Treatment of post-thalamic hemorrhage hydrocephalus: ventriculoperitoneal shunt or endoscopic third ventriculostomy? A retrospective observational study.

BACKGROUND: The aim of this study was to compare the efficacy of ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV) for the treatment of hydrocephalus after thalamic hemorrhage (TH) where external ventricular drainage (EVD) could not be removed after hematoma absorption, and to provide a theoretical basis for the clinical treatment of hydrocephalus after TH. METHODS: The clinical data of patients with hydrocephalus after TH whose EVD could not be removed after hematoma absorption were retrospectively analyzed. According to the patients' surgical methods, the patients were divided into the VPS group and ETV group. The operative time, length of hospital stay, complications, and reoperation rates of the two groups were compared. RESULTS: There was no statistically significant difference in intraoperative bleeding, length of hospital stay between the two groups. The EVD tubes were successfully removed in all patients after surgery. There were 4 (9.5%) complications in the ETV group and 3 (6.7%) complications in the VPS group, with no statistically significant difference in postoperative complications between the two groups. During the 1-year follow-up, 7 patients (16.7%) in the ETV group and 3 patients (6.7%) in the VPS group required reoperation. In the subgroup analysis of TH combined with fourth ventricular hemorrhage, 6 patients (14.3%) in the ETV group and 1 patient (2.2%) in the VPS group required reoperation, and the difference between the two groups was statistically significant. CONCLUSIONS: ETV had good efficacy in treating hydrocephalus caused by TH and TH that broke into the lateral ventricle and the third ventricle. However, if hydrocephalus was caused by TH with the fourth ventricular hematoma, VPS was a better surgical method because the recurrence rate of hydrocephalus in ETV was higher than that in VPS. Therefore, the choice of surgical method should be based on the patient's clinical features and hematoma location.

Prolonged infusion of linezolid is associated with improved pharmacokinetic/pharmacodynamic (PK/PD) profiles in patients with external ventricular drains.

OBJECTIVE: We previously investigated the pharmacokinetic and pharmacodynamic (PK/PD) parameters of routine linezolid infusions (1 h) in patients with external ventricular drains (EVD). The aim of the study was to determine whether extended linezolid infusions (200 mg/h for 3 h) were more efficacious than short linezolid infusions (600 mg/h for 1 h). METHODS: We collected cerebrospinal fluid (CSF) and plasma samples from 10 patients who received linezolid infusions after cerebral hemorrhage surgery with EVDs. Linezolid concentrations were measured by high-performance liquid chromatography (HPLC). A Monte Carlo simulation was used to measure the probability of target attainments (PTA) and the PK/PD indexes at four minimum inhibitory concentrations (MIC). RESULTS: When the same dose (600 mg) was given as an extended infusion (3 h), linezolid reached its maximum concentrations in the plasma and CSF at 3.00 h and 4.40 h, respectively. The mean penetration of linezolid in CSF was 41.31%. Using the parameter of AUC0-24 h/MIC ≥ 100, the plasma PTA provided good coverage at > 90% when MIC was ≤ 1 µg/mL, while the values were 0 in CSF. Using the parameter %T (time) > MIC ≥ 85%, the PTA in both the plasma and CSF provided good coverage when MIC ≤ 2 µg/mL. Compared with routine infusions, prolonged infusion times (3 h) showed increased PTA of linezolid. CONCLUSIONS: Prolonged infusion times increased the concentration of linezolid in the plasma, leading to improved therapeutic outcomes. However, this improvement did not exist in CSF. Lastly, the PK/PD indicator AUC/MIC ≥ 100 may be used to achieve improved outcomes in patients with critical infections.

Pre-emptive intrathecal vancomycin therapy reduces external ventricular drain infection: a single centre retrospective case-control study.

OBJECTIVES: External ventricular drain (EVD)-related infection is a significant source of morbidity in neurosurgical patients. Recently, there has been a drive to adopt new catheters with bactericidal properties to reduce infection rates. We propose that the use of standard catheters combined with pre-emptive intrathecal vancomycin (ITV) 10 mg daily provides an effective alternative. DESIGN: Retrospective study of all patients with EVDs between 2010 and 2012, comparing infection rates in those who did and did not receive pre-emptive ITV. All EVDs were of the standard silicon catheter type. CSF infection was defined, as per Centre for Disease Control (CDC) guidelines, as clinical suspicion ± positive CSF gram stain/culture or leucocytosis. Infection rates were compared using Pearson's chi-squared test. RESULTS: 262 EVDs were included in the study, of which 111 were managed with pre-emptive ITV. The infection rate was 2.7% in the vancomycin group and 11.9% in the control group (p<.01). There were no cases of vancomycin-resistant infection in either group. CONCLUSION: The use of pre-emptive ITV is associated with a significantly lower EVD infection rate. This compares favourably with those reported in the literature for bactericidal catheters.

