Risk factors for hemorrhage associated with external ventricular drain placement and removal

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OBJECTIVE

External ventricular drains (EVDs) have an important role in the management of neurological disease, and their placement is a frequently performed neurosurgical procedure. Hemorrhage is a common complication of EVD placement and occurs more frequently than originally believed. There is also risk of hemorrhage with removal of an EVD, which has not been well described. The authors investigated the risk factors associated with placement and removal of EVDs at their institution.

METHODS

A database was created including patients who required EVD placement from March 2008 to June 2014 at the University of Minnesota. A retrospective chart review was completed, and data were collected for each patient. All cranial imaging studies during the index hospitalization were reviewed to identify hemorrhages associated with either EVD placement or removal. The study was performed using a research protocol approved by the University of Minnesota's institutional review board.

RESULTS

Four hundred eighty-two EVDs were placed during the designated time period. Among the cases in which patients underwent imaging after the placement procedure, hemorrhage was found in 94 (21.6%). The hemorrhage volume ranged from 0.003 cm3 to 45.9 cm3 (mean [± SD] 1.96 ± 6.48 cm3). Two of these hemorrhages resulted in additional interventions: 1 surgical evacuation and 1 contralateral EVD. In 55 (22.5%) of the 244 cases in which imaging was performed after EVD removal, hemorrhage associated with removal was identified. The mean volume of these hemorrhages was 8.25 ± 20.34 cm3 (range 0.012–82.08 cm3). Two EVDs were replaced, and 1 patient died as a result of a large hemorrhage. Large hemorrhages (> 30 cm3) occurred in 2 patients on placement (0.46%) and in 5 patients on removal (2.0%). In this series, decreased platelet levels on admission and an increasing number of EVD placement attempts correlated with an increased risk of hemorrhage on placement. Only those with an EVD placed at bedside were more likely to have hemorrhage on EVD removal.

CONCLUSIONS

Multiple studies have reported varying EVD hemorrhage rates while very few studies have described hemorrhage secondary to EVD removal. This is the first reported analysis of risk factors associated with hemorrhage on EVD removal. Hemorrhages occur relatively frequently following EVD placement and removal, though clinical significance of these events seems to be low.

ABBREVIATIONSEVD = external ventricular drain; INR = international normalized ratio; OR = odds ratio.

Abstract

OBJECTIVE

External ventricular drains (EVDs) have an important role in the management of neurological disease, and their placement is a frequently performed neurosurgical procedure. Hemorrhage is a common complication of EVD placement and occurs more frequently than originally believed. There is also risk of hemorrhage with removal of an EVD, which has not been well described. The authors investigated the risk factors associated with placement and removal of EVDs at their institution.

METHODS

A database was created including patients who required EVD placement from March 2008 to June 2014 at the University of Minnesota. A retrospective chart review was completed, and data were collected for each patient. All cranial imaging studies during the index hospitalization were reviewed to identify hemorrhages associated with either EVD placement or removal. The study was performed using a research protocol approved by the University of Minnesota's institutional review board.

RESULTS

Four hundred eighty-two EVDs were placed during the designated time period. Among the cases in which patients underwent imaging after the placement procedure, hemorrhage was found in 94 (21.6%). The hemorrhage volume ranged from 0.003 cm3 to 45.9 cm3 (mean [± SD] 1.96 ± 6.48 cm3). Two of these hemorrhages resulted in additional interventions: 1 surgical evacuation and 1 contralateral EVD. In 55 (22.5%) of the 244 cases in which imaging was performed after EVD removal, hemorrhage associated with removal was identified. The mean volume of these hemorrhages was 8.25 ± 20.34 cm3 (range 0.012–82.08 cm3). Two EVDs were replaced, and 1 patient died as a result of a large hemorrhage. Large hemorrhages (> 30 cm3) occurred in 2 patients on placement (0.46%) and in 5 patients on removal (2.0%). In this series, decreased platelet levels on admission and an increasing number of EVD placement attempts correlated with an increased risk of hemorrhage on placement. Only those with an EVD placed at bedside were more likely to have hemorrhage on EVD removal.

CONCLUSIONS

Multiple studies have reported varying EVD hemorrhage rates while very few studies have described hemorrhage secondary to EVD removal. This is the first reported analysis of risk factors associated with hemorrhage on EVD removal. Hemorrhages occur relatively frequently following EVD placement and removal, though clinical significance of these events seems to be low.

External ventricular drain (EVD) placement has an important role in the management of neurological disease and is one of the most common neurosurgical procedures. An estimated 42,000 EVD placements were performed in 2006 in the United States, and this volume has increased over the past decade.27,32 EVDs are primarily used for CSF diversion and monitoring of intracranial pressure. Conditions for which they are placed include severe closed head injury, hydrocephalus, intraventricular hemorrhage, CSF fistulas, infections, and intracranial hypertension.

As with any invasive procedure, EVD placement carries risk; however, the reported complication rates are low enough to justify the routine use of ventriculostomies. The 2 most common complications associated with EVDs are infection and hemorrhage, with numerous published reports focusing on each complication. The widespread use of CT has resulted in increased postprocedural or surveillance imaging. Consequently, the incidence of hemorrhage following EVD placement has been shown to be much higher compared with historical reports. The contemporary literature describes the incidence of EVD-associated hemorrhage ranging broadly from 0% to 42%.1,6–11,13–15,17–26,28–31,33,34 The majority of these hemorrhages appear to be small and not clinically significant.

