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The importance of aspirin, catheterization accuracy, and catheter design in external ventricular drainage-related hemorrhage: a multicenter study of 1002 procedures

  • Original Article - Neurosurgery general
  • Published:
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Abstract

Background

External ventricular drainage (EVD) is the commonest neurosurgical procedure performed in daily neurosurgical practice, but relatively few studies have investigated the incidence and risk factors of its related hemorrhagic complications.

Methods

This was a multicenter retrospective review of consecutive EVD procedures. Patients 18 years or older who underwent EVD and had a routine postoperative computed tomography (CT) scan performed within 24 hours were included. EVD-related hemorrhage was defined as new intracranial hemorrhage immediately adjacent or within the ventricular catheter trajectory. The volume of hemorrhage and the position of the catheter tip were assessed. A review of patient-, disease-, and surgery-related factors including the ventricular catheter design utilized was conducted. The Bonferroni correction was applied to the alpha level of significance (0.05) for multivariable analysis.

Results

Nine hundred sixty-two patients underwent 1002 EVD performed by neurosurgeons in the operating theater. Sixteen percent (154) of patients were on aspirin before the procedure. Thirty-four percent (333) of patients had intracerebral hemorrhage, 25% (251) had aneurysmal subarachnoid hemorrhage and 16% (158) had traumatic brain injury. The mean duration from EVD to the first postoperative CT scan was 20 ± 4 h. EVD-related hematomas were detected after 81 procedures with a per-catheter risk of 8.1%. Mean hematoma volume was 1.2 ± 3.3 ml. Most were less than 1 ml (grade I, 79%, 64), 1 to 15 ml (grade II) in 20% (16) and a single clot larger than 15 ml (grade III, 1%) were detected. Clinically significant hemorrhage that resulted in catheter occlusion occurred in 1.7% (17) of procedures. Most catheters (62%, 625) were optimally placed, i.e., its tip being within the ipsilateral frontal horn or third ventricle. Three non-antibiotic-impregnated ventricular catheter designs were used with 55% (550) being the 2.2-mm Integra™ catheter, 14% (137) being the 2.8-mm Medtronic™ catheter, and 31% (315) being the 3.1-mm Codman™ catheter. Independent significant predictors for EVD-related hemorrhage were the preoperative prescription of aspirin (adjusted OR 1.94; 95% CI 1.10–3.44), catheter malposition (aOR 1.99; 95% CI 1.22–3.23), and use of the 2.8-mm Medtronic™ catheter (aOR 4.22; 95% CI 2.39–7.41).

Conclusions

The per-catheter risk of hemorrhage was 8.1%, but the incidence of symptomatic hemorrhage was low. The only patient risk factor was aspirin intake. This is the first study to evaluate and establish an association between catheter malposition and catheter design with EVD-related hemorrhage.

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Abbreviations

CI:

Confidence interval

CSF:

Cerebrospinal fluid

CT:

Computed tomography

DICOM:

Digital images for communications in medicine

EVD:

External ventricular drainage

ICH:

Intracerebral hematoma

OD:

Outer diameter

OR:

Odds ratio

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Authors and Affiliations

  1. Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China

    Peter Y. M. Woo, Jacob X. Xiao, Daniel Wong, Andrew Seto, Sandy Lam, Carmen Yim, Hong-Yip Lo & Kwong-Yau Chan

  2. Department of Neurosurgery, Queen Elizabeth Hospital, Hong Kong, China

    Ben C. F. Ng & Larry Y. W. Wong

  3. Department of Neurosurgery, Princess Margaret Hospital, Hong Kong, China

    Yin-Chung Po

  4. Department of Neurosurgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China

    Michael W. Y. Lee

  5. Department of Neurosurgery, Tuen Mun Hospital, Hong Kong, China

    Kwong-Yui Yam

  6. Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, Hong Kong, China

    Jenny K. S. Pu

  7. Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, Hong Kong, China

    Wai-Sang Poon

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Correspondence to Peter Y. M. Woo.

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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 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.

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Woo, P.Y.M., Ng, B.C.F., Xiao, J.X. et al. The importance of aspirin, catheterization accuracy, and catheter design in external ventricular drainage-related hemorrhage: a multicenter study of 1002 procedures. Acta Neurochir 161, 1623–1632 (2019). https://doi.org/10.1007/s00701-019-03978-2

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