Indications for external ventricular

drainage, lumbar CSF drainage

and
shunting, ventriculocisternostomy
Dr. Samuel Oluka

Supervisor: Dr. Omar

External Ventricular Drainage
(EVD)
Also known as a ventriculostomy or extraventricular drain
Defn:

• A temporary system that allows drainage of cerebral spinal fluid (CSF)

from the ventricles to an external closed system
History External ventricular drainage (EVD)
• One of the most commonly performed neurosurgical procedures.
• First performed as early as 1744 by Claude-Nicholas Le Cat.
• Developments
Changes in technique
Materials used
Indications for the procedure
Safety
4 eras of progress:
• Development of the technique (1850-1908)

• Technological advancements (1927-1950)

• Expansion of indications (1960-1995)

• Accuracy, training, and infection control (1995-present)

History
• William Williams Keen1890 published the first thorough report of EVD
technique and outcomes

• Many improvements, Adson and Lillie in 1927 addition of manometry

• Nils Lundberg, 1960. who published a thorough analysis of the use of

intracranial pressure (ICP) monitoring in patients with brain tumors
What followed?
• Application of EVD and ICP monitoring:

Subarachnoid haemorrhage,
Reye syndrome,
Traumatic brain injury
Recent developments
• Improving the overall safety of the procedure, which has included

Development of guidance-based systems

Virtual reality simulators for trainees

Antibiotic-impregnated catheters
Entry points
• Kocher’s point 11 X 3cm

Intra operatively
A. Posterior approaches
• Dady’s point: 3 cm superior to inion and 2 cm off midline – higher risk of visual
pathway damage.
• Frasier’s point 6cm X3cm, approximately 1 cm anterior to lambdoid suture
• Keen’s Point: 3 cm above and 3 cm posterior to auricle tip.

B. Pterional approaches
• Paine’s point 2.5cm X2.5cm
Indicators for external ventricular drain
insertion
1. ICP monitoring (EVD is gold standard)

2. CSF drainage in:

a. Intracranial hypertension
b. Shunt infections
c. SAH (↑ risk of bleeding if aneurysm is unsecured)
d. Intraoperative brain relaxation
Monitoring intracranial pressure
WHEN connected to an external strain gauge is currently the “gold
standard” for measuring ICP.
Versatile; bedside in the emergency department, intensive care unit
(ICU), or operating room, depending on local practice tradition.
Most practitioners use anatomic landmarks (freehand technique) to
insert the ventricular drain into the lateral ventricle with the tip in the
foramen of Monro
• The catheter can then be tunnelled subcutaneously to minimize CSF
leakage and infection.
• Ventricular fluid pressure, which represents ICP, is transmitted to an
external strain gauge transducer via the fluid-filled EVD. The strain
gauge transducer can be recalibrated without manipulation of the EVD.
• It can be connected to many standard ICU monitoring systems and
allows ICP measurements to be displayed along with other physiologic
data such as pulse, blood pressure, or central venous
pressure.
Monitoring intracranial pressure
• Gold standard – catheter in lateral ventricle

• Most accurate method + permits CSF drainage (as potential treatment

for raised ICP)
• It may also be placed under direct vision before closure of bone flap
ICP
• NORMAL WAVES – three major
components:
1. Baseline pressure level Normal ICP
Age group Normal range (mm Hg)
2. Cardiac pulsatile component
Adults and older children < 10–15
3. Pulmonary pulsatile Young children 3–7
component Term infants 1.5–6
• small pulsations transmitted from
the systemic blood pressure to the
intracranial cavity
• large (1–2 mm Hg) peak
corresponding to the arterial
systolic pressure wave, with a small
dicrotic notch
• Smaller and less distinct peaks
• Lastly peak corresponding to the
central venous “A” wave from the
right atrium
Indications of ICP monitor
• Traumatic brain injury
• Spontanious ICH
• ASAH
• Post excision of tumors
• Reyes syndrome
• Hepatic encephalopathy
Recommendation by BTF in TBI (level II)
1. Patients with Glasgow Coma Scale (GCS) less than 8
2. An abnormal computed tomogram (CT) scan of the head
3. Two or more of the following are present:
• Age greater than 40 years
• Unilateral or bilateral motor posturing
• Systolic blood pressure less than 90 mm Hg
Recommendation by BTF in TBI (level III)
Initially normal CT scan or with minor changes in CT images, but later
show features of neurologic worsening or progression on the repeat
scan
Evidence of brain swelling, e.g., compressed or absent basal cisterns
Large bifrontal contusions independent of the neurological condition
When sedation interruption to check neurological function is not
justified, e.g., respiratory failure from lung contusions and flail chest
When the neurological examination is not reliable, e.g., maxillofacial
trauma or spinal cord injury
Recommendation by BTF in TBI (level III)
• A decompressive craniectomy performed as a last resort for
intracranial hypertension refractory to medical management

