External ventricular drainage complications

External ventricular drainage complications

Acutely increased intracranial pressure (ICP) is frequently managed by external ventricular drainage (EVD). This procedure is life-saving but marred by a high incidence of complications. It has recently been indicated that bolt-connected external ventricular drainage (BC-EVD) compared to the standard technique of tunnelled EVD (T-EVD) may result in less complications 1).

Intracranial hemorrhage

Infection

Misplacement

Obstruction

Ventricular catheter obstruction.


The purpose of this study was to investigate whether a surgeon’s experience affects the associated complication rate. Methods This retrospective study included all adult patients undergoing EVD insertion at a single centre between July 2013 and June 2015. Medical records were retrieved to obtain details on patient demographics, surgical indication, risk factors for infection and use of anticoagulants or antiplatelets. Surgeon experience, operative time, intraoperative antibiotic prophylaxis, need for revision surgery and EVD associated infection were examined. Information on catheter tip position and radiological evidence of intracranial haemorrhage was obtained from postoperative imaging. Results A total of 89 patients were included in the study. The overall infection, haemorrhage and revision rates were 4.8%, 7.8% and 13.0% respectively, with no significant difference among surgeons of different experience. The mean operating time for patients who developed an infection was 22 minutes while for those without an infection, it was 33 minutes (p=0.474). Anticoagulation/antiplatelet use did not appear to increase the rate of haemorrhage. The infection rate did not correlate with known risk factors (eg diabetes and steroids), operation start time (daytime vs out of hours) or duration of surgery although intraoperative (single dose) antibiotic prophylaxis seemed to reduce the infection rate. There was also a correlation between longer duration of catheterisation and increased risk of infection. Conclusions This is the first study demonstrating there is no significant difference in complication rates between surgeons of different experience. EVD insertion is a core neurosurgical skill and junior trainees should be trained to perform it 2).


Patients were prospectively enrolled in the CLEAR III trial after placement of an EVD for obstructive intraventricular hemorrhage and randomized to receive recombinant tissue-type plasminogen activator or placebo. We counted any detected new hemorrhage (catheter tract hemorrhage or any other distant hemorrhage) on computed tomography scan within 30 days from the randomization. Meta-analysis of published series of EVD placement was compiled with STATA software.

Growing or unstable hemorrhage was reported as a cause of exclusion from the trial in 74 of 5707 cases (1.3%) screened for CLEAR III. The first 250 patients enrolled have completed adjudication of adverse events. Forty-two subjects (16.8%) experienced ≥1 new bleeds or expansions, and 6 of 250 subjects (2.4%) suffered symptomatic hemorrhages. Eleven cases (4.4%) had culture-proven bacterial meningitis or ventriculitis.

Risks of bleeding and infection in the ongoing CLEAR III trial are comparable to those previously reported in EVD case series. In the present study, rates of new bleeds and bacterial meningitis/ventriculitis are very low despite multiple daily injections, blood in the ventricles, the use of thrombolysis in half the cases, and generalization to >60 trial sites 3).

References

1)

Jensen TS, Carlsen JG, Sørensen JC, Poulsen FR. Fewer complications with bolt-connected than tunneled external ventricular drainage. Acta Neurochir (Wien). 2016 Aug;158(8):1491-4. doi: 10.1007/s00701-016-2863-8. Epub 2016 Jun 21. PubMed PMID: 27324657.
2)

Yuen J, Selbi W, Muquit S, Berei T. Complication rates of external ventricular drain insertion by surgeons of different experience. Ann R Coll Surg Engl. 2018 Mar;100(3):221-225. doi: 10.1308/rcsann.2017.0221. Epub 2018 Jan 24. PubMed PMID: 29364007; PubMed Central PMCID: PMC5930101.
3)

Dey M, Stadnik A, Riad F, Zhang L, McBee N, Kase C, Carhuapoma JR, Ram M, Lane K, Ostapkovich N, Aldrich F, Aldrich C, Jallo J, Butcher K, Snider R, Hanley D, Ziai W, Awad IA; CLEAR III Trial Investigators. Bleeding and Infection With External Ventricular Drainage: A Systematic Review in Comparison With Adjudicated Adverse Events in the Ongoing Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR-III IHV) Trial. Neurosurgery. 2015 Mar;76(3):291-301. doi: 10.1227/NEU.0000000000000624. PubMed PMID: 25635887; PubMed Central PMCID: PMC4333009.

