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DOI: 10.1055/s-0045-1809896
Hemorrhagic Complications Associated with External Ventricular Drain Placement
- Introduction
- Incidence and Clinical Significance
- Risk Factors for EVD-Related Hemorrhage
- Management Strategies
- Prevention Strategies
- Long-Term Consequences of EVD-Related Hemorrhage
- Comparative Analysis with Alternative CSF Diversion Techniques
- Advances in Procedural Safety and Risk Mitigation
- Conclusion
- Reference
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:
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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]
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Pre-placement antithrombotic use: Anticoagulants or antiplatelets within 96 hours of EVD placement are linked to higher hemorrhage rates.[14]
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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]
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Multiple insertion attempts: Each insertion attempt increases tissue trauma, placing pressure on blood vessels and elevating hemorrhagic risk.[16]
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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.
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Observation and follow-up imaging: Minor hemorrhages without mass effect or neurological decline often require only monitoring.
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Reversal of anticoagulation: Vitamin K, fresh frozen plasma, or prothrombin complex concentrates may be administered for excessive anticoagulation.
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Neurosurgical intervention: Large symptomatic hemorrhages with mass effect or midline shift necessitate surgical evaluation. In rare cases, hematoma evacuation may be required.
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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:
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Pre-procedural coagulation assessment: Routine INR and platelet count screening before EVD placement is standard practice.
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Limiting insertion attempts: Image-guided methods, such as neuronavigation or ultrasound, improve catheter placement accuracy and minimize insertion attempts.
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Antithrombotic therapy timing: Adjusting the timing of antiplatelet and anticoagulant administration around EVD placement reduces bleeding risks while balancing thromboembolic concerns.
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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.
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Reference
- 1 Fried HI, Nathan BR, Rowe AS. et al. The insertion and management of external ventricular drains: an evidence-based consensus statement: a statement for healthcare professionals from the Neurocritical Care Society. Neurocrit Care 2016; 24 (01) 61-81
- 2 Kosty J, Pukenas B, Smith M. et al. Iatrogenic vascular complications associated with external ventricular drain placement: a report of 8 cases and review of the literature. Neurosurgery 2013; 72 (2, suppl operative): ons208-ons213 , discussion ons213
- 3 Miller C, Tummala RP. Risk factors for hemorrhage associated with external ventricular drain placement and removal. J Neurosurg 2017; 126 (01) 289-297
- 4 Chung DY, Thompson BB, Kumar MA. et al. Association of external ventricular drain wean strategy with shunt placement and length of stay in subarachnoid hemorrhage: a prospective multicenter study. Neurocrit Care 2022; 36 (02) 536-545
- 5 Meyrat R, Vivian E, Dulaney B, Barrera Gutierrez JC. Predictors of tract hemorrhage after external ventricular drain placement: a single-center retrospective study. Sci Rep 2024; 14 (01) 27772
- 6 Garg K, Gupta D, Singh M, Chandra PS, Kale SS. Comparison of a bolt-connected external ventricular drain with a tunneled external ventricular drain—a narrative review and meta-analysis. Neurosurg Rev 2022; 45 (02) 937-949
- 7 Kim J, Lee J, Feng R. et al. Ventricular catheter tract hemorrhage as a risk factor for ventriculostomy-related infection. Oper Neurosurg (Hagerstown) 2020; 18 (01) 69-74
- 8 Moscote-Salazar LR, Joaquim AF, Agrawal A. Letter: ventricular catheter tract hemorrhage as a risk factor for ventriculostomy-related infection. Oper Neurosurg (Hagerstown) 2020; 18 (02) E61