While the risks associated with EVD placement have been studied extensively, there is little information regarding risks with EVD removal (Table 1). The incidence of hemorrhage associated with removal of an EVD has been documented in a few articles but has not been studied rigorously.8,18,28 The risk factors for EVD removal seem similar intuitively to those for EVD placement, but removal of an EVD is typically viewed as a trivial procedure. Given the relative scarcity of data on the subject, we investigated the incidence of hemorrhage and associated risk factors with both EVD placement and removal.

TABLE 1.

Example articles on EVD-related hemorrhage

Authors & YearNo. of EVDsPlacement HemorrhageRoutine Post-EVD CTRemoval Hemorrhage
No. of Cases%No. of Cases%
Friedman & Vries, 198010011.0N
Narayan et al., 198220741.9Y
North & Reilly, 198619921.0N
Paramore & Turner, 199425341.6Y
Khanna et al., 199510600N
Guyot et al., 199827493.3N
O'Leary et al., 20004900Y
Roitberg et al., 200110311.0N
Wiesmann & Mayer, 20019266.5Y
Ross & Dhillon, 20035123.923.9
Krötz et al., 20045211.9Y
Anderson et al., 2004681217.7Y
Hoh et al., 2005119*

251
12

25
10.1

10.0
Y
Maniker et al., 20061605232.5Y
Leung et al., 200613310.8N
Huyette et al., 2008981818.4Y
Kakarla et al., 2008346174.9Y
Saladino et al., 2009212157.1Y
Gardner et al., 20091886434.0Y136.9
Kung et al., 201191

50*
16

16
14.7

32.0
Y1

3
1.1

2
Phillips et al., 201347510.6Y
Scholz et al., 201327414.8Y
Ko et al., 20143707620.5Y
Sussman et al., 2014692231.9Y

N = no; Y = yes; — = not reported in article.

Indicates those patients receiving anticoagulant agent.

Both EVD and ventriculoperitoneal shunt were included in the analysis.

Methods

Patient Selection

This study was completed in accordance with a research protocol approved by the institutional review board at the University of Minnesota Medical Center. It followed the Health Insurance Portability and Accountability Act standards for privacy of personal health information. A departmental database was searched for any patient in whom an EVD was placed from March 2008 to June 2014. All medical records and brain images (MRI and helical CT) were reviewed for parameters including admission date and time; admission diagnosis; medical comorbidities; indication for ventriculostomy; coagulation parameters and platelet counts at admission, prior to EVD placement and prior to EVD removal; blood product transfusions administered prior to the procedure; location of EVD; number of passes needed for successful placement; time of postprocedural imaging; new hemorrhage on postprocedural imaging; duration of EVD; time of imaging following removal; hemorrhage on imaging following removal; and any other related complications during hospitalization.

Technique of EVD Placement

The majority of ventriculostomies were performed in the frontal region, using a standard technique. The patient is placed supine, and the entry point is identified just anterior to the coronal suture in the midpupillary plane. The area is shaved, prepared, and draped in a sterile fashion, and the planned incision is infiltrated with local anesthetic. A small opening is made in the skull with a twist drill, and the dura is punctured with a spinal needle. An antibiotic-impregnated ventricular catheter (Bactiseal, DePuy Synthes) is advanced over a stylet perpendicular to the brain, and the frontal horn of the lateral ventricle is cannulated. The catheter is then tunneled subcutaneously out a separate stab incision approximately 5 cm away from the insertion site, secured to the scalp, and connected to a closed drainage system.

An occipital approach was used for some patients. The insertion technique is similar, except that the patients are placed prone, with the entry point made 6 cm above the external occipital protuberance and 3 cm lateral to mid-line. The trajectory for the catheter is toward the ipsilateral medial canthus, and the catheter is inserted to a length up to 12 cm.

Determination of EVD-Related Hemorrhage

One author reviewed all imaging studies obtained during the index hospitalization for hemorrhage and compared findings to official radiology reports. Any imaging from the time of placement or removal to 3 days after was examined for hemorrhage to ensure that slowly forming hemorrhages were not missed. A hemorrhage related to EVD placement was defined as any new hemorrhage along the ventricular catheter tract noted on postprocedural imaging that was not present on preprocedural imaging. Hemorrhage related to EVD removal was described as any new hemorrhage noted along the prior catheter tract or within the ventricles after removal. This definition required that the post-EVD removal imaging was compared with an imaging study obtained following EVD insertion. The size and volume of each hemorrhage was calculated by measuring the maximal dimensions in the X (A), Y (B), and Z (C) axes and using the formula A×B×C/2.16 Medical records were reviewed to determine the clinical significance of the hemorrhage. We defined a hemorrhage to be clinically significant if the patient exhibited a temporally related deterioration in neurological examination. There was some difficultly in determining clinical significance of the hemorrhage if other processes confounded the patient's neurological condition.

Statistical Analysis

To compare groups, a 2-sample t-test was used for continuous variables (age, duration of EVD), and a chi-square test or Fisher's exact test was used for categorical variables (comorbidities, location). Logistic regression analysis was performed to examine potential risk factors for hemorrhage on EVD placement and EVD removal. The method of generalized estimating equations was used to account for within-patient correlations since some patients had multiple EVDs. Backward selection was conducted to select the strongest set of risk factors using statistical analysis software (version 9.3, SAS Institute Inc.). A 2-sided p value < 0.05 was considered statistically significant.

