Is External Ventricular Drainage E.V.D. a valuable treatment option for Intraventricular Haemorrhage?

Is External Ventricular Drainage E.V.D. a valuable treatment option for Intraventricular Haemorrhage?

Abdul Rahim H. Zwayed *, Dr. Sreenivas A.V, Dr Balola Margani, Dr Enas Hasan, Dr. Faisal  Al Balushi, Dr. Amir M. Shabana, Dr. Alaa Y. Hasan, Dr Abdul Rahman A. Al Yamani, Dr Hilal Al Shibli,

Dr. Soroush F. Nassiri, Dr. Yasser Abdul Raziek,  Dr. Reem, Dr. Ahmed Nasser, Dr. Mohammed Al Raisi, Dan Mohammed Abdel Fattah, S.N. Ashjan  Khalfan  Al Omrani

*Correspondence to: Abdul Rahim H. Zwayed, Neurosurgeon, Sohar Hospital, Sultanate of Oman.

Copyright

© 2026 Abdul Rahim H. Zwayed, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 05 June 2026

Published: 01 July 2026

DOI: https://doi.org/10.5281/zenodo.21067217

Abstract

An External Ventricular Drainage E.V.D. is primarily used to treat intraventricular haemorrhage (also called haemocephalus) to relieve elevated intracranial pressure when normal cerebrospinal fluid C.S.F. flow is obstructed.

Intra ventricular haemorrhage (I.V.H.)-bleeding into the brain ventricles -occurs in approximately 35 % to 45% of spontaneous intra cerebral hemorrhages (I.C.H.) however, it is associated with devastating outcomes.

Traumatic intra ventricular haemorrhage is an uncommon finding in head injuries with an overall prevalence reported between 0.4 %to 22 % of traumatic brain injuries cases heavily dependent on the severity of the injury.

Extension of intracranial haemorrhage (I.C.H.) into intraventricular haemorrhage (I.V.H.) has been consistently demonstrated as an independent predictor of poor outcome.

In most circumstances the increased intracranial pressure and acute hydrocephalus caused by I.C.H. is managed by placement of an external ventricular drain (E.V.D.).

We present a systematic review of the literature on the topic of E.V.D. in the setting of I.V.H. haemorrhage, articulating the scope of the problem and prognostic factors, clinical indications, surgical adjuncts, and other management issues.

Keywords: External ventricular drain (EVD), Ventriculostomy, Intraventricular haemorrhage(I.V.H.); I.C.H. intracranial haemorrhage; I.C.P. intracranial pressure; S.A.H. subarachnoid haemorrhage.

1 WHAT IS E.V.D.?

E.V.D.: is an external ventricular drain also known as a ventriculostomy or extra-ventricular drain, is a device used in primarily used to treat intraventricular haemorrhage whether traumatic or non-traumatic to relieve elevated intracranial pressure when normal CSF flow is obstructed.

The purpose of external ventricular drainage is to divert fluid from the ventricles of the brain and allow for monitoring of intracranial pressure.

2 WHERE?

The E.V.D. catheter is most frequently placed by way of a twist-drill craniostomy placed at Kocher's point, a location in the frontal bone of the skull, with the goal of placing the catheter tip in the frontal horn of the lateral ventricle or in the third ventricle.

3 WHEN? Purpose and Indications

An E.V.D. is primarily used to treat intraventricular haemorrhage whether traumatic or non-traumatic to relieve elevated intracranial pressure when normal CSF flow is obstructed. Also used to monitor intracranial pressure in patients with other indications include subarachnoid haemorrhage, traumatic brain injury, brain tumors, meningitis, or shunt malfunction. It can also be used before, during, or after brain surgery to manage fluid buildup and improve surgical visibility or healing.

Intraventricular haemorrhage (IVH) is a frequent complication of subarachnoid hemorrhage (SAH) and intracranial hemorrhage (ICH). IVH can range from mild layering of the blood in the posterior horn of the lateral ventricle to complete casting of all the ventricles.

Arguably the most common neurosurgical procedure done, usually at bedside, is placement of external ventricular drain (EVD) for monitoring and managing ICP and assisting with clearance of Intraventricular blood.