- 9 Phillips SB, Delly F, Nelson C, Krishnamurthy S. Bedside external ventricular drain placement: can multiple passes be predicted on the computed tomography scan before the procedure?. World Neurosurg 2014; 82 (05) 739-744
- 10 John JK, Robin AM, Pabaney AH. et al. Complications of ventricular entry during craniotomy for brain tumor resection. J Neurosurg 2017; 127 (02) 426-432
- 11 Maher Hulou M, Maglinger B, McLouth CJ, Reusche CM, Fraser JF. Freehand frontal external ventricular drain (EVD) placement: accuracy and complications. J Clin Neurosci 2022; 97: 7-11
- 12 Lele AV, Fong CT, Walters AM, Souter MJ. External ventricular drain placement, critical care utilization, complications, and clinical outcomes after spontaneous subarachnoid hemorrhage: a single-center retrospective cohort study. J Clin Med 2024; 13 (04) 1032
- 13 Foreman PM, Hendrix P, Griessenauer CJ, Schmalz PG, Harrigan MR. External ventricular drain placement in the intensive care unit versus operating room: evaluation of complications and accuracy. Clin Neurol Neurosurg 2015; 128: 94-100
- 14 Herrick DB, Ullman N, Nekoovaght-Tak S. et al. Determinants of external ventricular drain placement and associated outcomes in patients with spontaneous intraventricular hemorrhage. Neurocrit Care 2014; 21 (03) 426-434
- 15 Tavakoli S, Peitz G, Ares W, Hafeez S, Grandhi R. Complications of invasive intracranial pressure monitoring devices in neurocritical care. Neurosurg Focus 2017; 43 (05) E6
- 16 Dey M, Jaffe J, Stadnik A, Awad IA. External ventricular drainage for intraventricular hemorrhage. Curr Neurol Neurosci Rep 2012; 12 (01) 24-33
- 17 Maas MB, Jahromi BS, Batra A, Potts MB, Naidech AM, Liotta EM. Magnesium and risk of bleeding complications from ventriculostomy insertion. Stroke 2020; 51 (09) 2795-2800
- 18 Mahto N, Owodunni OP, Okakpu U. et al. Postprocedural complications of external ventricular drains: a meta-analysis evaluating the absolute risk of hemorrhages, infections, and revisions. World Neurosurg 2023; 171: 41-64
- 19 Ramanan M, Shorr A, Lipman J. Ventriculitis: infection or inflammation. Antibiotics (Basel) 2021; 10 (10) 1246
- 20 Tang Y, Zhong X, Lin T. et al. Bleeding complications related to external ventricular drainage placement in patients with ruptured intracranial aneurysms: a single-center study. Front Surg 2024; 11: 1403668
- 21 Huang TF, Su YK, Su IC. et al. Risk, predictive, and preventive factors for noninfectious ventriculitis and external ventricular drain infection. Neurocrit Care 2024; 41 (01) 109-118
- 22 Forte D, Peraio S, Huttunen TJ, James G, Thompson D, Aquilina K. Ventriculoatrial and ventriculopleural shunts as second-line surgical treatment have equivalent revision, infection, and survival rates in paediatric hydrocephalus. Childs Nerv Syst 2021; 37 (02) 481-489
- 23 Texakalidis P, Tora MS, Wetzel JS, Chern JJ. Endoscopic third ventriculostomy versus shunt for pediatric hydrocephalus: a systematic literature review and meta-analysis. Childs Nerv Syst 2019; 35 (08) 1283-1293
- 24 Coulson NK, Chiarelli PA, Su DK. et al. Ultrasound stylet for non-image-guided ventricular catheterization. J Neurosurg Pediatr 2015; 16 (04) 393-401
- 25 Manfield JH, Yu KKH. Real-time ultrasound-guided external ventricular drain placement: technical note. Neurosurg Focus 2017; 43 (05) E5
- 26 Hong B, Apedjinou A, Heissler HE. et al. Effect of a bundle approach on external ventricular drain-related infection. Acta Neurochir (Wien) 2021; 163 (04) 1135-1142
- 27 Zakaria J, Jusue-Torres I, Frazzetta J. et al. Effectiveness of a standardized external ventricular drain placement protocol for infection control. World Neurosurg 2021; 151: e771-e777
Address for correspondence
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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Reference
- 1 Fried HI, Nathan BR, Rowe AS. et al. The insertion and management of external ventricular drains: an evidence-based consensus statement: a statement for healthcare professionals from the Neurocritical Care Society. Neurocrit Care 2016; 24 (01) 61-81
- 2 Kosty J, Pukenas B, Smith M. et al. Iatrogenic vascular complications associated with external ventricular drain placement: a report of 8 cases and review of the literature. Neurosurgery 2013; 72 (2, suppl operative): ons208-ons213 , discussion ons213
- 3 Miller C, Tummala RP. Risk factors for hemorrhage associated with external ventricular drain placement and removal. J Neurosurg 2017; 126 (01) 289-297
- 4 Chung DY, Thompson BB, Kumar MA. et al. Association of external ventricular drain wean strategy with shunt placement and length of stay in subarachnoid hemorrhage: a prospective multicenter study. Neurocrit Care 2022; 36 (02) 536-545
