (Figure 2), we used the same technique described for the first
EVD.
To make the drainage device (Figure 5), we first, cut the
transfusion tubing 1 cm below the drip chamber (Figure 5A).
The distal end of the transfusion tubing included a detachable
latex part (Figure 5B). We disconnected that part to access the
distal portion of the plastic connector. The connector was cut at
its proximal portion with the tubing. It was then turned over
and mounted upside down at the latex part (Figure 5C). Next,
we obtained the distal portion comprising the latex portion,
which was attached to a plastic connector (Figure 5D). This
distal portion was directly connected to the proximal portion
(the drip chamber) previously prepared (Figure 5D). The result
was a short transfuser with a Luer lock at the distal end. We
WORLD NEUROSURGERY 119: 428-436, NOVEMBER 2018
DOING MORE WITH LESS
EVD: APPLICABLE, SAFE, AND COST-EFFECTIVE IMPROVISED DEVICE
part); (C) tubing of the Redon bottle; (D) coiled connector tube; (E)
disposable transfusion set; and (F) flat scale ruler used to adjust the level of
the external ventricular drainage.
attached the short transfuser to the Redon bottle using the Luer
lock (Figure 5D). A needle was inserted in the Redon bottle to
remove the vacuum. This needle would serve as the air inlet. A
compress soaked in antiseptic was applied around the needle.
The Redon tubing was cut at the distal end and assembled to
the transfuser (Figure 5E).
For connection and suspension of the drainage device
(Figure 6), the other end of the Redon tubing was connected to
coiled tubing, which then would be connected to the ventricular
catheter (Figure 6A). The level of the external acoustic meatus
was the conventional zero pressure level. The reference level of
the EVD was the drop chamber, which corresponded to the 20-
cm graduation on the flat ruler (Figure 6B).
The desired H2O cm pressure was determined by the difference
between the drop chamber and external acoustic meatus. First, we
projected a horizontal line from the external acoustic meatus. We
read the graduation on the flat ruler to indicate the level of that
line. We deducted the pressure value by simply subtracting 20
from the value read on the flat ruler. For example, if the desired
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BRAHIM KAMMOUN ET AL.
Figure 5. Method used to make the drainage device
with the second technique. (A) Cutting the tubing of
the transfuser. (B) Disconnection of the distal latex
part. (C) Plastic connector cut and assembled upside
down on the latex part. (D) Connection of the distal
level of the EVD was at þ10 cm, the level of the external acoustic
meatus had to be at 30 cm on the flat ruler (30  20 ¼ 10). Also,
the level of the external acoustic meatus had to be at 35 cm if the
desired pressure was þ15 cm H2O. The adjustment can be per-
formed easily by shortening or lengthening the suspension ropes.
432 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.07.261
DOING MORE WITH LESS
EVD: APPLICABLE, SAFE, AND COST-EFFECTIVE IMPROVISED DEVICE
part (latex part with connector) on the drip chamber
and connected to the Redon bottle. (E) Cutting of the
Redon tubing and connection to the transfuser. The
other end is connected to coiled tubing.
RESULTS
The new EVD device was used as a lifesaving treatment for 33
patients during a 20-month period (April 2015 to December 2016)
during which not enough conventional commercial sets were

