Extraventricular Drainage and Hematoma Evacuation to Treat Hydrocephalus Following Lysis of MCA Embolism
Main Text
Table of Contents
This is a clinical case of an elderly female patient who developed signs of hydrocephalus after receiving systemic thrombolysis for a middle cerebral artery (MCA) embolism, which was followed by intra-arterial thrombolysis a day before. The procedures were assessed as successful. Later on, despite the initial success, she was found exhibiting impaired consciousness. A follow-up head computed tomography (CT) revealed hemorrhaging of the cerebellum leading to the compression of the fourth ventricle and subsequent hydrocephalus. A decision was made to place an external ventricular drain (EVD), followed by a suboccipital craniotomy and evacuation of the cerebellar hematoma. The placement of an EVD is widely considered to be one of the most frequent and crucial life-saving interventions in the neurologic intensive care unit.1 An EVD is a temporary catheter specifically designed to drain cerebrospinal fluid (CSF) and facilitate the monitoring of intracranial pressure (ICP).2
While considering these interventions, it is imperative to evaluate potential contraindications. For EVD, significant bleeding disorders that may increase hemorrhage risk during placement and active infection at the insertion site must be ruled out. Similarly, suboccipital craniotomy is contraindicated in patients who are hemodynamically unstable or have severe comorbidities that render them unsuitable for surgery. Additionally, if the hematoma is deeply located or surrounded by critical structures, making surgical access too risky, this procedure would also be contraindicated.1,7
This video provides a detailed overview of the key steps involved in the EVD placement and hematoma evacuation, offering critical insights from skin incision to wound closure. The procedure begins with EVD placement. The patient is positioned supine with the head in a neutral position to avoid any distortion of anatomical landmarks. Hair is removed, and the scalp is prepared in a sterile fashion. A linear small incision is made at the Kocher’s point through the skin and down to the bone, and the periosteum is carefully retracted. Kocher's point is a commonly chosen entry site on the frontal bone for inserting CSF drainage catheters. It is located 2–3 cm lateral to the midline at the level of mid-pupillary line, 11 cm posterior to the nasion (or 10 cm posterior to the glabella). Following the skin incision, a burr hole is drilled. Then, after the dura is carefully incised, the catheter is placed. The catheter is advanced about 6 cm into the skull. It is directed in a vertical plane towards the inner corner of the ipsilateral eye and in the horizontal plane, posteriorly towards a point 1.5 cm in front of the ipsilateral earlobe. The aim is to place the catheter at the foramen of Monro. Common complications of this procedure are hemorrhage and catheter displacement.1 To prevent displacement and ensure stability, the drainage system is secured to the scalp using sutures․ Care is taken to avoid excessive tension on the scalp tissues, as this can impair blood flow and compromise wound healing. Proper fixation of the drainage system is essential to facilitate effective CSF drainage and mitigate the risk of postoperative complications. Finally, the incision site is closed with sutures. Hemostasis is confirmed, and the wound is dressed in a standard fashion to minimize the risk of infection.
Subsequently, to manage the intracranial hemorrhage (ICH) a suboccipital craniotomy is performed. The patient is placed in the prone position with the head flexed, ensuring the manubriomental distance is two fingerbreadths. First, the external occipital protuberance is identified. This serves as a prominent landmark guiding the surgical approach to the inferior fossa. The patient’s back skin is taped to retract it and facilitate the incision. Following the marking of anatomical landmarks, a midline skin incision is made to access the underlying structures. The overlying musculature on the right side is dissected and retracted to expose the underlying skull. Care is taken to avoid excessive depth. Two burr holes are drilled to facilitate the creation of a bone flap. A craniotome is employed to carefully cut out the bone flap, providing access to the underlying intracranial structures. In this case, a cerebral venous sinus is accidentally injured, and bleeding is observed. A dura suture is promptly placed to exert counter pressure, effectively controlling the hemorrhage. The placement of the dura suture is crucial for ensuring hemostasis. Injury to the sinuses can lead to rapid blood loss and serious morbidity or mortality if not promptly handled.3
Following craniotomy, a head frame is secured to the skull to provide stabilization and support during the surgical intervention. The next part of the video focuses on the alleviation of the cerebellar hematoma. Profuse bleeding is observed upon entry of the hematoma sac, necessitating immediate initiation of hematoma suction. The next step involves the insertion of a wire mesh. Additionally, a dural sealant is applied on wire mesh to enhance tissue adhesion and prevent CSF leakage. Finally, a synthetic bone substitute is carefully placed and secured with titanium plates and two screws on each side to ensure the structural integrity of the vault. The wound is meticulously closed using sutures, and a sterile dressing is applied. Care is taken to achieve optimal wound apposition and hemostasis to promote effective healing.