Analysis of the timing and the usage of drains following cranioplasty on outcomes and the incidence of bone resorption.

Background: Pediatric cranioplasty is associated with a high rate of complications, including bone resorption (BR) in 20-50% of cases. We aimed to evaluate factors contributing to BR, including the effect of the timing of cranioplasty and the use of post-surgical drains. Methods: This is a dual institution retrospective review of all patients under 18 years old who underwent a cranioplasty following a decompressive craniectomy (DC) for the treatment of traumatic brain injury between 2011 and 2021. Early cranioplasty was defined as within 30 days after DC and late cranioplasty as >30 days. Patients were grouped by BR and separately by timing to cranioplasty. Groups were compared based on the Glasgow Outcome Scale (GOS) and postoperative drain usage. Results: A total of 30 patients were included in the study. The mean age was 7.39 (standard deviation = 6.52) and 60% were male. The median time to cranioplasty was 13 days (interquartile range = 10-17). BR was present in 16.7% of cases. A subgaleal drain was utilized in 93.3% and an external ventricular drain (EVD) in 63.3% of patients following cranioplasty. Drain usage was not associated with BR and timing to cranioplasty was not associated with discharge or 6-month GOS. Conclusion: This study demonstrates that early cranioplasty following DC may have similar outcomes to late cranioplasty. Post-surgical EVDs and subgaleal drains did not increase the incidence of BR, suggesting their importance in the postoperative management of these patients.

Impact of an external ventricular drain bundle and limited duration antibiotic prophylaxis on drain-related infections and antibiotic resistance.

BACKGROUND/OBJECTIVE: Systemic prophylactic antibiotics have been used to reduce the rate of neurosurgical drain-related infections (DRIs) but the optimal duration is unknown. The Neurocritical Care Society Consensus Statement for External Ventricular Drain (EVD) management recommends a single antibiotic dose preoperatively. Data regarding antibiotic management for other neurosurgical drains (e.g. subgaleal and subdural drains) are lacking. Previously at our institution antibiotics were continued for the duration of drain placement. In 2016 an EVD bundle was implemented to standardize nursing care, and antibiotic duration was changed to one preoperative dose for all neurosurgical drains. The objective of this study was to compare the incidence of DRI, non-DRI, and antibiotic resistance before and after the implementation of an EVD bundle and limited duration antibiotics. PATIENTS AND METHODS: This was a single center, quasi-experimental study that included patients status post EVD or craniotomy/craniectomy with subgaleal or subdural drain placement. The pre-intervention period was June 2014 through May 2015 and the post-intervention period was January 2017 through December 2017. RESULTS: Ninety-one patients were included in the pre-intervention group and 54 in the post-intervention group. The use of limited duration antibiotics (< 48 h) was 14.3 % in the pre-intervention group and 96.3 % in the post-intervention group (p < 0.001). Five DRIs were identified in the pre-intervention group and 3 in the post-intervention group (5.5 % vs 5.6 %, p = 1.00). Of patients who developed a non-DRI, 77.5 % had a resistant non-DRI in the pre-intervention group compared to 48 % in the post-intervention group (p = 0.01). The rates of resistant DRI (80 % vs 66.7 %, p = 1.00) and Clostridium difficile infection (1.1 % vs 3.7 %, p = 0.56) were similar between groups. CONCLUSIONS: Implementation of an EVD bundle and limited duration antibiotics reduced antibiotic exposure with no associated increase in risk of DRI. Rates of resistant non-DRI were significantly lower in the post-intervention group.

Preliminary Results of Emergency Computed Tomography-Guided Ventricular Drain Placement-Precision for the Most Difficult Cases.

BACKGROUND: External ventricular drainage (EVD) catheter placement is one of the most commonly performed neurosurgical procedures. The study's objective was to compare a computed tomography (CT) bolt scan-guided approach for the placement of EVDs with conventional landmark-based insertion. METHODS: In this retrospective case-control study, we analyzed patients undergoing bolt-kit EVD catheter placement, either CT-guided or landmark-based, between 2013 and 2016. The CT bolt scan-guided approach was based on a dose-reduced CT scan after bolt fixation with immediate image reconstruction along the axis of the bolt to evaluate the putative insertion axis. If needed, angulation of the bolt was corrected and the procedure repeated before the catheter was inserted. Primary endpoint was the accuracy of insertion. Secondary endpoints were the overall number of attempts, duration of intervention, complication rates, and cumulative radiation dose. RESULTS: In total, 34 patients were included in the final analysis. In the group undergoing CT-guided placement, the average ventricle width was significantly smaller (P = 0.04) and average midline shift significantly more pronounced (P = 0.01). CT-guided placement resulted in correct positioning of the catheter in the ipsilateral frontal horn in all 100% of the cases compared with landmark-guided insertion (63%; P = 0.01). Application of the CT-guided approach increased the number of total CT scans (3.6 ± 1.9) and the overall radiation dose (3.34 ± 1.61 mSv) compared with the freehand insertion group (1.84 ± 2.0 mSv and 1.55 ± 1.66 mSv). No differences were found for the other secondary outcome parameters. CONCLUSIONS: CT-guided bolt-kit EVD catheter placement is feasible and accurate in the most difficult cases.