Results

From March 2008 to June 2014, 482 EVDs were placed in 380 patients (Table 2). Four hundred nine EVDs were placed in adult patients (age 18–81 years), and 73 were placed in pediatric patients (age 2 weeks–17 years). The majority of the EVDs were placed in the frontal region (457), followed by the occipital (14), parietal (8), and temporal regions (3). Fifty-five percent of the procedures (267) were performed at bedside, with the remainder (215) placed in the operating room. Frameless stereotactic image guidance was used in 54 ventriculostomies, ultrasound guidance for 25, and endoscopy for 13. Table 3 displays the indications for EVDs, the most frequent of which was hemorrhage (213).

TABLE 2.

Demographics and clinical characteristics of patients requiring EVD placement*

CharacteristicNo. of Pts (n = 380)
Pediatric73
Adult409
Location of EVD
  Frontal457
  Occipital14
  Temporal3
  Parietal8
Placement site
  Bedside267
  Operating room215
Navigation
  Frameless stereotaxy53 (1 bedside)
  Ultrasound25
  Endoscopic13
  None390

Pts = patients.

A total of 482 EVDs were placed.

TABLE 3.

Reasons for EVD placement

ReasonNo. of EVDs
Hemorrhage
  SAH119
  IPH/IVH/SDH85
  Cerebellum9
Tumor86
Shunt infection/malfunction57
Hydrocephalus48
Stroke/edema17
Trauma8
Other53

IPH = intraparenchymal hemorrhage; IVH = intraventricular hemorrhage; SAH = subarachnoid hemorrhage; SDH = subdural hematoma.

The length of time for which an EVD was necessary varied from 1 to 38 days (mean [± SD] 8.56 ± 6.17 days). Seventy-six EVDs (15.8%) were eventually converted to permanent CSF shunts. The mean length of time during which the EVD was in place in this group was 12.0 ± 7.52 days. Care was withdrawn in 87 patients (22.9%) while the EVD was in place.

One hundred sixteen EVDs were placed in patients who had been on anticoagulants or antiplatelet agents upon presentation to the hospital. Forty-six EVDs were placed in patients with underlying systemic coagulopathies due to liver disease, end stage renal disease, lymphoproliferative disorders, and chemotherapy, while 25 were placed in patients with both prior anticoagulant/antiplatelet and a systemic coagulopathy. Anticoagulation or antiplatelet therapy was initiated prior to EVD removal in 148 cases.

Hemorrhage Associated With Placement

Imaging was obtained after 435 EVD placements, and 94 hemorrhages (21.6%) were identified (Fig. 1). Three hundred forty-one EVDs were not associated with a hemorrhage, while no imaging was obtained after 47 EVD placements. The hemorrhage volume ranged from 0.003 cm3 to 45.9 cm3 (mean 1.96 ± 6.48 cm3). The vast majority of these hemorrhages (83) were intracerebral, in addition to 1 intraventricular hemorrhage, 3 epidural hematomas, 2 subdural hematomas, and 5 events that were a combination of hemorrhages. One patient had a large intraparenchymal hemorrhage that required surgical evacuation (hemorrhage volume 36.8 cm3), and 1 patient required the placement of a contralateral EVD. Two patients with hemorrhage had withdrawal of care shortly after EVD placement given their poor prognosis from their underlying disease.

FIG. 1.
FIG. 1.

CT scans of examples of hemorrhages occurring on EVD placement showing the variation in hemorrhage size from moderate (left, arrow) to small (right, arrow). Figure is available in color online only.

Univariate analysis was performed on all recorded parameters in patients with hemorrhage following EVD placement, and several parameters were found to be statistically significant: international normalized ratio (INR) at admission, admission platelet count, pre-EVD platelet count, number of placement attempts, presence of liver or renal disease, transfusion prior to placement, and setting for placement (Table 4). After backward model selection, we found that only admission platelet count and the number of attempts at placement were associated with hemorrhage on EVD placement (odds ratio [OR], 95% CI 0.99–0.99, p = 0.01; OR 3.06, 95% CI 1.81–5.18, p < 0.01, respectively). For an admission platelet count increase of 1000, we expect to see a 0.3% decrease in the odds of hemorrhage on EVD placement. For each additional attempt, we expect to see a 306% increase in the odds of hemorrhage on EVD placement.

TABLE 4.

Statistical analysis of the relationship between variables and hemorrhage on EVD placement

ParameterAll PtsUnivariate AnalysisMultivariate Analysis
HemorrhageNo Hemorrhagep ValueAdjusted OR (95% CI)p Value
No. of Pts48294388
Age in years0.061.00 (0.99–1.02)0.58
  Mean48.143.8
  SD18.523.2
Admit INR0.031.87 (0.84–4.167)0.12
  Mean1.311.11
  SD0.900.26
Admit PC0.020.99 (0.99–1.00)0.30
  Mean228253
  SD91118
Pre-EVD INR0.310.53 (0.08–3.33)0.50
  Mean1.111.09
  SD0.190.15
Pre-EVD PC0.031.00 (0.99–1.00)0.90
  Mean221246
  SD97±116
No. of attempts<0.013.09 (1.76–5.43)<0.01
  Mean1.31.05
  SD0.720.31
Resident year0.140.96 (0.83–1.12)0.62
  Mean3.133.42
  SD1.721.76
Comorbidities, n (%)0.01
  No LD or RD42675 (17.6)351 (82.4)Ref
  LD238 (34.8)15 (65.2)1.33 (0.51–3.43)0.56
  RD3311 (33.3)22 (66.7)2.46 (0.94–6.46)0.07
Smoker, n (%)0.45
  N29756 (18.9)241 (81.1)Ref
  Y10318 (17.5)85 (82.5)0.73 (0.37–1.43)0.36
  Past8220 (24.4)62 (75.6)1.39 (0.72–2.70)0.33
Coagulopathy, n (%)0.11
  N43681 (18.6)355 (81.4)Ref
  Y4613 (28.3)33 (71.7)0.87 (0.40–1.88)0.72
Prior anticoag/antiplate, n (%)0.71
  N36670 (19.1)296 (80.9)Ref
  Y11624 (20.7)92 (79.3)0.52 (0.26–1.02)0.06
Prior transfusion, n (%)<0.01
  N41071 (17.3)339 (82.7)Ref
  Y7223 (31.9)49 (68.1)1.68 (0.79–3.56)0.17
Placement site, n (%)0.02
  Bedside26762 (23.2)205 (76.8)Ref
  Operating room21532 (14.9)183 (85.1)0.76 (0.42–1.39)0.38
Image guidance, n (%)0.39
  N39079 (20.3)311 (79.7)Ref
  Y9216 (16.3)77 (83.7)0.97 (0.47–2.00)0.93

