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

Abstract

V entriculostomy occlusion is a common complication after external ventricular drain (EVD) placement. A review of published prospective and retrospective studies indicates that approximately 1% to 7% of EVDs require replacement secondary to occlusion. [1][2][3]5,8,9,20 Furthermore, in a Nationwide Inpatient Sample database study of more than 101,000 hospitalizations in which ventriculostomy was performed, nearly 6% of patients required at least 1 additional ventriculostomy procedure. 18Studies have demonstrated nonpatent EVD in 19% to 47% of patients; 3,4,15 however, no study to date has prospectively evaluated EVD occlusion as a primary end point, reported on the number of catheter irrigations performed, or identified the risk factors for EVD occlusion.The morbidity and costs associated with the occlusion of EVD catheters is not insignificant. Patients with nonfunctional catheters often require CT imaging to evaluate the catheter position, subjecting the patient to ionizing radiation. Replacement of EVD catheters may be costly and uncomfortable for patients. In addition, studies have documented an increased risk of ventriculostomy infection with replacement. 4,12 Finally, catheter irrigation performed to restore the patency of occluded catheters may not be a benign maneuver (unpublished results). OBJectiVe Ventriculostomy occlusion is a known complication after external ventricular drain (EVD) placement. There have been no prospective published series that primarily evaluate the incidence of and risk factors for EVD occlusion. These phenomena are investigated using a prospective database. methOdS An ongoing prospective study of all patients undergoing frontal EVD placement in the Neurosurgery Intensive Care Unit at the University of Florida was accessed for the purposes of this analysis. Demographic, procedural, and radiographic data were recorded prospectively and retrospectively. The need for catheter irrigation or replacement was meticulously documented. Univariate and multivariate regression analyses were performed. reSultS Ninety-eight of 101 total enrolled patients had accessible data, amounting to 131 total catheters and 1076 total catheter days. Nineteen percent of patients required at least 1 replacement. Forty-one percent of catheters developed at least 1 temporary occlusion, with an average of 2.4 irrigations per patient. Intracranial hemorrhage occurred in 28% of patients after the first EVD placement (2% resulting in new neurological deficit) and in 62% of patients after 1 replacement. The cost of occlusion is estimated at $615 per enrolled patient. Therapeutic anticoagulation and use of small EVD catheters were statistically significant predictors of permanent occlusion (p = 0.01 and 0.04, respectively). cONcluSiONS EVD occlusion is frequent and imparts a significant burden in terms of patient morbidity, physician upkeep, and cost. This study suggests that developing strategies or devices to prevent EVD occlusion, such as the preferential use of larger diameter catheters, may be beneficial in red...

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

“…In the current study, we failed to detect differences in the occurrence of postoperative hematoma in the two groups, and the frequency was also considerably lower than previous reports [6,9,17,18,[21][22][23]. Studies have previously reported rates of close to non-existent to approximately 40% [9,17,22].…”

“…It is difficult to explain why there was a greater occurrence of occlusion in the tunnelated group, but this may have been associated with misplacement; in the tunnelated group, there was a trend towards fewer EVDs in optimal placement compared to the bolt group. One recent study reported that permanent catheter occlusion was however more frequently correlated to small catheter diameter and therapeutic anticoagulation, whilst a non-ideal catheter position was only marginally significant [6].…”

Spontaneous Intraventricular Hemorrhage: When Should Intraventricular tPA Be Considered?

“…In a prospective database regarding EVD insertion and practice for all indications, 19% of 98 patients required at least one EVD replacement, and 41% developed at least one temporary occlusion. 46 In a retrospective analysis of 227 patients with IVH requiring EVD, large bore catheters decreased the risk of catheter obstruction without any increase in catheter-related hemorrhages, and a nonsignificant decrease in catheter-related infections was also noted. Despite this, mortality was higher in the large bore catheter group, likely due to a selection bias where patients with larger volume hematomas were selected to receive the large bore catheters.…”

“…Experimental studies of thrombolytic-mediated clot removal have consistently demonstrated improved blood clot removal, hydrocephalus, and inflammation. 45,46,[48][49][50][51] In 2000, a systematic review of 16 retrospective studies (n ¼ 201) with severe IVH (Graeb score !7) secondary to ICH reported that combined therapy with EVD placement and IVF was associated with a significantly lower mortality rate (9%) and lower risk for unfavorable outcome (22%), as compared with patients treated with EVD alone (mortality 56%; poor outcome: 87%). 40 In 2002, a Cochrane database systematic review of 10 independent studies (8 case series/ retrospective studies, 1 quasi-RCT, 1 RCT) using IVF found anecdotal evidence supporting safety and possible therapeutic value.…”

External ventricular drain practice variations: results from a nationwide survey

“…tion of pseudoaneurysms, 1,10,18,29 arteriovenous fistulas, 18 or intracranial hemorrhage that causes new neurological deficits. 8 Lastly, EVDs can result in local surgical-site infections or, worse, infection of the meninges, brain parenchyma, or ventricular system. 16,23 The risk factors for EVD-related infections include intraventricular hemorrhage, craniotomy, and the duration of EVD placement, with a significant increase in risk after 5 days of drainage.…”