External ventricular drain placement is associated with lower mortality after intracerebral hemorrhage with intraventricular hemorrhage

Andrew D Warren; Qi Li; Kristin Schwab; Brenna McKaig; Alexa N Goldstein; Steven M Greenberg; Anand Viswanathan; Christopher Anderson; M Edip Gurol; Aman Patel; Joshua N Goldstein

doi:10.1186/s12245-022-00450-4

External ventricular drain placement is associated with lower mortality after intracerebral hemorrhage with intraventricular hemorrhage

Int J Emerg Med. 2022 Sep 15;15(1):51. doi: 10.1186/s12245-022-00450-4.

Authors

Affiliations

¹ Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA.
² Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
³ Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
⁴ Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
⁵ Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
⁶ Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. [email protected].

Abstract

Background and aims: Many patients with intracerebral hemorrhage (ICH) develop intraventricular hemorrhage (IVH), which is associated with higher mortality and worse clinical outcome. External ventricular drains (EVDs) are often placed, but there is little data on how much patients benefit from this intervention. We explored the use, timing, and location of EVD in ICH patients and any association with clinical outcome.

Results: During the study period, 2870 patients presented with primary ICH, and 2486 were included in analyses. Overall, patients were 73 (± 13) years old; 54% were male, and 46% had associated IVH. An EVD was placed in 29% of patients with IVH and 4% of those without. IVH patients with EVD were younger (67 ± 13 vs 74 ± 13, p < 0.001), had larger IVH volumes (17 mL vs 8 mL, p < 0.001), and lower GCS scores (7 vs 10, p < 0.001), compared to those without EVD. Ninety-day mortality was available in 2486 (100%) patients, while 90-day mRS was available in 1673 (67.3%). In univariate analysis, EVD placement was associated with lower likelihood of 90-day mortality (53% vs 59%, p = 0.048) but higher likelihood of poor outcome (88% vs 85%, p < 0.001) in those for whom this was available. Those with poor outcomes underwent faster EVD placement (0.46 days vs. 0.96 days, p = 0.01). In multivariate analysis, EVD placement was associated with lower 90-day mortality (OR 0.19, 95% CI 0.053-0.657, p = 0.009), but not with lower odds of poor outcome (OR 1.64, 95% CI 0.508-5.309, p = 0.4). In multivariate analysis, days to EVD placement was associated with lower 90-day mortality (OR 0.69, 95% CI 0.49-0.96, p = 0.027).

Conclusion: IVH is relatively common after ICH. After controlling for potential confounds, EVD placement is associated with lower mortality, but not clearly with better neurologic outcome. In addition, more rapid EVD placement is associated with higher mortality, potentially reflecting early development of herniation or obstructive hydrocephalus.

Keywords: Brain diseases; Cerebral hemorrhage; Cerebrovascular disorders; Intracranial hemorrhages; Ventriculostomy.