Anticoag = anticoagulation; antiplate = antiplatelet; LD = liver disease; PC = platelet count; RD = renal disease; Ref = reference.

Hemorrhage Associated With EVD Removal

Fifty-five new hemorrhages (22.5%) were noted after 244 EVD removals in patients in whom imaging was obtained after the EVD was removed (Fig. 2). Imaging was not obtained after 238 EVD removals, with approximately one-third (87) of these patients progressing to death. The mean hemorrhage volume was 8.25 ± 20.34 cm3 (range 0.012–82.08 cm3). Intracerebral hemorrhages, again, accounted for the majority of the hemorrhages (46), as well as intraventricular hemorrhage in 6 patients and a combination of hemorrhages in 3 patients. No patients required surgical evacuation; however, 2 patients needed EVD replacement. One patient died due to a large intracerebral hemorrhage after EVD removal (hemorrhage volume 82.08 cm3). Eighteen patients had hemorrhage on both EVD placement and removal.

FIG. 2.
FIG. 2.

CT scans showing intracerebral hemorrhages on EVD removal that vary in size and clinical significance. The large hemorrhage (left, arrow) resulted in withdrawal of care and the small hemorrhage (right, arrow) was asymptomatic. Figure is available in color online only.

The only parameter found to be statistically significant on univariate analysis for hemorrhage following EVD removal was the use of image guidance (Table 5). Multivariate analysis was completed with only the physical location for EVD placement (bedside vs operating room) being associated with hemorrhage (OR 1.00, 95% CI 1.00–1.00, reference p value; OR 0.47, 95% CI 0.26–0.85, p = 0.01, respectively). We found that the odds of a hemorrhage occurring on EVD removal were 53% lower for placement procedures carried out in the operating room than for those performed at the bedside.

TABLE 5.

Statistical analysis of the relationship between variables and hemorrhage on EVD removal

ParameterAll PtsHemorrhageNo Hemorrhagep ValueAdjusted OR (95% CI)p Value
No. of Pts48255427
Age in years0.380.98 (0.96–1.00)0.07
  Mean42.344.9
  SD21.022.6
No. of attempts0.730.99 (0.53–1.86)0.99
  Mean1.131.10
  SD0.550.42
Resident year0.090.91 (0.74–1.12)0.37
  Mean3.003.41
  SD1.641.77
Pre-removal INR0.990.65 (0.11–3.88)0.64
  Mean1.111.11
  SD0.150.16
Pre-removal PC0.510.99 (.0.99–1.00)0.55
  Mean250262
  SD132129
Days with EVD0.330.95 (0.90–1.01)0.12
  Mean7.788.58
  SD5.596.26
Comorbidities, n (%)
  No LD or RD42647 (11.0%)379 (89.0%)0.26Ref
  LD235 (21.7%)18 (78.3%)1.63 (0.51–5.23)0.41 
  RD333 (9.1%)30 (90.9%)0.81 (0.20–3.20)0.76
Smoker, n (%)
  N29732 (10.8%)265 (89.2%)0.28Ref
  Y10316 (15.5%)87 (84.5%)1.50 (0.72–3.12)0.28
  Past827 (8.5%)75 (94.5%)0.84 (0.32–2.22)0.72
Coagulopathy, n (%)
  N43646 (10.6%)390 (89.4%)0.07Ref
  Y469 (19.6%)37 (80.4%)1.70 (0.60–4.86)0.32
Prior anticoag/antiplate, n (%)
  N36641 (11.2%)325 (88.8%)0.80Ref
  Y11614 (12.01%)102 (87.9%)1.37 (0.60–3.09)0.45
Placement site, n (%)
  Bedside26739 (14.6%)228 (85.4%)0.13Ref
  Operating room21516 (7.4%)199 (92.6%)0.48 (0.18–1.25)0.13
Image guidance, n (%)
  N39049 (12.6%)341 (87.4%)0.01Ref
  Y926 (6.5%)86 (93.5%)0.65 (0.22–1.95)0.44
DVT prophylaxis/anticoag, n (%)
  N33437 (11.1%)297 (88.9%)0.73Ref
  Y14818 (12.2%)130 (87.8%)1.36 (0.68–2.74)0.39
Removal site
  Bedside39643 (10.9%)353 (89.1%)0.41Ref
  Operating room8612 (13.9%)74 (86.1%)2.00 (0.95–4.22)0.07

DVT = deep vein thrombosis.

