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External Ventricular Drain
Indications and Contraindications
The placement of an external ventricular drain (EVD) is a very common neurosurgical bedside procedure. EVDs are commonly placed to manage hydrocephalus and monitor intracranial pressure (ICP) in a wide variety of pathologies. Despite their widespread use, recommendations on EVD placement and management are based on low-quality data. Several available guidelines include: Brain Trauma Foundation, , American Heart and Stroke Associations, and combined American Association of Neurological Surgeons, Congress of Neurological Surgeons committee, and Neurocritical Care Society guidelines.
Major indications for EVD placement include intracranial pressure monitoring in the setting of traumatic brain injury and treatment of acute symptomatic hydrocephalus. Some causes of symptomatic hydrocephalus are intracranial and intraventricular hemorrhage (IVH), aneurysmal subarachnoid hemorrhage, neoplasms, meningitis/encephalitis, or acute stroke despite decompressive hemicraniectomy. Another common use for EVDs is to temporize hydrocephalus symptoms in patients with malfunctioning or infected shunts. In some instances, an EVD may be placed in lieu of a lumbar drain to facilitate intraoperative brain relaxation or may be used for targeted therapeutic interventions such as the use of intraventricular tissue plasminogen activator for IVH, or intraventricular antibiotics for intracranial infections.
There are many different types of EVDs, including antibiotic- or silver- impregnated catheters. Unlike other neurosurgical procedures, the placement of an EVD may take place in a variety of locations (e.g. emergency department, intensive care unit, operating room) and may be performed by a wide variety of practitioners (e.g. neurocritical care team, neurosurgical residents, nurse practitioners, physician assistants). The Neurocritical Care Society Committee suggests that the location of EVD insertion (operating room or bedside) should be dictated by patient and clinical circumstances. The Committee did not find evidence that type of training, experience, or specialty affects the risk of complications during EVD insertion. However, they recommend the involvement of neurosurgeons in training and protocol development, and state the need for neurosurgical backup.
Contraindications to EVD placement include patients with coagulopathy or thrombocytopenia without correction and scalp infection at the site of insertion.
Stepwise Procedure ( 
)
Preprocedural Considerations
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Ensure that consent has been obtained from patient or family when possible.
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Review head CT and laboratory studies to evaluate for contraindications to the procedure.
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Correct coagulopathies if necessary.
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Evaluate the skull thickness to determine the depth of the burr hole.
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Assess anatomy (e.g. the presence of midline shift) for planning the burr hole position and catheter trajectory.
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Ensure that there is a plan to monitor and manage ABCs and sedation during the procedure. This can be done in conjunction with the intensive care unit team or the emergency department team.
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If the patient is intubated, ensure that the patient is on pressure or volume-controlled ventilation.
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If the patient is not intubated, place the patient on oxygen with a face mask or nasal cannula.
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Administer periprocedural IV antibiotics prior to incision.
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Ensure that the drainage bag and transducer kit are set up.
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Communicate and coordinate with emergency room, critical care, and nursing teams who will assist with patient management while the procedure is performed.
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