- 5 Meyrat R, Vivian E, Dulaney B, Barrera Gutierrez JC. Predictors of tract hemorrhage after external ventricular drain placement: a single-center retrospective study. Sci Rep 2024; 14 (01) 27772
- 6 Garg K, Gupta D, Singh M, Chandra PS, Kale SS. Comparison of a bolt-connected external ventricular drain with a tunneled external ventricular drain—a narrative review and meta-analysis. Neurosurg Rev 2022; 45 (02) 937-949
- 7 Kim J, Lee J, Feng R. et al. Ventricular catheter tract hemorrhage as a risk factor for ventriculostomy-related infection. Oper Neurosurg (Hagerstown) 2020; 18 (01) 69-74
- 8 Moscote-Salazar LR, Joaquim AF, Agrawal A. Letter: ventricular catheter tract hemorrhage as a risk factor for ventriculostomy-related infection. Oper Neurosurg (Hagerstown) 2020; 18 (02) E61
- 9 Phillips SB, Delly F, Nelson C, Krishnamurthy S. Bedside external ventricular drain placement: can multiple passes be predicted on the computed tomography scan before the procedure?. World Neurosurg 2014; 82 (05) 739-744
- 10 John JK, Robin AM, Pabaney AH. et al. Complications of ventricular entry during craniotomy for brain tumor resection. J Neurosurg 2017; 127 (02) 426-432
- 11 Maher Hulou M, Maglinger B, McLouth CJ, Reusche CM, Fraser JF. Freehand frontal external ventricular drain (EVD) placement: accuracy and complications. J Clin Neurosci 2022; 97: 7-11
- 12 Lele AV, Fong CT, Walters AM, Souter MJ. External ventricular drain placement, critical care utilization, complications, and clinical outcomes after spontaneous subarachnoid hemorrhage: a single-center retrospective cohort study. J Clin Med 2024; 13 (04) 1032
- 13 Foreman PM, Hendrix P, Griessenauer CJ, Schmalz PG, Harrigan MR. External ventricular drain placement in the intensive care unit versus operating room: evaluation of complications and accuracy. Clin Neurol Neurosurg 2015; 128: 94-100
- 14 Herrick DB, Ullman N, Nekoovaght-Tak S. et al. Determinants of external ventricular drain placement and associated outcomes in patients with spontaneous intraventricular hemorrhage. Neurocrit Care 2014; 21 (03) 426-434
- 15 Tavakoli S, Peitz G, Ares W, Hafeez S, Grandhi R. Complications of invasive intracranial pressure monitoring devices in neurocritical care. Neurosurg Focus 2017; 43 (05) E6
- 16 Dey M, Jaffe J, Stadnik A, Awad IA. External ventricular drainage for intraventricular hemorrhage. Curr Neurol Neurosci Rep 2012; 12 (01) 24-33
- 17 Maas MB, Jahromi BS, Batra A, Potts MB, Naidech AM, Liotta EM. Magnesium and risk of bleeding complications from ventriculostomy insertion. Stroke 2020; 51 (09) 2795-2800
- 18 Mahto N, Owodunni OP, Okakpu U. et al. Postprocedural complications of external ventricular drains: a meta-analysis evaluating the absolute risk of hemorrhages, infections, and revisions. World Neurosurg 2023; 171: 41-64
- 19 Ramanan M, Shorr A, Lipman J. Ventriculitis: infection or inflammation. Antibiotics (Basel) 2021; 10 (10) 1246
- 20 Tang Y, Zhong X, Lin T. et al. Bleeding complications related to external ventricular drainage placement in patients with ruptured intracranial aneurysms: a single-center study. Front Surg 2024; 11: 1403668
- 21 Huang TF, Su YK, Su IC. et al. Risk, predictive, and preventive factors for noninfectious ventriculitis and external ventricular drain infection. Neurocrit Care 2024; 41 (01) 109-118
- 22 Forte D, Peraio S, Huttunen TJ, James G, Thompson D, Aquilina K. Ventriculoatrial and ventriculopleural shunts as second-line surgical treatment have equivalent revision, infection, and survival rates in paediatric hydrocephalus. Childs Nerv Syst 2021; 37 (02) 481-489
- 23 Texakalidis P, Tora MS, Wetzel JS, Chern JJ. Endoscopic third ventriculostomy versus shunt for pediatric hydrocephalus: a systematic literature review and meta-analysis. Childs Nerv Syst 2019; 35 (08) 1283-1293
- 24 Coulson NK, Chiarelli PA, Su DK. et al. Ultrasound stylet for non-image-guided ventricular catheterization. J Neurosurg Pediatr 2015; 16 (04) 393-401
- 25 Manfield JH, Yu KKH. Real-time ultrasound-guided external ventricular drain placement: technical note. Neurosurg Focus 2017; 43 (05) E5
- 26 Hong B, Apedjinou A, Heissler HE. et al. Effect of a bundle approach on external ventricular drain-related infection. Acta Neurochir (Wien) 2021; 163 (04) 1135-1142
- 27 Zakaria J, Jusue-Torres I, Frazzetta J. et al. Effectiveness of a standardized external ventricular drain placement protocol for infection control. World Neurosurg 2021; 151: e771-e777