Discussion

Ventriculostomy is one of the most common neurosurgical procedures and is the mainstay of management for many neurosurgical conditions. The most common complications of ventriculostomy are infection and hemorrhage. A review of 13 studies from 1970 to 2008, comprising 1790 EVDs, found the incidence of hemorrhage associated with placement to be 5.7%.4 A meta-analysis of 16 studies over the same period involving 2428 EVDs reported an incidence of 7.0%.3 The recent literature on hemorrhage related to EVD placement has shown that it is more prevalent than previously reported.8,11,15,20,33 This may be due to standard imaging protocols, which have become more routine in contemporary practice, and advancements in imaging, allowing the detection of very small hemorrhages.

Numerous articles have reported hemorrhage associated with EVD placement, and several have identified related risk factors. In a study investigating the use of tissue plasminogen activator in patients with intraventricular hemorrhage, there was an increased risk of hemorrhage if the EVD had been incorrectly placed.12 A separate study showed patients over the age of 75 years who presented with intracerebral hemorrhage had an increased incidence of hemorrhage related to EVD placement.33 Another report claimed that admission diagnosis of cerebrovascular disease increased the incidence of EVD placement hemorrhage.20 The presence of antiplatelet exposure prior to EVD placement in studies has also been associated with increased hemorrhage rates.15,18 Two studies have also reported a trend toward increased rates of hemorrhage with EVDs placed while patients were in the intensive care unit compared with those placed while patients were in an operating room.6,8

In our study population, the incidence of hemorrhage on EVD placement was 21.6% in all patients who underwent postventriculostomy imaging. The vast majority of these hemorrhages were small (87 of 94 were less than 5 cm3), and only 1 patient required surgical intervention. To our surprise, we did not find an association between the use of antiplatelet agents and increased risk of hemorrhage following EVD placement, as has been reported in previous studies. However, we did find that a decreased platelet count on admission was associated with hemorrhage following placement. We found only 1 other study that included admission platelets in its analysis, but no correlation was found between this variable and hemorrhage.33 In our population, an increasing number of attempts for EVD placement was also found to have an increased risk of hemorrhage. This differs from a study reviewing multiple passes during EVD placement, in which no connection was identified between the number of passes and incidence of hemorrhage.25

To our knowledge, hemorrhage following removal of EVD has only been cited in 3 articles. These studies reported the incidence, which ranged from 1.1% to 6.9%, but did not explore the possible causative factors. In the present study, we found an incidence of 22.5%, although it is important to note that only half of our patients underwent imaging after EVD removal. It is possible that the incidence may be higher with additional small asymptomatic hemorrhages not being identified. Several parameters were evaluated in this study to determine their relationship to hemorrhage on EVD removal. We found that only the bedside placement was associated with an increase in EVD removal hemorrhage. This correlation may be incidental as we did not study the relationship between location of the procedure and the number of attempts. Unexpectedly, the INR value prior to placement and removal was not related to hemorrhage risk. This finding has also been found in trauma patients, where supratherapeutic INRs (> 1.2) were not associated with an increased risk of EVD hemorrhage.2,5

While the mechanism of hemorrhage on EVD placement is understood, the exact etiology for hemorrhage on EVD removal is unclear. There are several potential causes for these hemorrhages. In patients with intraventricular hemorrhage, pulling of the EVD may draw some of this blood along the catheter tract. In a similar manner, it is possible that scalp bleeding may track along the course of the catheter. The catheter itself may injure and tamponade a small vessel during insertion, or its radio-opacity may obscure a small hemorrhage until it is removed. The catheter can become adherent to the choroid plexus or surrounding parenchyma that may hemorrhage on removal. Direct trauma to the parenchyma from EVD withdrawal is possible, although removals are performed without a rigid inner stylet. The removal of EVDs is often viewed as a benign procedure, and many clinicians may have less stringent requirements for coagulation parameters and the use of anticoagulants or antiplatelet agents, which could lead to these hemorrhages.

The majority of the hemorrhages found in this study were small and asymptomatic (Fig. 3). Small hemorrhages of less than 10 cm3 usually do not cause mass effect, as we found with 89 of 94 placement hemorrhages and 47 of 54 removal hemorrhages. Large hemorrhages (> 30 cm3) only occurred in 2 of 94 placement hemorrhages and 5 of 54 removal hemorrhages, with 1 hemorrhage necessitating an EVD, 1 requiring surgical evacuation, and 1 leading to withdrawal of care. Interestingly, 3 of the large hemorrhages noted with EVD removal were entirely intraventricular. Regardless of the size of the hemorrhage, there can be associated clinical consequences, such as potential seizure focus, parenchymal damage, and neurocognitive changes. EVD-related hemorrhages can also affect a patient's recovery, length of hospitalization stay, and may require additional procedures. A large hemorrhage after EVD removal resulted in the death of 1 of our patients. Despite the small size of many of these hemorrhages, it is important to recognize the potential serious complications associated with this procedure.

FIG. 3.
FIG. 3.

Bar graph showing the breakdown of hemorrhage volumes for EVD placement and EVD removal. The majority of hemorrhages had volumes less than 5 cm3, and only a small percentage had moderate or large volumes. Figure is available in color online only.