Chlorhexidine shower

Surgical site infections (SSI) are common spine surgery complicationsPrevention is critical to maintaining safe patient care and reducing additional costs associated with treatment.

To determine the efficacy of preoperative chlorhexidine (CHG) showers on SSI rates following fusion and nonfusion spine surgery Chan et al., implemented a shower protocol at UCSF Medical CenterMilwaukee in November 2013. A cohort comparison of 4266 consecutive patients assessed differences in SSI rates for the pre- and postimplementation periods. Subgroup analysis was performed on the type of spinal surgery (eg, fusion vs nonfusion). Data represent all spine surgeries performed between April 2012 and April 2016.

The overall mean SSI rate was 0.4%. There was no significant difference between the pre- (0.7%) and postimplementation periods (0.2%; P = .08). Subgroup analysis stratified by procedure type showed that the SSI rate for the nonfusion patients was significantly lower in the post- (0.1%) than the preimplementation group (0.7%; P = .02). There was no significant difference between SSI rates for the pre- (0.8%) and postimplementation groups (0.3%) for the fusion cohort (P = .21). In multivariate analysis, the implementation of preoperative CHG showers were associated with significantly decreased odds of SSI (odds ratio = 0.15, 95% confidence interval [0.03-0.55], P < .01).

This is the largest study investigating the efficacy of preoperative Chlorhexidine showers on SSI following spinal surgery. In adjusted multivariate analysis, Chlorhexidine showers was associated with a significant decrease in SSI following spinal surgery 1).


In 2013 a search of electronic databases was undertaken to identify prospective controlled trials evaluating whole-body preoperative bathing with chlorhexidine versus placebo or no bath for prevention of SSI. Summary risk ratios were calculated using a DerSimonian-Laird random effects model and a Mantel-Haenzel dichotomous effects model.

Sixteen trials met inclusion criteria with a total of 17,932 patients: 7,952 patients received a chlorhexidine bath, and 9,980 patients were allocated to various comparator groups. Overall, 6.8% of patients developed SSI in the chlorhexidine group compared with 7.2% of patients in the comparator groups. Chlorhexidine bathing did not significantly reduce overall incidence of SSI when compared with soap, placebo, or no shower or bath (relative risk, 0.90; 95% confidence interval: 0.77-1.05, P = .19).

Meta-analysis of available clinical trials suggests no appreciable benefit of preoperative whole-body chlorhexidine bathing for prevention of SSI. However, most studies omitted details of chlorhexidine application. Better designed trials with a specified duration and frequency of exposure to chlorhexidine are needed to determine whether preoperative whole-body chlorhexidine bathing reduces SSI 2).

References

1)

Chan AK, Ammanuel SG, Chan AY, Oh T, Skrehot HC, Edwards CS, Kondapavulur S, Miller CA, Nichols AD, Liu C, Dhall SS, Clark AJ, Chou D, Ames CP, Mummaneni PV. Chlorhexidine Showers are Associated With a Reduction in Surgical Site Infection Following Spine Surgery: An Analysis of 4266 Consecutive Surgeries. Neurosurgery. 2018 Dec 22. doi: 10.1093/neuros/nyy568. [Epub ahead of print] PubMed PMID: 30590721.
2)

Chlebicki MP, Safdar N, O’Horo JC, Maki DG. Preoperative chlorhexidine shower or bath for prevention of surgical site infection: a meta-analysis. Am J Infect Control. 2013 Feb;41(2):167-73. doi: 10.1016/j.ajic.2012.02.014. Epub 2012 Jun 19. Review. PubMed PMID: 22722008.

UpToDate: Cranioplasty timing

Cranioplasty timing

There is an increasing body of evidence in the recent literature, which demonstrates that cranioplasty may also accelerate and improve neurological recovery. Although the exact pathophysiological mechanisms for this improvement remain essentially unknown, there are a rapidly growing number of neurosurgeons adopting this concept.

Cranioplasty performed between 15 and 30 days after initial craniectomy may minimize infectionseizure, and bone flap resorption, whereas waiting > 90 days may minimize hydrocephalus but may increase the risk of seizure 1).


Communicating hydrocephalus is an almost universal finding in patients after hemicraniectomy. Delayed time to cranioplasty is linked with the development of persistent hydrocephalus, necessitating permanent CSF diversion in some patients.

