Hemorrhage rates after external ventricular drain placement

Clinical article

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External ventricular drain (EVD) placement is one of the most common neurosurgical procedures performed. Rates and significance of hemorrhage associated with this procedure have not been well quantified.


All adults who underwent EVD placement at the University of Pittsburgh Medical Center between July 2002 and June 2003 were evaluated for catheter-associated hemorrhage. Patients without postprocedural imaging were excluded.


Seventy-seven (41%) of 188 EVDs were associated with imaging evidence of hemorrhage after either placement or removal. Most of these were insignificant, punctate intraparenchymal, or trace subarachnoid hemorrhages (51.9%). Thirty-seven (19.7%) were associated with larger hemorrhages, which were divided into 3 groups according to volume of hemorrhage: 16 patients (8.5%) had < 15 ml of hemorrhage, 20 (10.6%) had hemorrhages of > 15 ml or associated intraventricular hemorrhage, and in 1 case there was a subdural hematoma that required surgical evacuation. No hemorrhages larger than punctate or trace were seen after EVD removal. Hemorrhage was associated with 44.3% of EVDs placed in an intensive care unit compared with 34.8% in EVDs placed in the operating room (p > 0.10).


External ventricular drain placement has a significant risk of associated hemorrhage. However, the hemorrhages are rarely large and almost never require surgical intervention. There is a favorable trend, but no significant risk reduction when EVDs are placed in the operating room rather than the intensive care unit.

Abbreviations used in this paper: CSF = cerebrospinal fluid; EVD = external ventricular drain; ICH = intracerebral hemorrhage; ICU = intensive care unit; IVH = intraventricular hemorrhage; OR = operating room; SAH = subarachnoid hemorrhage; SDH = subdural hematoma; UPMC = University of Pittsburgh Medical Center.

Article Information

Address correspondence to: Paul A. Gardner, M.D., Department of Neurological Surgery, University of Pittsburgh School of Medicine, 203 Lothrop Street, Suite 500, Pittsburgh, Pennsylvania 15213. email: gardpa@upmc.edu.

© AANS, except where prohibited by US copyright law.



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    Axial CT scan obtained after EVD placement. A trace hemorrhage associated with the catheter is shown.

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    Axial CT scan obtained after EVD placement demonstrating a small (< 15 ml) catheter-associated hemorrhage.

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    Axial CT scan obtained after EVD placement demonstrating a large hemorrhage (> 15 ml).

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    Axial CT scan obtained after EVD placement showing a new IVH associated with catheter placement.

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    Axial CT scan obtained after evacuation of a contralateral SDH and placement of an ipsilateral EVD showing a new, large, ipsilateral SDH that required subsequent evacuation. It is impossible to know whether the new hematoma was a consequence of EVD placement (versus contralateral decompression) but is assumed to be, given that it occurred on the same side.



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