• Following craniotomy wherein there are relevant risk factors for the
propagation of brain edema, e.g., confounding hypoxia, hypotension,
pupil abnormalities, midline shift greater than 5 mm
causes of inaccurate information
• Catheter occlusion
• blood or
• necrotic brain)
• Ventricle collapse around catheter tip
Complications of Ventricular Catheter-
based ICP Monitoring
• Intracranial and tract hemorrhage - 10%
• Infection (ventriculitis) - 20%
• Technical failure (failure to tap ventricle or misplacement) - 5%
• Over drainage can lead to aneurysmal rebleed and in cases of
hydrocephalus complicate the upward transtentorial herniation.
• Kinks and blockage by air, blood, and debris are also frequent, leading
to the poor and false recording of the ICP.
• There can be localized elevations of ICP due to compartmentalization
from mass lesions.
EVD Infection (Epidemiology)
Incidence. The incidence of EVD infection is approximately 9.5%.

Risk factors.
1. Duration of EVD
2. Site leakage
3. Blood in CSF (IVH and SAH)
4. Irrigation and flushing
EVD infection common terminology
Contamination:
isolated positive CSF culture and/or Gram stain, with expected CSF cell
count and glucose with NO attributable symptoms or signs.
Ventriculostomy colonization:
Multiple positive CSF cultures and/or Gram stain, with expected CSF cell
count and glucose levels with NO attributable symptoms or signs.
Possible ventriculostomy-related infection: Progressive rise in cell index or
progressive decrease in CSF: blood glucose ratio or an extreme value for
CSF WBC count (> 1000/micro L) or CSF:blood glucose ratio (< 0.2), with
attributable symptoms and signs, but NEGATIVE Gram stain & cultures
Probable ventriculostomy-related infection: CSF WBC count or
CSF:blood glucose ratio MORE abnormal than expected, but NOT an
extreme value (CSF WBC count 1000/micro L or CSF:blood glucose ratio
< 0.2) and stable (not progressively worsening) attributable symptoms
and signs and POSITVE Gram stain & cultures
Definitive meningitis: Progressive rise in cell index or progressive
decrease in CSF:blood glucose ratio or an extreme value for CSF WBC
count (> 1000/micro L) or CSF:blood glucose ratio (< 0.2), with
attributable symptoms or signs and a POSITIVE Gram stain & cultures
Prevention of infection
Antibiotic-Impregnated Catheter
• A recent development in EVD catheter technology

• Rifampin is capable of releasing in controlled-release manner.

• Significantlyreduces bacterial adhesion versus controls

• In one RCT, Zabramski and coworkers, catheter (minocycline and

rifampin) reduced the infection rate significantly from 9.4% to 1.3%
when compared with the nonimpregnated
Prophylactic Antibiotic Use
• Currently, the Guidelines for the Management of Severe Traumatic
Brain Injury do not recommend antibiotic prophylaxis for EVD
placement or catheterization
Prophylactic Catheter Exchange
• 5 day prophylactic catheter change has no benefit

• This was also observed in one prospective, randomized trial

comparing the infection rate in a group that underwent prophylactic
catheter exchange versus a control group that did not undergo
prophylactic catheter exchange.
Extended Tunnelling
• Most EVD insertion kits today contain a trocar for subcutaneous
tunnelling in excess of 5cm.

• Sandalcioglu and Stolke reported that there was a significant

difference in infection rate (83% versus 17%) for catheters that were
tunnelled less than 5 cm subcutaneously versus catheters that were
tunnelled more than 5 cm, respectively.37
Venue of External Ventricular Drain
Placement
• Lozier and coworkers analyzed five studies that looked at whether
there is a difference in infection rates in EVDs placed in the operating
room, ICU, or emergency department.

