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Review
. 2019 Sep 10;8(9):1422.
doi: 10.3390/jcm8091422.

The Evolution of the Role of External Ventricular Drainage in Traumatic Brain Injury

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Free PMC article
Review

The Evolution of the Role of External Ventricular Drainage in Traumatic Brain Injury

Charlene Y C Chau et al. J Clin Med. .
Free PMC article

Abstract

External ventricular drains (EVDs) are commonly used in neurosurgery in different conditions but frequently in the management of traumatic brain injury (TBI) to monitor and/or control intracranial pressure (ICP) by diverting cerebrospinal fluid (CSF). Their clinical effectiveness, when used as a therapeutic ICP-lowering procedure in contemporary practice, remains unclear. No consensus has been reached regarding the drainage strategy and optimal timing of insertion. We review the literature on EVDs in the setting of TBI, discussing its clinical indications, surgical technique, complications, clinical outcomes, and economic considerations.

Keywords: EVD; ICP; TBI; intracranial pressure; neurosurgery; neurotrauma; ventriculostomy.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Timeline of selected events in the history of external ventricular drainage. Source: authors.
Figure 2
Figure 2
A recording featuring arterial blood pressure (ABP) and intraparenchymal pressure (IPP—bottom pane, grey line) together with EVD pressure (ICP—bottom panel, black line) using an external transducer in patient after poor grade aneurysmal subarachnoid haemorrhage. The left panel demonstrates the results with the drain opened, whereas the right panel demonstrates results with the drain closed. With an open EVD, the two pressure readings failed to correlate. EVD pressure is held constant at a value representing the calibrated level of the drain above the heart. With a closed EVD (right panel), the two measured pressure values correlate over time.
Figure 3
Figure 3
Sigmoidal curve delineating the intracranial pressure–volume relationship. Three distinct phases are shown: (i) Compensatory phase (“flat part”) represented by high intracranial compliance and low ICP due to physiological buffer systems; (ii) “steep part”: Decompensation phase marked by exponential increases in ICP with small increases in intracranial volume due to low compensatory reserve, indicated by the Rap index; (iii) phase with exhausted compensatory reserve and deranged cerebrovascular reactivity. TBI patients with intracranial hypertension are often in the second or third phase. Figure taken from Steiner et al. [73].
Figure 4
Figure 4
Kocher’s point (marked by “X”) indicated by surface anatomy. (a) Located 11 cm posterior to nasion and 3 cm lateral to the midline (red dotted line); (b) 1 cm anterior to the coronal suture and 3 cm lateral to the midline (red dotted line). Skull image obtained from 3D4Medical Complete Anatomy 2018 Version 3.3.0 ®.
Figure 5
Figure 5
Grading system for catheter tip location. Figure taken from Kakarla et al. [105].
Figure 6
Figure 6
Recommendation of entry point with the Ghajar device (10 cm from nasion and 3 to 4 cm lateral to the midline). From: European Patent Office. Ghajar J: Apparatus for Guiding Catheter into Cerebral Ventricle. EP:0229105B1 (22/07/87) [108].

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