This analysis is a retrospective, single institution study with several limitations. We maintain a database specifically for EVD placement, and the data are entered by the operators following each procedure. A procedure note is also written in the electronic medical record after every procedure, which includes the number of attempts. Consequently, there may be underreporting of the number of attempts needed for each EVD placement. There is no uniform protocol for obtaining routine imaging after EVD placement or removal, and the decision to do so is often left to the neurosurgeon's discretion. It is possible that some hemorrhages were missed in patients who did not undergo imaging. If so, these hemorrhages were of small volume, as clinically significant hemorrhages often lead to neurological changes prompting further imaging. The underlying neurological disease that necessitates an EVD often obscures the examination, making it difficult to determine whether a hemorrhage is asymptomatic or clinically significant. Given that many of our patients had a substantial degree of neurological dysfunction, it is possible that any new deficits related to the EVD placement or removal were not detected.

A significant potential confounder for this study is the possibility that radio-opaque catheters may obscure small hemorrhages associated with placement, and that these hemorrhages may not be identified until the catheter is removed. Without performing the study with radiolucent catheters, which are not available at our institution, it is impossible to identify these hemorrhages. Of the 55 hemorrhages recorded after EVD removal, 34 of these hemorrhages had volumes less than 1.0 cm3, a volume that has the possibility of being obscured by a catheter. The imaging for this subset of patients was reviewed a second time. Based on the volume and location, 24 of these hemorrhages could have been obscured by the catheter while 10 of the hemorrhages would have been evident with the catheter in place.

Conclusions

Multiple studies have investigated hemorrhage related to EVD placement, with rates varying from 0% to 42%, while very few studies have described hemorrhage secondary to EVD removal. This is the first reported analysis of risk factors associated with hemorrhage on EVD removal. In this series of patients, decreased platelet count on admission and an increasing number of attempts for placement correlated with an increased risk of hemorrhage on EVD placement. Bedside placement was more likely to be associated with hemorrhage on EVD removal.

Acknowledgments

Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health Award Number UL1TR000114. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. We would like to acknowledge Qi Wang, Research Fellow in the Biostatistical Design and Analysis Center, University of Minnesota, for her assistance with the statistical analysis.

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    Davis JWDavis ICBennink LDHysell SECurtis BVKaups KL: Placement of intracranial pressure monitors: are “normal” coagulation parameters necessary?. J Trauma 57:117311772004

  • 6

    Foreman PMHendrix PGriessenauer CJSchmalz PGHarrigan MR: External ventricular drain placement in the intensive care unit versus operating room: evaluation of complications and accuracy. Clin Neurol Neurosurg 128:941002015

  • 7

    Friedman WAVries JK: Percutaneous tunnel ventriculostomy. Summary of 100 procedures. J Neurosurg 53:6626651980

  • 8

    Gardner PAEngh JAtteberry DMoossy JJ: Hemorrhage rates after external ventricular drain placement. J Neurosurg 110:102110252009

  • 9

    Guyot LLDowling CDiaz FGMichael DB: Cerebral monitoring devices: analysis of complications. Acta Neurochir Suppl 71:47491998

  • 10

    Hoh BLNogueira RGLedezma CJPryor JCOgilvy CS: Safety of heparinization for cerebral aneurysm coiling soon after external ventriculostomy drain placement. Neurosurgery 57:8458492005

  • 11

    Huyette DRTurnbow BJKaufman CVaslow DFWhiting BBOh MY: Accuracy of the freehand pass technique for ventriculostomy catheter placement: retrospective assessment using computed tomography scans. J Neurosurg 108:88912008

  • 12

    Jackson DAPatel AVDarracott RMHanel RAFreeman WDHanley DF: Safety of intraventricular hemorrhage (IVH) thrombolysis based on CT localization of external ventricular drain (EVD) fenestrations and analysis of EVD tract hemorrhage. Neurocrit Care 19:1031102013

  • 13

    Kakarla UKKim LJChang SWTheodore NSpetzler RF: Safety and accuracy of bedside external ventricular drain placement. Neurosurgery 63:1 Suppl 1ONS162ONS1672008

  • 14

    Khanna RKRosenblum MLRock JPMalik GM: Prolonged external ventricular drainage with percutaneous long-tunnel ventriculostomies. J Neurosurg 83:7917941995

  • 15

    Ko JKCha SHChoi BKLee JIYun EYChoi CH: Hemorrhage rates associated with two methods of ventriculostomy: external ventricular drainage vs. ventriculoperitoneal shunt procedure. Neurol Med Chir (Tokyo) 54:5455512014

  • 16

    Kothari RUBrott TBroderick JPBarsan WGSauerbeck LRZuccarello M: The ABCs of measuring intracerebral hemorrhage volumes. Stroke 27:130413051996

  • 17

    Krötz MLinsenmaier UKanz KGPfeifer KJMutschler WReiser M: Evaluation of minimally invasive percutaneous CT-controlled ventriculostomy in patients with severe head trauma. Eur Radiol 14:2272332004

  • 18

    Kung DKPoliceni BACapuano AWRossen JDJabbour PMTorner JC: Risk of ventriculostomy-related hemorrhage in patients with acutely ruptured aneurysms treated using stent-assisted coiling. J Neurosurg 114:102110272011

  • 19

    Leung GKNg KBTaw BBFan YW: Extended subcutaneous tunnelling technique for external ventricular drainage. Br J Neurosurg 21:3593642007

  • 20

    Maniker AHVaynman AYKarimi RJSabit AOHolland B: Hemorrhagic complications of external ventricular drainage. Neurosurgery 59:4 Suppl 2ONS419ONS4252006

  • 21

    Narayan RKKishore PRBecker DPWard JDEnas GGGreenberg RP: Intracranial pressure: to monitor or not to monitor? A review of our experience with severe head injury. J Neurosurg 56:6506591982