BRAHIM KAMMOUN ET AL.
Figure 6. Connection and suspension of the drainage
device. (A) Connection of the coiled tubing to the
central venous catheter, with transfuser drip chamber
fixed to a flat ruler suspended by an adjustable
suspension rope. (B) Drip chamber and Redon bottle
available. The patients’ characteristics, indications and compli-
cations of EVD, and outcomes in our series are listed in Table 1.
Of the 33 patients, good outcomes were obtained for 11 (33%).
Seven patients (21%) developed meningitis after EVD with an
average delay of 11.7 days (range, 5e25). A total of 5 isolates from
EVD infections were recorded (4 gram-negative bacilli and 1 gram-
positive cocci). Malfunction of the EVD device occurred in 6 of the
33 patients (18%) requiring EVD replacement in 4 (12%) and
catheter washout in 2 (6%). Of the 33 patients, 22 died (66%).
Death was due to post-EVD meningitis in 4 patients (12%), un-
derlying diseases in 15 (45%), and other complications in 3
patients (9%).
The cost of a standard EVD set in Tunisia ranges from US$170
to US$380. In contrast, the cost of our new EVD device using
WORLD NEUROSURGERY 119: 428-436, NOVEMBER 2018
DOING MORE WITH LESS
EVD: APPLICABLE, SAFE, AND COST-EFFECTIVE IMPROVISED DEVICE
fixed to the flat ruler. The reference level is the drop
chamber, which corresponds to the 20-cm graduation
on the flat ruler. The whole drainage device was
suspended.
locally procured materials was less than US$20 for the first tech-
nique and less than US$10 for the second technique. However, the
objective of the cost analysis was not to downplay the importance
of the standard set but to allow broader access to care in resource-
challenged environments.
DISCUSSION
The important finding from our study was that EVD can be
effectively and safely performed using simple materials when the
standard commercial sets are not available. In our center, we saved
the life of 11 of 33 patients (33%) who had presented with acute
hydrocephalus. The CSF drainage procedure was successful in 29
of the 33 patients (88%) but was complicated by fatal meningitis in
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BRAHIM KAMMOUN ET AL.

Table 1. Patient Characteristics, Complications, and Outcomes
Patient Age (Years) Indication Malfunction Delay (Days) Meningitis Delay (Days) CSF Culture Antibiotic Treatment Outcome
www.SCIENCEDIRECT.com

1 62 SAH No NA No NA NA NA DUD
2 45 ICH No NA No NA NA NA Good
3 53 SAH No NA No NA NA NA DUD
4 63 Tumor No NA No NA NA NA Good
5 49 SAH No NA No NA NA NA DUD
6 46 SAH No NA No NA NA NA DUD
7 51 SAH No NA No NA NA NA DUD
8 58 Tumor No NA No NA NA NA DUD
9 49 Tumor No NA No NA NA NA DUD
10 35 Tumor No NA No NA NA NA Good
11 72 Tumor No NA Yes 20 Negative Imipenem, Death from meningitis
fosfomycin
12 35 Tumor No NA No NA NA Good
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.07.261

13 53 Tumor Yes; replacement 34 Yes 25 Streptococcus Vancomycin Death from meningitis

hemolyticus (IV and intraventricular)

EVD: APPLICABLE, SAFE, AND COST-EFFECTIVE IMPROVISED DEVICE

14 86 ICH No NA No NA NA NA DUD
15 10 months Meningitis No NA No NA NA NA Good
16 4 months Meningitis No NA No NA NA NA Good
17 53 Tumor No NA No NA NA NA Good
18 32 Arachnoid cyst No NA No NA NA NA Good
19 59 Tumor; meningitis No NA Yes Before EVD Enterobacter spp. Imipenem; colimycin DUD
20 53 ICH Yes; replacement 3 No NA NA NA Death from other
complications
21 35 SAH No NA No NA NA NA DUD
22 50 Tumor Yes; washing out 5 No NA NA NA DUD
23 62 Tumor No NA Yes 5 Pseudomonas Imipenem DUD
aeruginosa
24 51 Tumor No NA No NA NA NA Death from other

DOING MORE
complications
25 46 Tumor No NA No NA NA NA Good
26 43 Tumor No NA Yes 13 Klebsiella Imipenem Death from
pneumoniae meningitis

