A one year Review of External Ventricular Drains In the Management of Hemorrhagic Stroke with Intra

A one year Review of External Ventricular Drains In the Management of Hemorrhagic Stroke with Intra ventricular extension and Obstructive Hydrocephalus.

Ugwuanyi CU*,  Solanke O**,  Nwaribe E*,  Ugwu E***,  Udoh L E*,  Jamgbadi SS**

*Neurosurgery Unit National Hospital Abuja, Wellington Neurosurgery Centre Abuja

**Neuroanasthesia Unit National Hospital Abuja, Wellington Neurosurgery Centre Abuja

***Neuroanasthesia Unit, Federal Staff Hospital Abuja, Wellington Neurosurgery Centre

INTRODUCTION: Hemorrhagic stroke (HS)account for approximately 20% of all stroke globally.  Hemorrhagic Stroke may result from intracerebral hemorrhage (ICH) or from aneurysmal subarachnoid hemorrhage (SAH). ICH may result from poorly controlled hypertension, vascular malformations, amyloid angiopathy.  In either case the cerebrum is abnormally exposed to direct contact with blood and its products with unpleasant consequences. Often acute bleed dissects through some natural barriers in the brain into the ventricular system and cause interference with the normal physiologic flow of CSF and acute obstructive hydrocephalus(HCP)frequently follows. The mass effect of the initial hematoma and the associated acute obstructive HCP inevitably cause a rapid rise in intracranial pressure (ICP). This results in abnormal cerebral cellular metabolism, impairment of neurotransmission and drop in GCS.   Without intervention, death results from herniation. Reported mortality from ICH alone is 44% 1, but may be up to 80%2 when associated with IVH and acute HCP.  The timely application of EVD provides a quick and minimally invasive approach to managing this additional increase in ICP. To what extent EVD intervention impacts on the outcome of this fatal condition is the subject of this study.

AIMS/OBJECTIVE OF STUDY:To evaluate the Impact of EVD intervention on the outcome of HS with IVH and acute obstructive hydrocephalus.

METHODOLOGY: Retrospectively, only patients who suffered hemorrhagic stroke with associated intraventricular extension and obstructive hydrocephalus and treated with EVD were included in this research.  Demography, admitting GCS, admitting BP, Time to intervention from onset of symptoms, Duration of EVD, Need for permanent VPshunts,Need and duration for Ventilatory support. Primary Outcome is modified Rankin score(mRs) at discharge and secondary outcome is mRs at three months were the study parameters

RESULTS: A total of 11 patients met the inclusion criteria. Sex ratio was M: F = 2.7:1. Oldest was 72 years, youngest 34 years, Mean 52.5 years. All presented with sudden onset headache and GCS drop. All but one of the patients presented with severe hypertension with an average MABP of 135mmHg. Earliest presentation was 6hrs and longest presentation was 14 days with an average of 2.5 days.CT Brain confirmed SAH as the primary source of bleed in 63.6% (7/11) and ICH in 37.3% (4/11). Subsequent CT Angiography on the SAH cases only isolated Right sided MCA Aneurysmal bleed in 2/7(28%), Right PCOM and ACOM Aneurysmal bleed each recorded one case (14%) . Three (42%) were referred for further DSA to define culpable SAH vessel. All patients had EVD inserted on same day of admission as an emergency procedure. Average duration of EVD in-situ was seven days. Mechanical ventilatiory support was needed in two (18%). Of course all patient required antihypertensive medications for blood pressure control. We found a combination of Exforge(amlodipine, valsartan, HCT) and Labetalol very useful in all patients. Four (37.3%) required further VP shunt for continued ventricular drainage. Six (54.5%) were discharged with an average mRs score of 2 at discharge and 1 at three months review. One patient suffered accidental dislodgement of EVD which required replacement while two patients suffered ventriculitis which added to the mortality.  5/11(45%) mortality was recorded in this study.

CONCLUSIONS:

In spite of the obvious limitation of numbers in this study, it has indeed demonstrated nearly 40% reduction in mortality when this condition is treated with prompt application of EVD. The high mortality associated with this condition demands all potentially useful resources to be deployed early in its management. EVD is one of such and should be recommended in the initial management protocol of this potentially fatal condition.

Key words

External Ventricular Drain, Hemorrhagic Stroke, Intraventricular Hemorrhage, Acute Obstructive Hydrocephalus

Corresponding author- Charles Ugwuanyi, MD, FMCS, FNIMC. Consultant Neurosurgeon, National Hospital Abuja, Wellington Neurosurgery Centre Abuja.

References:

2-Broderick JP, Brott TG, Tomsick T:  Intra cerebral hemorrhage more than twice as common as subarachnoid hemorrhage. J Neurosurg 78: 188-91,1993.

3-Holly E. Hinston, Daniel F. Hanly, Wendy C. Zai:Curr Neurol Neurosc Rep. 2010 Mar;10(2):73-82