The E.V.D.is leveled to a common reference point that corresponds to the skull base, usually the tragus or external auditory meatus.

The E.V.D.is set to drain into a closed, graduated burette at a height corresponding to a particular pressure level, as prescribed by a healthcare professional, usually a neurosurgeon or neuro-intensivist.

Leveling the E.V.D. to a set pressure level is the basis for cerebrospinal fluid (C.S.F.) drainage; hydrostatic pressure dictates C.S.F. drainage.

 Several recent studies have attempted to grade the extent of IVH in relation to patient outcome (14, 19, 24, 25).

The “Graeb score” (Table 1) considers the extent of involvement of the respective ventricles and associated ventriculomegaly, and has been extensively validated in outcomes studies (6,15,21).

Table 1; The Graeb score Modified from Graeb et al.

[1] Location: Lateral ventricles (each lateral ventricle is scored separately)

[2] Third and fourth ventricles

Total   Range: 0–12

A sudden increase in hourly output of cerebrospinal fluid C.S.F. may

1. Indicate intracranial hypertension
2. Bloody C.S.F. may indicate recurrent aneurysm rupture.
3. Cloudy C.S.F. may indicate brain infection.

Table: 2 In Sohar Hospital

From 01/01/2015    to   31/12/2024

Conclusions

An E.V.D. is a flexible plastic catheter placed by a neurosurgeon and managed by intensive care unit (ICU) physicians and nurses. (3,12)

The purpose of external ventricular drainage is to divert fluid from the ventricles of the brain and allow for monitoring of intracranial pressure.(7,11)

An E.V.D. must be placed in a center with neurosurgical capabilities, because immediate neurosurgical intervention can be needed if a complication of E.V.D. placement, such as bleeding, is encountered.(13,27)

E.V.D.s are a short-term solution to hydrocephalus, and if the underlying hydrocephalus does not eventually resolve, it may be necessary to convert the E.V.D. to a cerebral shunt, which is a fully internalized, long-term treatment for hydrocephalus.(5,18)

Intraventricular haemorrhage is a bleeding inside or around the ventricles, the spaces in the brain containing the cerebral spinal fluid. These are strokes that are caused by a rupture in a blood vessel in the brain (2,8). 

An E.V.D. must be placed in a center with neurosurgical capabilities because immediate neurosurgical intervention can be needed if a complication of E.V.D. placement, such as bleeding, is encountered.(1,20)

Extension of intracranial hemorrhage (I.C.H.) into the ventricles or Intraventricular hemorrhage (IVH) has been consistently demonstrated as an independent predictor of poor outcome.(17)

Spontaneous I.C.H. with Intraventricular extension accounts for only 10% to 15% of all strokes(8,22).

A study examining patients with large IVH found that the etiology of the IVH was more important in predicting outcome than the volume of I.V.H. (26).

 In the setting of very large IVH (>40 cc) with casting and mass effect, Hinson et al.  showed that use of bilateral simultaneous E.V.D catheters may increase clot resolution with or without adjunctive thrombolytic therapy.(22) Conversely, Staykov et al.  found no difference in clot resolution between the groups treated with one versus two E.V.D.s in the setting of severe I.V.H.(32); however, they did find a trend toward a longer E.V.D. duration and higher infection rate in the bilateral E.V.D. group. The Staykov study did not include a comparison with single catheter cases, controlling for IVH volume.(16)

In 1890, Keen  first reportedly used skull landmarks to cannulate the lateral ventricle and in 1918 .(9).

Dandy published a technique involving anterior and occipital ventricular horn punctures for air ventriculography(20). The standard neurosurgical technique for bedside E.V.D. insertion has gradually evolved in subsequent decades using preassembled kits, and ultimately the introduction of disposable instruments and drills and tunneling of the catheter(4,9,20)

Ghajar introduced the principle of cannulating the cerebral ventricle by precise perpendicular trajectory to the skull surface, and he developed a tool to facilitate this approach(28).