Simulation workshops as an adjunct to perioperative care bundles in the management of external ventricular drains: improving surgical technique and reducing infection.

OBJECTIVETemporary CSF diversion through an external ventricular drain (EVD) comes with the risk of EVD-related infections (ERIs). The incidence of ERIs varies from 0.8% to 22%. ERIs increase mortality, morbidity, length of stay, and costs; require prolonged courses of antibiotics; and increase the need for subsequent permanent CSF diversion. The authors report the results of a quality improvement project designed to improve infection rates and EVD placement using simulation training in addition to a standardized perioperative care bundle. This project resulted not only in a decrease in ERIs, but also a significant improvement in surgical outcomes.METHODSA best-practice standardized perioperative approach and care bundle was approved by consensus among the senior neurosurgeons at the authors' institution, and a standardized operative note was designed to encourage adherence to policy and improve documentation. This approach was adapted from the bundle previously described by Kubilay et al. Simulation workshops were introduced to teach safe sampling technique, administration of intrathecal drugs, and a standardized operative technique using the Rowena head surgical model. Effects of the interventions on placement, infection rates, and displacement were measured at two distinct time points over a 2-year period.RESULTSBaseline audits demonstrated satisfactory EVD placement in 74%, an infection rate of 8.5%, and displacement occurring in 20%. In the 2 years following the interventions, satisfactory placement improved to 96%, infection rate fell to 4.8%, and inadvertent displacement occurred in only 1.7%.CONCLUSIONSSimulation training and standardizing the perioperative care of patients requiring EVDs dramatically improved placement accuracy, reduced infection rates, and reduced EVD displacement rate.

Surveillance of infection associated with external ventricular drains: proposed methodology and results from a pilot study.

BACKGROUND: The insertion of external ventricular drains (EVDs) is necessary in some neurosurgical patients, but increases the risk of meningitis/ventriculitis. While there are well-recognized risk factors, the proportion of patients who develop meningitis/ventriculitis varies partly due to differences in definitions. A multi-disciplinary working group was established to agree definitions for EVD-associated meningitis/ventriculitis, and a surveillance system was piloted in four centres in the UK and Ireland. METHODS: Definitions were agreed based on those published previously and on clinical and microbiological criteria. An agreed dataset was developed to monitor patients after the insertion of an EVD and until the EVD was removed and the microbial aetiology was recorded. FINDINGS: Four neurosurgical centres participated, with 61-564 patients surveyed in each unit. The vast majority of drains were cranial. Intracranial haemorrhage was the most common indication for the EVD insertion. Between 6% and 35% of EVDs were inserted by consultants rather than junior doctors. The proportion of patients who developed meningitis/ventriculitis varied from 3% to 18% and from 4.8 to 12.7/1000 EVD-days. Coagulase-negative staphylococci were the most common microbial causes. CONCLUSIONS: Routine and ongoing monitoring of patients with an EVD in situ to detect meningitis/ventriculitis presents logistical difficulties, and few units do so. This pilot study suggests that a national system of surveillance with agreed definitions and a methodology to enable unit-to-unit comparisons of EVD meningitis/ventriculitis is both necessary and feasible. This will, in turn, inform quality improvement processes leading to the minimization of infection.

Preventing ventriculostomy-related infections with antibiotic-impregnated drains in hospitals: a two-centre Dutch study.

This observational cohort study assessed the effect of the introduction of antibiotic-impregnated external ventricular drains (AI-EVDs), as opposed to plain silicone EVDs, on the occurrence of ventriculostomy-related infections (VRIs) in two Dutch hospitals, with no other changes to their clinical practice. VRI was defined using the criteria of the Centers for Disease Control and Prevention, and with a culture-based definition. A propensity-score-adjusted competing risks survival analysis showed that introduction of AI-EVDs did not significantly decrease the risk of VRIs in routine care, nor affect the bacterial aetiology, even after adjustment for confounding and competing events.