  • 22

    North BReilly P: Comparison among three methods of intracranial pressure recording. Neurosurgery 18:7307321986

  • 23

    O'Leary STKole MKHoover DAHysell SEThomas AShaffrey CI: Efficacy of the Ghajar Guide revisited: a prospective study. J Neurosurg 92:8018032000

  • 24

    Paramore CGTurner DA: Relative risks of ventriculostomy infection and morbidity. Acta Neurochir (Wien) 127:79841994

  • 25

    Phillips SBDelly FNelson CKrishnamurthy S: Bedside external ventricular drain placement: can multiple passes be predicted on the computed tomography scan before the procedure?. World Neurosurg 82:7397442014

  • 26

    Roitberg BZKhan NAlp MSHersonskey TCharbel FTAusman JI: Bedside external ventricular drain placement for the treatment of acute hydrocephalus. Br J Neurosurg 15:3243272001

  • 27

    Rosenbaum BPVadera SKelly MLKshettry VRWeil RJ: Ventriculostomy: Frequency, length of stay and in-hospital mortality in the United States of America, 1988–2010. J Clin Neurosci 21:6236322014

  • 28

    Ross IBDhillon GS: Ventriculostomy-related cerebral hemorrhages after endovascular aneurysm treatment. AJNR Am J Neuroradiol 24:152815312003

  • 29

    Saladino AWhite JBWijdicks EFLanzino G: Malplacement of ventricular catheters by neurosurgeons: a single institution experience. Neurocrit Care 10:2482522009

  • 30

    Schödel PProescholdt MUllrich OWBrawanski ASchebesch KM: An outcome analysis of two different procedures of burr-hole trephine and external ventricular drainage in acute hydrocephalus. J Clin Neurosci 19:2672702012

  • 31

    Scholz CHubbe UDeininger MDeininger MH: Hemorrhage rates of external ventricular drain (EVD), intracranial pressure gauge (ICP) or combined EVD and ICP gauge placement within 48 h of endovascular coil embolization of cerebral aneurysms. Clin Neurol Neurosurg 115:139914022013

  • 32

    Sekula RFCohen DBPatek PMJannetta PJOh MY: Epidemiology of ventriculostomy in the United States from 1997 to 2001. Br J Neurosurg 22:2132182008

  • 33

    Sussman ESKellner CPNelson EMcDowell MMBruce SSBruce RA: Hemorrhagic complications of ventriculostomy: incidence and predictors in patients with intracerebral hemorrhage. J Neurosurg 120:9319362014

  • 34

    Wiesmann MMayer TE: Intracranial bleeding rates associated with two methods of external ventricular drainage. J Clin Neurosci 8:1261282001

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: both authors. Acquisition of data: Miller. Analysis and interpretation of data: Miller. Drafting the article: Miller. Critically revising the article: Miller. Reviewed submitted version of manuscript: Miller. Approved the final version of the manuscript on behalf of both authors: Miller. Statistical analysis: Miller. Study supervision: Tummala.

Supplemental Information

Previous Presentations

Portions of this work were presented in 2015 at the Congress of Neurological Surgeons Annual Meeting (September 26–20, New Orleans, LA).

If the inline PDF is not rendering correctly, you can download the PDF file here.

Article Information

INCLUDE WHEN CITING Published online April 1, 2016; DOI: 10.3171/2015.12.JNS152341.

Correspondence Catherine Miller, Department of Neurosurgery, University of Minnesota, 420 Delaware St. SE, MMC 96, Room D429 Mayo Building, Minneapolis, MN 55455. email: mill5459@umn.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    CT scans of examples of hemorrhages occurring on EVD placement showing the variation in hemorrhage size from moderate (left, arrow) to small (right, arrow). Figure is available in color online only.

  • View in gallery

    CT scans showing intracerebral hemorrhages on EVD removal that vary in size and clinical significance. The large hemorrhage (left, arrow) resulted in withdrawal of care and the small hemorrhage (right, arrow) was asymptomatic. Figure is available in color online only.

  • View in gallery

    Bar graph showing the breakdown of hemorrhage volumes for EVD placement and EVD removal. The majority of hemorrhages had volumes less than 5 cm3, and only a small percentage had moderate or large volumes. Figure is available in color online only.

References

1

Anderson RCKan PKlimo PBrockmeyer DLWalker MLKestle JR: Complications of intracranial pressure monitoring in children with head trauma. J Neurosurg 101:1 Suppl53582004

2

Bauer DFMcGwin G JrMelton SMGeorge RLMarkert JM: The relationship between INR and development of hemorrhage with placement of ventriculostomy. J Trauma 70:111211172011

3

Bauer DFRazdan SNBartolucci AAMarkert JM: Meta-analysis of hemorrhagic complications from ventriculostomy placement by neurosurgeons. Neurosurgery 69:2552602011

4

Binz DDToussaint LG IIIFriedman JA: Hemorrhagic complications of ventriculostomy placement: a meta-analysis. Neurocrit Care 10:2532562009

5

Davis JWDavis ICBennink LDHysell SECurtis BVKaups KL: Placement of intracranial pressure monitors: are “normal” coagulation parameters necessary?. J Trauma 57:117311772004

6

Foreman PMHendrix PGriessenauer CJSchmalz PGHarrigan MR: External ventricular drain placement in the intensive care unit versus operating room: evaluation of complications and accuracy. Clin Neurol Neurosurg 128:941002015

7

Friedman WAVries JK: Percutaneous tunnel ventriculostomy. Summary of 100 procedures. J Neurosurg 53:6626651980