Roitberg et al.  reported minimal complications and successful E.V.D. placement and maintenance for duration of required drainage in a retrospective series of 103 consecutive cases of bedside E.V.D. placement in the intensive care unit (I.C.U.), with sterile technique and short subcutaneous tunneling of the catheter.(10).

 Kakarla et al.  confirmed the safety and accuracy of E.V.D. placement by neurosurgical trainees by bedside ventriculostomy for I.C.P. monitoring and C.S.F. drainage.(3).

 It has been postulated that rupture of intra cerebral haemorrhage ICH into the ventricles would be beneficial to lessen the mass effect from the large ICH on surrounding structures, but in fact the extension of ICH into the ventricles  has been consistently demonstrated as an independent predictor of poor outcome in patients with I.C.H. (4,7,9,12).

Predictors of poor outcome in the setting of IVH  include severity of initial hemorrhage, older age, longer time to treatment, and size and location of Pathology (18,20,31)

I.C.H. extending into the cerebral ventricles can contribute to obstruction of cerebrospinal fluid (C.S.F.) circulation and acute hydrocephalus .(23,27)

There is much variability in E.V.D. placement, including whether anatomical landmarks should be used, placing the EVD in a freehand manner, or using image guidance to place the catheter. (8,17,26,32) .

Suboptimal placement is more likely when using anatomical landmarks for insertion, but this is often the most efficient technique in emergent situations, and image guidance is not always readily available. (9,21,29) Other variability exists in terms of target placement, whether to place the catheter through the lateral ventricle with greater or lesser blood, or how far from the foramen of Monro the catheter should be placed. (11,27)

In a series of patients with supratentorial I.C.H. & I.V.H., Young et al. demonstrated a strong predictor between ventricular blood volume and poor outcome and determined that patients with more than 20 cc of interventricular blood in general had poor outcome.(30)

Retrospective S.A.H., I.V.H.183 (with postoperative CT scan)50% (other than frontal horn of the lateral ventricle) Toma et al.(32).

Retrospective Trauma, I.C.H., S.A.H.98(22.4%) (extra ventricular spaces) Huyette et al. (23)

Retrospective chart review Pediatric traumatic brain injury 68(8.8% )(outside ventricular system) Anderson et al. (31)

Retrospective S.A.H., trauma,. IC.H., I.V.H .346 13% (eloquent tissue) Kakarla et al. (20,31).

An analysis of I.V.H. cohort in a large prospective randomized study of surgery for I.C.H. (21) demonstrated that continuous drainage of CSF contributes to the normalization of ICP.

 However, the placement of E.V.D. does not eliminate the morbidity and mortality of I.V.H., perhaps due to underlying damage from the associated stroke, and the toxic effects of ventricular blood on adjacent periventricular brain tissue, including hippocampus, diencephalon, and brainstem. (2,19,32)

Catheter occlusions occur frequently in the setting of large I.V.H. volume, with casting and clotting on ventricular blood, and these can result in poor I.C.P. control. (11)

Catheter occlusions also require repeated catheter removals and insertions, thus increasing the risks of hemorrhage and infection (5,17).

The precise thresholds for insertion of E.V.D. after I.V.H. have not been clarified, but it is generally agreed that the presence of hydrocephalus and deteriorating neurologic condition are an indication for placing an E.V.D. (3,13,28).

E.V.D. and Clearance of I.V.H.

The placement of EVD does not immediately clear the I.V.H. and is sometimes not sufficiently effective due to obstruction of the catheter by blood. Naff et al. showed that blood clot resolution in C.S.F. follows first-order kinetics. And it has been suggested that E.V.D. could even potentially slow the rate of I.V.H. clearance by removing the tissue plasminogen activator released from the clot into the C.S.F. (2,15,22,31)

A systematic review comparing indirect observational studies comparing conservative treatment, E.V.D., and E.V.D. combined with fibrinolysis in the setting of severe I.V.H. due to S.A.H. or I.C.H. found that the fatality rate for conservative treatment was 78%, for E.V.D 58%, and for E.V.D. with fibrinolytic agents 6%; and the poor outcome rate for conservative treatment was 90%, EVD 89%, and E.V.D. with fibrinolytic agents 34% (7,18,22).