Cost-consequence analysis of antibiotic-impregnated shunts and external ventricular drains in hydrocephalus.

OBJECT: Despite multiple preventive strategies for reducing infection, up to 15% of patients with shunt catheters and 27% of patients with external ventricular drains (EVDs) may develop an infection. There are few data on the cost-effectiveness of measures to prevent hydrocephalus catheter infection from the hospital perspective. The objective of this study was to perform a cost-consequence analysis to assess the potential clinical and economic value of antibiotic-impregnated catheter (AIC) shunts and EVDs compared with non-AIC shunts and EVDs in the treatment of hydrocephalus from a hospital perspective. METHODS: The authors used decision analytical techniques to assess the clinical and economic consequences of using antibiotic-impregnated shunts and EVDs from a hospital perspective. Model inputs were derived from the published, peer-reviewed literature. Clinical studies comparing infection rates and the clinical and economic impact of infections associated with the use of AICs and standard catheters (non-AICs) were evaluated. Outcomes assessed included infections, deaths due to infection, surgeries due to infection, and cost associated with shunt- and EVD-related infection. A subanalysis using only AIC shunt and EVD Level I evidence (randomized controlled trial results) was conducted as an alternate to the cumulative analysis of all of the AIC versus non-AIC studies (13 of the 14 shunt studies and 4 of the 6 EVD studies identified were observational). Sensitivity analyses were conducted to determine how changes in the values of uncertain parameters affected the results of the model. RESULTS: In 100 patients requiring shunts, AICs may be associated with 0.5 fewer deaths, 71 fewer hospital days, 11 fewer surgeries, and $128,228 of net savings in hospital costs due to decreased infection. Results of the subanalysis showed that AICs may be associated with 1.9 fewer deaths, 1611 fewer hospital days, 25 fewer surgeries, and $346,616 of net savings in hospital costs due to decreased infection. The rate of decrease in infection with AIC shunts was shown to have the greatest impact on the cost savings realized with use of AIC shunts. In 100 patients requiring EVDs, AICs may be associated with 2.7 fewer deaths and 82 fewer hospital days due to infection. The relative risk of more severe neurological impairment was estimated to be 5.33 times greater with EVD infection. Decreases in infection with AIC EVDs resulted in an estimated $264,069 of net savings per 100 patients treated with AICs. Results of the subanalysis showed that AIC EVDs may be associated with 1.0 fewer deaths, 31 infection-related hospital days averted, and $74,631 saved per 100 patients treated with AIC EVDs. As was seen with AIC shunts, the rate of decrease in infection with AIC EVDs was shown to have the greatest impact on the cost savings realized with use of AIC EVDs. CONCLUSIONS: The current value analysis demonstrates that evidence supports the use of AICs as effective and potentially cost-saving treatment.

No additional protection against ventriculitis with prolonged systemic antibiotic prophylaxis for patients treated with antibiotic-coated external ventricular drains.

OBJECT External ventricular drains (EVDs) are commonly used for CSF diversion but pose a risk of ventriculitis, with rates varying in frequency from 2% to 45%. Results of studies examining the utility of prolonged systemic antibiotic therapy for the prevention of EVD-related infection have been contradictory, and no study to date has examined whether this approach confers additional benefit in preventing ventriculitis when used in conjunction with antibiotic-coated EVDs (ac-EVDs). METHODS A prospective performance analysis was conducted over 4 years to examine the impact of discontinuing systemic antibiotic prophylaxis after insertion of an ac-EVD on rates of catheter-related ventriculitis. Ventriculitis and other nosocomial infections were ascertained by a qualified infection disease nurse using definitions based on published standards from the Centers for Disease Control and Prevention, comparing the period when patients received systemic antibiotic therapy for the duration of EVD treatment (Period 1) compared with only for the peri-insertion period (Period 2). Costs were analyzed and compared across the 2 time periods. RESULTS Over the 4-year study period, 866 patients were treated with ac-EVDs for a total of 7016 catheter days. There were 8 cases of ventriculitis, for an overall incidence of 0.92%. Rates of ventriculitis did not differ significantly between Period 1 and Period 2 (1.1% vs 0.4%, p = 0.22). The rate of nosocomial infections, however, was significantly higher in Period 1 (2.0% vs 0.0% in Period 2, p = 0.026). Cost savings of $162,516 were realized in Period 2 due to decreased drug costs and savings associated with the reduction in nosocomial infections. CONCLUSIONS Prolonged systemic antibiotic therapy following placement of ac-EVDs does not seem to reduce the incidence of catheter-related ventriculitis and was associated with a higher rate of nosocomial infections and increased cost.