• All but one of the studies revealed no significant difference in

infection rate whether the EVD was placed in the operating room,
ICU, or emergency department.
CONTRAINDICATIONS
1. Concurrent use of anticoagulant drugs

2. Bleeding disorders

3. Scalp infection

4. Brain abscess
Lumbar CSF drainage and shunting
Indications
• 1. Intraoperative brain relaxation (e.g. for aneurysm or tumor
exposure)
• 2. CSF leak prevention or treatment
• (typically after posterior fossa or transsphenoidal procedures)
• 3. Assessment of potential response to shunting in normal-pressure
hydrocephalus
Set up
Procedure
14G Tuohy needle* is inserted with bevel facing laterally.
• Needle with a lateral opening at the distal end, designed to cause a catheter passing through
the needle's lumen to exit laterally at a 45° angle; used to place catheters into the subarachnoid
• once brisk CSF flow is obtained, bevel is turned superiorly.
• Lumbar drainage catheter (± with wire stylet) is inserted until resistance is met (20-40 cm)
• Pursestring suture is placed around the catheter exit on the skin while Tuohy needle is still in
place (avoids injuring catheter).
• Tuohy needle is withdrawn.
• Catheter stylet is withdrawn.
• Catheter is attached to supplied Luer-Lok connector and sutured to skin; coil rest of drain and
cover with large Tegaderm / OpSite.
• N.B. it is easy to kink he catheter or tie suture too tight – check CSF flow often!
Apparatus

Tuohy needle
Maintenace
• Keep drain clamped if patient is COMPLICATIONS
ambulatory. 1. Infection
• Unclamp as needed to drain CSF
(e.g. certain amount of CSF per
hour), or keep drain open at 2. Overdrainage: transforaminal
shoulder level in recumbent brain herniation (potentially
patients for continuous drainage. lethal)
• Drain is removed / changed
every 5-7 days.
Lumboperitoneal shunt
Lumboperitoneal shunt
• A lumbar peritoneal (LP) shunt is a technique of cerebrospinal fluid
(CSF) diversion from the lumbar thecal sac to the peritoneal cavity

• In spite of the large number of indications of this shunt and being

reasonably good, safe, and effective, very few reports about the LP
shunt exist in the literature.
• This procedure did not get its due importance due to some initial
negative reports
Indications
• Communicating hydrocephalus,
• Idiopathic intracranial hypertension,
• normal pressure hydrocephalus,
• Spinal and cranial cerebrospinal fluid (CSF) leaks,
• Pseudomeningoceles
• Slit ventricle syndrome,
• Growing skull fractures which are difficult to treat by conventional methods such as when dural defect
extends deep in the cranial base or across venous sinuses and in recurrent cases after conventional surgery,
• Raised intracranial pressure following chronic meningitis,
• Persistent bulging of the craniotomy site after intracranial tumours or head trauma surgery,
• Syringomyelia
• failed endoscopic third ventriculostomy with patent stoma
Complications
• 1. if at all possible, should not be used in growing child unless ventricular access is unavailable
(e.g. due to slit ventricles) because of:

• a) laminectomy in children causes scoliosis in 14% 1)

• b) risk of progressive cerebellar tonsillar herniation (Chiari I malformation) 2) in up to 70% of

cases 3) 4).

• 2. overshunting harder to control when it occurs (a special horizontal-vertical (H-V) valve

increases resistance when upright).

• 3. difficult access to proximal end for revision or assessment of patency.

Complications cont….
• 4. lumbar nerve root irritation (radiculopathy).

• 5. leakage of CSF around catheter.

• 6. pressure regulation is difficult.

• 7. bilateral 6th and even 7th cranial nerve dysfunction from overshunting.

• 8. high incidence of arachnoiditis and adhesions

Complications of LP shunts
• Shunt block
• infections
• CSF leak
• acquired Chiari malformation (ACM)
• Intracranial hypotension
• sudden visual loss
• intracranial hematoma
• Shunt migration
• syringomyelia
Ventriculocisternostomy
Ventriculocisternostomy
• Aka, Torkildsen’s operation, or Torkildsen’s shunt

• The first CSF shunt in the history of the treatment of hydrocephalus.

• First performed in 1937 by Dr. Arne Torkildsen, a Norwegian neurosurgeon, and

reported in 1939

• Gained widespread use in the 1940s and 1950s before the introduction of extracranial
shunts

• It prevailed until VA and VP shunts were introduced for the treatment of hydrocephalus
Procedure
• Bypasses the cerebrospinal fluid (CSF) flow from the lateral ventricle
to the cisterna magna
• internal shunt.
• regarded as a historical procedure
• (a) the suboccipital bone was exposed, and a craniectomy was performed
• (b). If Torkildsen found an infratentorial tumor, it was removed. In the absence
of free CSF flow from the fourth ventricle, he performed a VCS. A catheter was
placed in the occipital horn of the lateral ventricle via occipital trephination
• (c). The catheter was tunneled subcutaneously to the suboccipital opening (d)
and then inserted into the cisterna magna
• (e). Panel
• (f) shows the Nélaton catheter extending from the occipital horn to the
cisterna magna. Reproduced with permission from Universitetsforlaget AS,
Oslo, Norway.
Indication
• Obstruction of the third ventricle, the aqueduct of Sylvius, and the
fourth ventricle