Like any other procedure or device, external ventricular drain (EVD) and lumbar drain (LD) use can result in complications. You should be aware of the range of complications that can occur with both types of drains and follow existing protocols to manage each complication. Intracranial hemorrhage can occur with EVD placement, and spinal epidural hemorrhage can occur with LD placement. Both drains can also lead to infections such as ventriculitis and meningitis. If lumbar drainage is overaggressive, it can precipitate a subdural hemorrhage or even brain herniation. Finally, given the prolonged immobilization of patients with either an EVD or an LD or both, you must always keep venous thromboembolism in mind as an ever-present concern.
Once an external ventricular drain (EVD) or a lumbar drain (LD) has been placed, the care team must stay vigilant for complications. Each category of complications has specific management options. In this chapter, we review some of the more commonly encountered complications, how to prevent them, and how to deal with them when they do occur.
EVD COMPLICATION MANAGEMENT
Intracranial hemorrhage (ICH) from EVD placement has been the topic of discussion largely in reports of observational studies. A baseline risk of approximately 1.1% for ICH has been reported for all craniotomies.1 True hemorrhage rates associated with EVDs are difficult to calculate because of the differences in the types and timing of imaging after EVD placement. There is also the question of whether to define a hemorrhage as symptomatic or asymptomatic. Most of the reports in the neurosurgery literature group hemorrhages as tract or intraparenchymal, intraventricular, subdural, or some combination of these three types of hemorrhages (Figs. 6.1 and 6.2). The range of risk for all EVD-related hemorrhages is reported as 5% to 41%, whereas the range for symptomatic hemorrhage is ≤2.5%.2–6 Of the symptomatic or larger hemorrhages, <1% typically require surgical intervention.2,5
The typical locations of hemorrhage associated with external ventricular drain (EVD) placement are demonstrated, including subdural, intraparenchymal, and intraventricular.
External ventricular drain (EVD) hemorrhage. Axial computed tomograms demonstrate a combination (A) intraparenchymal hematoma and (B) intraventricular hemorrhage after EVD removal. The patient underwent contralateral EVD placement and recovered.
If a new hemorrhage is identified on postplacement imaging, the typical next step is to repeat the imaging until the bleed is deemed stable. This evaluative process requires judgment gained with experience over time. A small tract hemorrhage usually can be noted without the need for further follow-up, whereas a patient with a large subdural hemorrhage with midline shift should ...