Techniques of E.V.D. Insertion

Due to occasional complications associated with bedside E.V.D. placement we have recommended placement of the E.V.D. in the operating room, with a rationale of better sterile technique, and more optimal visualization and hemostasis of burr hole exposure and brain surface cannulation (1,10,28). However, the acute nature of increased I.C.P. and the added time involved with operating room access and patient transport have continued to favor the emergent use of bedside technique. (17)

Standard Technique of E.V.D. Insertion

Usually right frontal E.V.D. at the Kocher’s point is preferred.

Management of E.V.D. “Measuring Opening Pressure

One of the most important facts obtained from the E.V.D is the opening I.C.P. measurement. This value has significant prognostic implications, and it influences the subsequent strategy and threshold of C.S.F. drainage through the E.V.D. In all but cases of impending cerebral herniation, special attention is paid so as not to allow significant C.S.F. escape from the E.V.D.before documenting pressure, and this can be accomplished with a manometer or transducer. Once the pressure is measured, the E.V.D. catheter is secured and connected with the drainage bag system and pressure transducer.(3,9,17)

Continuous drainage may allow more rapid clearance of ventricular blood, and presumably spasmogenic and irritative contents of bloody C.S.F., but may also be vulnerable to overdrainage during patient suctioning and mobilization (experienced units protocolize temporary clamping of the E.V.D. during those maneuvers). Others have cautioned that overdrainage of C.S.F. could predispose to cerebral vasospasm as well as hydrocephalus (7,11)

Infection Prophylaxis:

Incidence of ventriculostomy-related infections has been reported from 0% to 22% (3,9,11). This frequently necessitates replacement of E.V.D., prolonged hospital stay, antibiotic-associated cost and morbidities, and occasionally life-threatening sequelae. Risk factors that have been suggested in association with E.V.D.-related infections include previous craniotomy, systemic infection, depressed cranial fracture, lack of tunneling of the catheter, I.V.H., duration of E.V.D., catheter irrigation, site leaks, and frequency of C.S.F. sampling (9,22). Most of these suggestions have attributed particular interventions to a low infection rate, or have compared sequential periods or different series with various protocols, but there have not been careful controlled studies addressing these adjuncts. Some studies showed an associated risk of infection if the catheter is left more than 5 days (4,13,20), and a linear correlation between infection rates and duration of catheter and C.S.F.leakage (8,). Other studies have shown that length of E.V.D. duration has no effect on the rate of infection (9,23).

Antibiotic Use

o reduce infections associated with E.V.D., a common practice is to administer intravenous antibiotics to cover common skin flora (1). However, antibiotic prophylaxis may contribute to the development of resistant organisms, or much more morbid gram-negative ventriculitis (2,11,30). Protocols of antibiotic use have varied widely, including perioperative use at and for short period after E.V.D.insertion, or continued for the duration of drainage (5,16,31)

In the setting of C.S.F. infection with indwelling E.V.D., it is commonly advised to remove the presumably colonized E.V.D., and replace it with a clean E.V.D., preferentially at a different “clean” site. The new E.V.D. allows resumption of C.S.F. drainage, may enhance clearance of ventriculitis, allows C.S.F. sampling to monitor response to treatment, and provides a route for intraventricular antibiotic administration. The latter may be lifesaving in fulminant ventriculitis. In addition to changing the E.V.D., intravenous antibiotics should be started or adjusted in response to the specific offending agent, and intraventricular antibiotic instillation should be considered for more fulminant or recalcitrant infections.

Removal of E.V.D.