WITH LESS
27 5 Tumor No NA No NA NA NA Good
 DOING MORE WITH LESS

BRAHIM KAMMOUN ET AL. EVD: APPLICABLE, SAFE, AND COST-EFFECTIVE IMPROVISED DEVICE

4 (12%). Moreover, the described techniques were inexpensive

and easy to use. Thus, such EVD devices could be useful in many

Death from other

complications
Death from regions worldwide.
meningitis

Good
DUD

DUD
DUD

Advantages of the EVD Device

First, the EVD device can be created in any operating room, even in
non-neurosurgeryededicated ones or by the bedside in neurosurgical
intensive care units. Second, it seems to be effective and less expen-
sive than the commercial sets. Finally, we were able to use a larger
diameter catheter, for example, in the case of hemorrhagic CSF.
fosfomycin
Imipenem;

Imipenem

Despite these advantages, complications such as infections

CSF, cerebrospinal fluid; SAH, subarachnoid hemorrhage; NA, not applicable; DUD, death from underlying disease; ICH, intracerebral hematoma; IV, intravenous; EVD, external ventricular drainage.
NA

NA

NA

NA

and dysfunction can occur. Postoperative meningitis and ven-

triculitis are likely, especially when an EVD device has been
inserted to monitor or control ICP.9 Ventriculitis and/or
meningitis developing after EVD insertion has been a relatively
common healthcare-acquired infection in neurosurgical pa-
Pseudomonas aeruginosa

Enterobacter aerogenes;
Acinetobacter baumanii
Klebsiella pneumoniae;

tients.10-12 According to reported studies, the incidence of men-

400 PNN, culture

ingitis and/or ventriculitis complicating EVD insertion varied

(negative)

from 3.5% to 18.3%.9,13,14 However, although malfunction or

NA

NA

NA

infection occurred in some cases, the new device was efficient in

CFS drainage, and we saved the life of 11 of 33 patients (33%).

Future Prospects
The new device using a central venous catheter has many future
prospects. First, it can be generalized as a technical standard to
Before EVD

treat any patient with acute hydrocephalus because this catheter

NA

NA
6
6

seems to be suitable for CSF drainage. Second, using a 2-lumen

central venous catheter (one lumen for drainage and the other to
monitor the ICP) can further improve the technique. Indeed, we
can introduce an ICP sensor into the second lumen. The use of a
Yes
Yes

Yes

Yes

2-lumen catheter could also be useful to “wash” the ventricle

No

No

cavities in the case of intraventricular hemorrhage. Third, it

might be possible to use a central venous catheter coated with
antiseptics or antibiotics to reduce or avoid infectious compli-
1 (6 hours)

cations. Data, mainly from nonrandomized studies, have shown

NA

NA

NA
15

that using antibiotic-impregnated catheters and silver-coated

catheters reduces the risk of infection in patients undergoing
CSF shunting.15,16 However, further randomized controlled trials
are required to confirm their feasibility, safety, and effectiveness.
Yes; washing out

Yes; washing out

Yes; replacement

CONCLUSIONS
No

No

No

The new EVD device has the potential to improve the quality of
efficiency of care in the difficult economic times that have changed
the medical landscape, because it is both easy to make and cost-
Tumor/meningitis

effective. In some hospitals that lack a neurosurgical depart-

ment, it could be useful to rescue patients waiting to be transferred
Trauma

Trauma
Tumor
ICH

ICH

to a tertiary care unit. Because it is an inexpensive technique, it

could also be suitable for low-income countries, where neurosur-
gery is not yet the first and foremost health priority.

ACKNOWLEDGMENTS
38

62
39

10

54
45

The authors thank Abdessalem Kallel, M.D. (Assistant Professor,

Maxillofacial Surgery Department) for the video and photo-
graphs. They also thank all the neurosurgery, anesthesiology,
intensive care unit, and emergency medical service staff of Habib
Bourguiba University Hospital for their encouragement and
28

29
30

31

32
33

collaboration.

WORLD NEUROSURGERY 119: 428-436, NOVEMBER 2018 www.WORLDNEUROSURGERY.org 435


BRAHIM KAMMOUN ET AL.
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Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 11 April 2018; accepted 28 July 2018
Citation: World Neurosurg. (2018) 119:428-436.
https://doi.org/10.1016/j.wneu.2018.07.261
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2018 Elsevier Inc. All
rights reserved.