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CC BY 4.0 · Indian Journal of Neurotrauma
DOI: 10.1055/s-0045-1809896
Letter to the Editor

Hemorrhagic Complications Associated with External Ventricular Drain Placement

Luis Rafael Moscote-Salazar 
1   Department of Research, Colombian Clinical Research Group in Neurocritical Care, Bogota, Colombia
2   Department of Research, AV Healthcare Innovators, LLC, Madison, Wisconsin, United States
,
Md Moshiur Rahman 
3   Department of Neurosurgery, Holy Family Red Crescent Medical College, Dhaka, Bangladesh
,
Tariq Janjua 
4   Department of Neurology, Regions Hospital, Saint Paul, Minnesota, United States
,
William A. Florez-Perdomo 
5   International Consortium of Neurological Research, Minneapolis, Minnesota, United States
,
Amit Agrawal 
6   Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Introduction

Effective management of EVDs is essential for treating patients with severe traumatic brain injuries, intracranial hemorrhages, subarachnoid hemorrhages, and hydrocephalus. EVDs provide a temporary CSF diversion, thus alleviating intracranial pressure (ICP) and preventing secondary brain injuries.[1] [2] Despite their benefits, EVDs pose risks, including tract hemorrhage, infection, and catheter malposition.[3] Tract hemorrhage is the most critical hemorrhagic complication, as it can result in neurological deficits, extended hospital stays, and the necessity for further surgical procedures.[4] Significant hemorrhages may cause elevated ICP, midline shift, or neurological deterioration.[5] Subclinical bleeding is also linked to ventriculitis, requiring a thorough evaluation and management of EVD related hemorrhages.[6]


 

Incidence and Clinical Significance

Tract hemorrhages are a well-documented risk in neurosurgical procedures, occurring in up to 30% of cases.[7] [8] However, the incidence of clinically significant hemorrhages—those resulting in mass effect, midline shift, or neurological deterioration—is much lower. Most bleeding complications arise during catheter insertion rather than removal.[9] Blood in the ventricular system may facilitate secondary complications, such as infection.[10] Blood-derived products in CSF create a medium conducive to bacterial growth, increasing the likelihood of ventriculitis.[11] Studies indicate a correlation between EVD-induced hemorrhage and an elevated prevalence of GNR ventriculitis, making even minor bleeding clinically significant.[12]


 

Risk Factors for EVD-Related Hemorrhage

Several risk factors contribute to EVD-related bleeding complications. These include:

  1. Older age: Elderly patients have an increased risk of hemorrhagic complications due to cerebral atrophy, fragile blood vessels, and a higher likelihood of anticoagulant use.[13]

  2. Pre-placement antithrombotic use: Anticoagulants or antiplatelets within 96 hours of EVD placement are linked to higher hemorrhage rates.[14]

  3. Elevated INR (>1.4): An elevated international normalized ratio (INR) has been shown to be a predictive marker for bleeding, though the exact threshold remains debated.[15]

  4. Multiple insertion attempts: Each insertion attempt increases tissue trauma, placing pressure on blood vessels and elevating hemorrhagic risk.[16]

  5. Coagulopathy and thrombocytopenia: Patients with coagulation disorders or platelet dysfunction have an increased risk of hemorrhage.[17]


 

Management Strategies

The management of EVD-related hemorrhages depends on the severity of bleeding and its clinical implications.

  1. Observation and follow-up imaging: Minor hemorrhages without mass effect or neurological decline often require only monitoring.

  2. Reversal of anticoagulation: Vitamin K, fresh frozen plasma, or prothrombin complex concentrates may be administered for excessive anticoagulation.

  3. Neurosurgical intervention: Large symptomatic hemorrhages with mass effect or midline shift necessitate surgical evaluation. In rare cases, hematoma evacuation may be required.

  4. Infection prevention: Given the link between hemorrhage and ventriculitis, strict aseptic techniques, antibiotic prophylaxis, and CSF monitoring are critical.[18] [19]


 

Prevention Strategies

Preventing hemorrhagic complications involves several key measures:

  1. Pre-procedural coagulation assessment: Routine INR and platelet count screening before EVD placement is standard practice.

  2. Limiting insertion attempts: Image-guided methods, such as neuronavigation or ultrasound, improve catheter placement accuracy and minimize insertion attempts.

  3. Antithrombotic therapy timing: Adjusting the timing of antiplatelet and anticoagulant administration around EVD placement reduces bleeding risks while balancing thromboembolic concerns.

  4. Protocol development: Institutional protocols should include operator training, checklists for insertion, and post-insertion verification protocols to standardize EVD placement.[20]


 

Long-Term Consequences of EVD-Related Hemorrhage

While minor hemorrhages often resolve without significant clinical consequences, more extensive hemorrhages can contribute to prolonged ICU stays, increased dependency on ventilatory support, and more substantial healthcare costs. Additionally, persistent intraventricular hemorrhage may lead to obstructive hydrocephalus, requiring a ventriculoperitoneal (VP) shunt. Studies have shown that EVD-associated bleeding has a higher likelihood of developing post-hemorrhagic hydrocephalus, which can lead to long-term neurological sequelae.[21]


 

Comparative Analysis with Alternative CSF Diversion Techniques

EVD placement is one of several methods for CSF diversion. Compared with lumbar drains, EVDs carry a higher risk of hemorrhagic complications due to direct insertion into the brain parenchyma. Stereotactic-guided or neuronavigation-assisted catheter placement has been shown to reduce the risk of vascular injury. The surgical technique of tunneled EVDs and the use of antibiotic-impregnated catheters have helped to lower the infection rate in patients with hemorrhage-induced ventriculitis.[22] [23]


 

Advances in Procedural Safety and Risk Mitigation

Recent advancements have led to improved safety measures for EVD placement. Real-time ultrasound guidance can be used to reduce catheter misplacement and minimize hemorrhagic risk.[24] [25] Additionally, studies have suggested that implementing a standardized insertion checklist significantly reduces procedural complications. There is a need for research on the role of hemostatic agents and novel anticoagulation reversal protocols which may further enhance the safety profile of EVD placement, particularly in high-risk patients.[26] [27]


 

Conclusion

EVD placement remains a crucial procedure in neurocritical care but is associated with hemorrhagic complications. At the same time, minor hemorrhages are common, though rare, and significant bleeding can cause ventriculitis. Understanding risk factors, implementing management strategies, and adopting preventive measures can enhance patient safety. Future studies should focus on refining risk mitigation strategies to improve outcomes for patients undergoing EVD placement.


 

 

Conflict of Interest

None declared.


Address for correspondence

Luis Rafael Moscote-Salazar, MD
Department of Research, AV Healthcare Innovators, LLC;
Madison, WI 53716
United States   

Publikationsverlauf

Artikel online veröffentlicht:
26. Juni 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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