With I.V.H. and S.A.H., there is often obstruction of arachnoid villi and the ventricular and cisternal drainage pathways causing acute hydrocephalus and thus the need for E.V.D. However, C.S.F. flow dynamics may recover in some cases after clearance of ventricular blood, allowing the E.V.D. to be discontinued. In other cases, chronic hydrocephalus develops requiring the need for long-term C.S.F. diversion by shunt placement. The decision of E.V.D. removal or conversion to shunt is based on E.V.D. weaning and clamping trials.(5,9,17,29)

Weaning and Clamping Trials

Extrapolating from other medical devices such as chest or endotracheal tubes, the conventional way of E.V.D. removal is a multiday stepwise weaning by progressive height elevation of the drainage system leading to clamping of the E.V.D. During this multiday process the size of the ventricles are usually monitored with serial imaging, along with the patient’s neurologic condition and the volume of C.S.F. drained at various thresholds. If the size of the ventricles increases during this process, or significant I.C.P. elevations of persistent need of drainage are otherwise documented, those patients are deemed to be in need for permanent C.S.F. diversion strategy such as a shunt. However, a study looking that the gradual versus rapid weaning of the E.V.D. in the setting of S.A.H. found that multistep gradual E.V.D. weaning may have provided no definite advantage, only delaying the ultimate shunt procedure, and contributed to more prolonged I.C.U. and hospital stays (2,5,8,16). However, it is clear that different patients recover from E.V.D. dependency at varying rates, and many would not require a shunt after a longer period of E.V.D. drainage, which could best be gauged through repeated clamping trials, if not gradual weaning.

Complication

An external ventricular drain (E.V.D.) leakage refers to the unintended escape of cerebrospinal fluid (C.S.F.) from the system. This can happen due to various reasons, such as a dislodged or blocked catheter, or a breach in the system.

Signs of E.V.D. leakage include:

Wetness around the insertion site

Decreased C.S.F. drainage

Swelling or discomfort at the site

Immediate actions to take if you suspect an E.V.D. leakage:

Notify medical staff immediately.

Avoid manipulating the drain.

Keep the patient's head elevated to reduce the risk of excessive drainage.

It's crucial to address this promptly to prevent complications like infection or increased intracranial pressure. Do you have any specific concerns or symptoms you're noticing?

E.V.D. placement is an invasive procedure.

It is associated with several potential complications:

1. *Bleeding:

Bleeding can occur along the E.V.D. insertion tract or in the several layers of the meninges that prohibit passage into the brain. If drilling or dural puncture is not successful, the surgeon may dissect away dura and create a secondary bleed known as an epidural or subdural hemorrhage.

 Bleeding from E.V.D. placement can be life-threatening and can require neurosurgical intervention in some cases.

The risk of haemorrhage with E.V.D. placement is increased if the patient suffers from coagulopathy.

Mechanical complications from E.V.D. placement can be categorized into:

2. *Malplacement

Mal placement of the E.V.D. tube into the brain tissue instead of ventricles can occur in 10 to 40% of the cases.

Therefore, computed tomography (C.T.), ultrasound, endoscopy, and stereotactic neuro-navigation are used to minimize placement errors of E.V.D. tubes

3. *Obstruction

Obstruction/occlusion of E.V.D. commonly due to fibrinous/clot like material or kinking of the tube. The brain can swell due to pressure build up in the ventricles and permanent brain damage can occur. Physicians or nurses may have to adjust or flush these small diameter catheters to manage medical tube obstructions and occlusions at the intensive-care bedside.

4. *Migration

After E.V.D. placement, the drain is tunneled subcutaneously and secured with surgical sutures and/or surgical staples.

However, it is possible for the E.V.D. to dislodge or migrate.

This will cause the tip of the drain to migrate away from its intended position and provide inaccurate intra cranial pressure I.C.P. measurement or lead to occlusion of the drain.

The E.V.D. is a foreign body inserted into the brain, and as such it represents a potential portal for serious infection.

Historically, the rate of infections associated with E.V.D.s has been very high, ranging from 5% to > 20%.

Infections associated with E.V.D.s can progress to become a severe form of brain infection known as ventriculitis.

Protocols designed to reduce the rate of E.V.D. infections have been successful, applying infection control 'bundle' approaches to reduce the rate of infection to well less than 1%.

Although neurological deficits from passing the E.V.D. catheter across the brain are uncommon, there can be an association of a patient's poor neurological status with E.V.D. malplacement.

In one report, the E.V.D. was inserted too deeply into the fourth ventricle; the authors hypothesized that the patient's coma was due to irritation of the recticular activating system.

The patient's level of consciousness improved after the E.V.D. was adjusted.

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