Neurocritical Care

, Volume 30, Issue 2, pp 340–347 | Cite as

Characterizing the Response to Cerebrospinal Fluid Drainage in Patients with an External Ventricular Drain: The Pressure Equalization Ratio

  • Carlos Candanedo
  • Omer Doron
  • J. Claude HemphillIII
  • Fernando Ramirez de Noriega
  • Geoffrey T. Manley
  • Rani Patal
  • Guy RosenthalEmail author
Original Article



An external ventricular drain (EVD) is the gold standard for measurement of intracranial pressure (ICP) and allows for drainage of cerebrospinal fluid (CSF). Different causes of elevated ICP, such as CSF outflow obstruction or cerebral swelling, respond differently to CSF drainage. This is a widely recognized but seldom quantified distinction. We sought to define an index to characterize the response to CSF drainage in neurocritical care patients.


We studied consecutive patients admitted to the neurointensive care unit who had an EVD. The EVD was closed for 30 min prior to assessment. We documented pre-drainage ICP, opened EVD to drainage allowing CSF to drain until it ceased, and recorded post-drainage ICP at EVD closure. We calculated the pressure equalization (PE) ratio as the difference between pre-drainage ICP and post-drainage ICP divided by the difference between pre-drainage ICP and EVD height.


We studied 60 patients (36 traumatic brain injury [TBI], 24 non-TBI). As expected, TBI patients had more signs of cerebral swelling on CT and smaller ventricles. Although TBI patients had significantly higher pre-drainage ICP (26 ± 10 mm Hg) than non-TBI patients (19 ± 5 mm Hg, p < 0.001) they drained less CSF (7 cc vs. 4 cc, p < 0.01). PE ratio was substantially higher in non-TBI than in TBI patients (0.86 ± 0.36 vs. 0.43 ± 0.31, p < 0.0001), indicating that non-TBI patients were better able to equalize pressure with EVD height than TBI patients.


PE ratio reflects the ability to equalize pressure with the preset height of the EVD and differs substantially between TBI and non-TBI patients. A high PE ratio likely indicates CSF outflow obstruction effectively treated by CSF diversion, while a lower PE ratio occurs when cerebral swelling predominates. Further studies could assess whether the PE ratio would be useful as a surrogate marker for cerebral edema or the state of intracranial compliance.


Pressure equalization ratio Intracranial pressure External ventricular drain Traumatic brain injury Intracranial compliance 


Author Contribution

CC contributes to acquisition of data, analysis and interpretation of data, revising article; OD contributes to conception and design, acquisition of data, interpretation and analysis of data, derived equation for PE ratio, revising article and contributes equally to this manuscript; JCH contributes to interpretation of data, critically revising article; FR contributes to acquisition of data, analysis of data, revising article; GM contributes to interpretation of data, critically revising article; RP contributes to acquisition of data, critically revising article; GR contributes to conception and design, analysis and interpretation of data, drafting and revising article. All authors approved the final version of the manuscript.

Source of support

No funding.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. This study was approved by the Hadassah-Hebrew University Medical Center Institutional Review Board (IRB approval number 19384).


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society 2018

Authors and Affiliations

  • Carlos Candanedo
    • 1
  • Omer Doron
    • 1
  • J. Claude HemphillIII
    • 2
  • Fernando Ramirez de Noriega
    • 1
  • Geoffrey T. Manley
    • 3
  • Rani Patal
    • 1
  • Guy Rosenthal
    • 1
    Email author
  1. 1.Department of NeurosurgeryHadassah-Hebrew University Medical CenterJerusalemIsrael
  2. 2.Department of NeurologyUniversity of California, San FranciscoSan FranciscoUSA
  3. 3.Department of NeurosurgeryUniversity of California, San FranciscoSan FranciscoUSA

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