8

Gardner PAEngh JAtteberry DMoossy JJ: Hemorrhage rates after external ventricular drain placement. J Neurosurg 110:102110252009

9

Guyot LLDowling CDiaz FGMichael DB: Cerebral monitoring devices: analysis of complications. Acta Neurochir Suppl 71:47491998

10

Hoh BLNogueira RGLedezma CJPryor JCOgilvy CS: Safety of heparinization for cerebral aneurysm coiling soon after external ventriculostomy drain placement. Neurosurgery 57:8458492005

11

Huyette DRTurnbow BJKaufman CVaslow DFWhiting BBOh MY: Accuracy of the freehand pass technique for ventriculostomy catheter placement: retrospective assessment using computed tomography scans. J Neurosurg 108:88912008

12

Jackson DAPatel AVDarracott RMHanel RAFreeman WDHanley DF: Safety of intraventricular hemorrhage (IVH) thrombolysis based on CT localization of external ventricular drain (EVD) fenestrations and analysis of EVD tract hemorrhage. Neurocrit Care 19:1031102013

13

Kakarla UKKim LJChang SWTheodore NSpetzler RF: Safety and accuracy of bedside external ventricular drain placement. Neurosurgery 63:1 Suppl 1ONS162ONS1672008

14

Khanna RKRosenblum MLRock JPMalik GM: Prolonged external ventricular drainage with percutaneous long-tunnel ventriculostomies. J Neurosurg 83:7917941995

15

Ko JKCha SHChoi BKLee JIYun EYChoi CH: Hemorrhage rates associated with two methods of ventriculostomy: external ventricular drainage vs. ventriculoperitoneal shunt procedure. Neurol Med Chir (Tokyo) 54:5455512014

16

Kothari RUBrott TBroderick JPBarsan WGSauerbeck LRZuccarello M: The ABCs of measuring intracerebral hemorrhage volumes. Stroke 27:130413051996

17

Krötz MLinsenmaier UKanz KGPfeifer KJMutschler WReiser M: Evaluation of minimally invasive percutaneous CT-controlled ventriculostomy in patients with severe head trauma. Eur Radiol 14:2272332004

18

Kung DKPoliceni BACapuano AWRossen JDJabbour PMTorner JC: Risk of ventriculostomy-related hemorrhage in patients with acutely ruptured aneurysms treated using stent-assisted coiling. J Neurosurg 114:102110272011

19

Leung GKNg KBTaw BBFan YW: Extended subcutaneous tunnelling technique for external ventricular drainage. Br J Neurosurg 21:3593642007

20

Maniker AHVaynman AYKarimi RJSabit AOHolland B: Hemorrhagic complications of external ventricular drainage. Neurosurgery 59:4 Suppl 2ONS419ONS4252006

21

Narayan RKKishore PRBecker DPWard JDEnas GGGreenberg RP: Intracranial pressure: to monitor or not to monitor? A review of our experience with severe head injury. J Neurosurg 56:6506591982

22

North BReilly P: Comparison among three methods of intracranial pressure recording. Neurosurgery 18:7307321986

23

O'Leary STKole MKHoover DAHysell SEThomas AShaffrey CI: Efficacy of the Ghajar Guide revisited: a prospective study. J Neurosurg 92:8018032000

24

Paramore CGTurner DA: Relative risks of ventriculostomy infection and morbidity. Acta Neurochir (Wien) 127:79841994

25

Phillips SBDelly FNelson CKrishnamurthy S: Bedside external ventricular drain placement: can multiple passes be predicted on the computed tomography scan before the procedure?. World Neurosurg 82:7397442014

26

Roitberg BZKhan NAlp MSHersonskey TCharbel FTAusman JI: Bedside external ventricular drain placement for the treatment of acute hydrocephalus. Br J Neurosurg 15:3243272001

27

Rosenbaum BPVadera SKelly MLKshettry VRWeil RJ: Ventriculostomy: Frequency, length of stay and in-hospital mortality in the United States of America, 1988–2010. J Clin Neurosci 21:6236322014

28

Ross IBDhillon GS: Ventriculostomy-related cerebral hemorrhages after endovascular aneurysm treatment. AJNR Am J Neuroradiol 24:152815312003

29

Saladino AWhite JBWijdicks EFLanzino G: Malplacement of ventricular catheters by neurosurgeons: a single institution experience. Neurocrit Care 10:2482522009

30

Schödel PProescholdt MUllrich OWBrawanski ASchebesch KM: An outcome analysis of two different procedures of burr-hole trephine and external ventricular drainage in acute hydrocephalus. J Clin Neurosci 19:2672702012

31

Scholz CHubbe UDeininger MDeininger MH: Hemorrhage rates of external ventricular drain (EVD), intracranial pressure gauge (ICP) or combined EVD and ICP gauge placement within 48 h of endovascular coil embolization of cerebral aneurysms. Clin Neurol Neurosurg 115:139914022013

32

Sekula RFCohen DBPatek PMJannetta PJOh MY: Epidemiology of ventriculostomy in the United States from 1997 to 2001. Br J Neurosurg 22:2132182008

33

Sussman ESKellner CPNelson EMcDowell MMBruce SSBruce RA: Hemorrhagic complications of ventriculostomy: incidence and predictors in patients with intracerebral hemorrhage. J Neurosurg 120:9319362014

34

Wiesmann MMayer TE: Intracranial bleeding rates associated with two methods of external ventricular drainage. J Clin Neurosci 8:1261282001

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