Waziri et al., propose that early cranioplasty, when possible, may restore normal intracranial pressure dynamics and prevent the need for permanent CSF diversion in patients after hemicraniectomy 2).

Factors

One modifiable factor that may alter the risk of cranioplasty is the timing of cranioplasty after craniectomy. Case series suggest that early cranioplasty is associated with higher rates of infection while delaying cranioplasty may be associated with higher rates of bone resorption.

When considering ideal timing for cranioplasty, predominant issues include residual brain edema, brain retraction into the cranial vault, risk of infection, and development of delayed post-traumatic hydrocephalus.


Waiting to perform cranioplasty is important to prevent the development of devitalized autograft or allograft infections.

It is generally accepted to wait 3 to 6 months before reconstructive surgery. If there is an infected area, this waiting period can be as long as one year.

Cranioplasty is performed after craniectomy when intracranial pressure is under control for functional and aesthetic restorations and for protection, but it may also lead to some neurological improvement after the bone flap placement 3) 4) 5).

Timing of cranioplasty after decompressive craniectomy for trauma

The optimal timing of cranioplasty after decompressive craniectomy for trauma is unknown.

After decompressive craniectomy for trauma, early (<12 weeks) cranioplasty does not alter the incidence of complication rates. In patients <18 years of age, early (<12 weeks) cranioplasty increases the risk of bone resorption. Delaying cranioplasty (≥12 weeks) results in longer operative times and may increase costs 6).

Timing of cranioplasty after decompressive craniectomy for malignant middle cerebral artery infarction

Patients with malignant middle cerebral artery infarction frequently develop hydrocephalus after decompressive hemicraniectomy. Hydrocephalus itself and known shunt related complications after ventriculoperitoneal shunt implantation may negatively impact patients outcome.

A later time point of cranioplasty might lead to a lower incidence of required shunting procedures in general 7).

References

1)

Morton RP, Abecassis IJ, Hanson JF, Barber JK, Chen M, Kelly CM, Nerva JD, Emerson SN, Ene CI, Levitt MR, Chowdhary MM, Ko AL, Chesnut RM. Timing of cranioplasty: a 10.75-year single-center analysis of 754 patients. J Neurosurg. 2018 Jun;128(6):1648-1652. doi: 10.3171/2016.11.JNS161917. Epub 2017 Aug 11. PubMed PMID: 28799868.

2)

Waziri A, Fusco D, Mayer SA, McKhann GM 2nd, Connolly ES Jr. Postoperative hydrocephalus in patients undergoing decompressive hemicraniectomy for ischemic or hemorrhagic stroke. Neurosurgery. 2007 Sep;61(3):489-93; discussion 493-4. PubMed PMID: 17881960.

3)

Honeybul S, Janzen C, Kruger K, Ho KM. The impact of cranioplasty on neurological function. Br J Neurosurg. 2013;27:636–641. doi: 10.3109/02688697.2013.817532.

4)

Jelcic N, De Pellegrin S, Cecchin D, Della Puppa A, Cagnin A. Cognitive improvement after cranioplasty: a possible volume transmission-related effect. Acta Neurochir (Wien) 2013;155:1597–1599. doi: 10.1007/s00701-012-1519-6.

5)

Di Stefano C, Sturiale C, Trentini P, Bonora R, Rossi D, Cervigni G, et al. Unexpected neuropsychological improvement after cranioplasty: a case series study. Br J Neurosurg. 2012;26:827–831. doi: 10.3109/02688697.2012.692838.

6)

Piedra MP, Nemecek AN, Ragel BT. Timing of cranioplasty after decompressive craniectomy for trauma. Surg Neurol Int. 2014 Feb 25;5:25. doi: 10.4103/2152-7806.127762. PubMed PMID: 24778913; PubMed Central PMCID: PMC3994696.

7)

Finger T, Prinz V, Schreck E, Pinczolits A, Bayerl S, Liman T, Woitzik J, Vajkoczy P. Impact of timing of cranioplasty on hydrocephalus after decompressive hemicraniectomy in malignant middle cerebral artery infarction. Clin Neurol Neurosurg. 2016 Dec 9;153:27-34. doi: 10.1016/j.clineuro.2016.12.001. [Epub ahead of print] PubMed PMID: 28012353.
WhatsApp WhatsApp us
%d bloggers like this: