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Discontinuation of External Ventricular Drainage in Patients with Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage - a Scandinavian Multi-institutional Survey

  • Original Article - Vascular Neurosurgery - Aneurysm
  • Published:
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Abstract

Background

Hydrocephalus requiring external ventricular drainage is common following aneurysmal subarachnoid hemorrhage (aSAH). Timing and strategy for the discontinuation of the external ventricular drain (EVD) are, however, controversial as guidelines are based on limited scientific evidence. A recent similar survey showed that guidelines and recommendations are not being followed. We conducted a questionnaire survey regarding the management of EVD treatment in patients with aSAH and investigated current treatment practice, consensus, and adherence to guidelines within the neurosurgical departments in Scandinavia.

Methods

A questionnaire concerning the management of EVD discontinuation in patients with hydrocephalus following aSAH was distributed to all 14 neurosurgical departments in Scandinavia (Norway, Sweden, and Denmark). Neurosurgeons and neurosurgical trainees at all levels were asked to complete the questionnaire individually. A total of 175 completed questionnaires were received between May 2018 and April 2019, resulting in a response rate of 64 %.

Results

Eighty-five percent of respondents reported no knowledge of international guidelines regarding EVD discontinuation in patients with hydrocephalus following aSAH. Within every department, respondents disagreed on whether a common discontinuation strategy was followed or not. Seventy-four percent decided upon the EVD discontinuation strategy mainly determined by patients’ clinical condition and drainage volume. Forty-five percent considered Glasgow Coma Score (GCS) the most important clinical variable when assessing the timing of EVD discontinuation. There was general agreement towards the initiation of EVD discontinuation 4–7 days after ictus of aSAH in a stable patient with a drainage volume of < 150 ml/day and intracranial pressure (ICP) < 15 mmHg.

Conclusion

Awareness of and adherence to international guidelines regarding EVD discontinuation in patients with hydrocephalus following aSAH were limited in Scandinavia. Internal consensus at department level was absent. Initiation of the discontinuation process appeared to be case dependent and mainly influenced by the patients’ clinical condition and drainage volume. GCS was the clinical variable considered most important when deciding on the initiation of EVD discontinuation.

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Abbreviations

aSAH:

Aneurysmal subarachnoid hemorrhage

CSF:

Cerebrospinal fluid

CT:

Computer tomography

EVD:

External ventricular drain

GCS:

Glasgow Coma Score

ICP:

Intracranial pressure

ICU:

Intensive care unit

LOS:

Length of stay

NICU:

Neuro intensive care unit

VP:

Ventriculo-peritoneal

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Acknowledgments

The group of authors would like to thank every 175 neurosurgeons in Sweden, Norway, and Denmark for taking the time to complete the questionnaire and share their opinion on this complex matter.

A special appreciation to the local representatives who besides author and co-authors enabled the practical distribution and return of the questionnaires:

  • Martin Nilsson, Department of Neurosurgery, University Hospital Linköping, Sweden

  • Niklas Marklund, Department of Neurosurgery, Lund University Hospital, Sweden

  • Magnus Tisell, Department of Neurosurgery, Sahlgrenska University Hospital, Göteborg, Sweden

  • Peter Lindvall, Department of Neurosurgery, University Hospital of Umea, Sweden

  • Hans Ericsson, Department of Neurosurgery, Uppsala University Hospital, Sweden

  • Angelika Sorteberg, Department of Neurosurgery, Oslo University Hospital, Norway

  • Ole Solheim, Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway

  • Kaja Heiberg, Department of Neurosurgery, University Hospital of North Norway, Tromso, Norway

  • Tina Obbekjær, Department of Neurosurgery, Aarhus University Hospital, Denmark

  • Hans Gram, Department of Neurosurgery, Aalborg University Hospital, Denmark

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark

    Tenna Capion, Alexander Lilja-Cyron, Marianne Juhler & Tiit Mathiesen

  2. Department of Neurosurgery, Karolinska University Hospital, Eugeniavägen 3, 171 76, Stockholm, Sweden

    Jiri Bartek Jr

  3. Department of Neurosurgery, Odense University Hospital, J.B. Winslows Vej 4, 5000, Odense, Denmark

    Axel Forsse

  4. Department of Neurosurgery, Haukeland University Hospital, Jonas Lies Vei 65, 5021, Bergen, Norway

    Nicola Logallo

Authors
  1. Tenna Capion
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  2. Alexander Lilja-Cyron
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  3. Jiri Bartek Jr
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  4. Axel Forsse
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  5. Nicola Logallo
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  6. Marianne Juhler
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  7. Tiit Mathiesen
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Corresponding author

Correspondence to Tenna Capion.

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The authors declare that they have no conflict of interest.

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Comments

Whereas the use of external ventricular drains (EVDs) is highly common in the treatment of posthemorrhagic hydrocephalus, sufficient data are lacking on when and how to discontinue drainage after subarachnoid hemorrhage. Therefore, Dr. Capion and colleagues have conducted a comprehensive multi-institutional survey across Scandinavia to analyze and compare current treatment practices. The vast majority of respondents stated very little or even no knowledge of guidelines for the management of EVD patients. More than half of the inquired departments seem to have no consensus regarding discontinuation strategies. Three-fourths of responses reflected preference towards clinical assessment as the most relevant parameter when determining the timing of discontinuation. The Glasgow Coma Scale (GCS) was the variable considered most important when deciding on the initiation of discontinuation in nearly half of the respondents, although the validity of the GCS should be interpreted with caution especially in neurocritical care patients. There was wide agreement towards terminating EVD treatment between four and seven days after bleeding in cases of clinically stable patients with a cerebrospinal fluid (CSF) drainage volume of less than 150 ml per day and an intracranial pressure under 15 mmHg. Apart from clinical assessability and CSF drainage volume, further potential decision criteria and management options such as cranial imaging, neuromonitoring, risk of cerebral vasospasm, adequate treatment of bleeding source, amount and distribution of hemorrhage, and clearance of CSF from intracranial blood additionally would be of interest and might be taken into account. Finally, the present study is based on Scandinavian patient cohorts and generalizing or translating the results to settings worldwide should be critically done. Despite these considerations, the present article is an important contribution to the field of neurointensive care medicine and clinical management of EVDs. While currently there seems to be a lack of awareness of corresponding guidelines, the results of the study encourage us to further improve basic knowledge, develop evidence-based strategies, and standardize procedures regarding the management of posthemorrhagic hydrocephalus and EVDs.

Markus Florian Oertel

Zurich, Switzerland

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Capion, T., Lilja-Cyron, A., Bartek, J. et al. Discontinuation of External Ventricular Drainage in Patients with Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage - a Scandinavian Multi-institutional Survey. Acta Neurochir 162, 1363–1370 (2020). https://doi.org/10.1007/s00701-020-04317-6

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  • DOI: https://doi.org/10.1007/s00701-020-04317-6

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