The special equipment, materials, and instruments used throughout the case include manual and automatic drills, a craniotome, an extraventricular drainage kit, self-retaining wound retractors, a Freer elevator, wire mesh, dural sealant spray, synthetic bone putty, and a titanium Bioplate cranial fixation system.
Hemorrhagic transformation (HT) is a potentially life-threatening complication of acute ischemic stroke that is particularly common following thrombolytic therapy.4 Systemic thrombolysis is associated with a 6–8% risk of intracerebral hemorrhage (ICH).5 Attention should be paid to identifying the patients who are at elevated risk of HT.6 To ensure timely discovery of occult HT, head CT should be performed in patients at risk. This video is a valuable step-by-step demonstration of the surgical approach in similar clinical scenarios.
Citations
- Muralidharan R. External ventricular drains: management and complications. Surg Neurol Int. 2015;6(7). doi:10.4103/2152-7806.157620.
- Bertuccio A, Marasco S, Longhitano Y, et al. External ventricular drainage: a practical guide for neuro-anesthesiologists. Clin Pract. 2023;13(1). doi:10.3390/clinpract13010020.
- Oh GS, Arnone GD, Abou-Al-Shaar H, Barks AL, Wong A, Charbel FT. Surgical repair of iatrogenic transverse-sigmoid sinus laceration with a dural flap during skull base tumor surgery: a technical case report. World Neurosurg. 2017;106. doi:10.1016/j.wneu.2017.06.100.
- Spronk E, Sykes G, Falcione S, et al. Hemorrhagic transformation in ischemic stroke and the role of inflammation. Front Neurol. 2021;12. doi:10.3389/fneur.2021.661955.
- Miller DJ, Simpson JR, Silver B, Silver B. Safety of thrombolysis in acute ischemic stroke: a review of complications, risk factors, and newer technologies. Neurohospitalist. 2011;1(3). doi:10.1177/1941875211408731.
- Zhang J, Yang Y, Sun H, Xing Y. Hemorrhagic transformation after cerebral infarction: current concepts and challenges. Ann Transl Med. 2014;2(8). doi:10.3978/j.issn.2305-5839.2014.08.08.
- Jin C, Yang Y. Surgical evacuation of spontaneous cerebellar hemorrhage: comparison of safety and efficacy of suboccipital craniotomy and robotic-assisted stereotactic hematoma drainage. Clin Neurol Neurosurg. 2024;239:108192. doi:10.1016/j.clineuro.2024.108192.
Cite this article
Prinz V, Czabanka M. Extraventricular drainage and hematoma evacuation to treat hydrocephalus following lysis of MCA embolism. J Med Insight. 2024;2024(142). doi:10.24296/jomi/142.
Procedure Outline
Table of Contents
- Preparation and Draping
- Skin Marking and Incision
- Drill through Corticalis
- Identify and Open Dura
- Insert Extraventricular Drain
- Fix Drain to Scalp
- Close Wound
- Mark Midline and Inion
- Identify Inion
- Make Midline Incision
- Remove Overlaying Musculature
- Drill Burr Holes
- Use Craniotome and Remove Bone Flap
- Insert Dura Suture
- Enter Cerebellum
- Suction Hematoma and Control Bleeding
- Insert Wire Mesh and Spray Dural Sealant
- Place Artificial Bone Putty
- Attach Bioplates to Artificial Bone
- Fasten Artificial Bone to Skull
- Close Wound
Transcription
CHAPTER 1
Hello from the neurosurgery operating room at Charite in Berlin. And right now we are having an elderly lady, which suffered from ischemia in the territory of the middle cerebral artery on the left side. She got systemic lysis and then also yesterday an intra-arterial lysis to take out the embolysis, which was quite successful. First of all, she recovered fine, but then she was found with reduced consciousness to Glasgow Coma Scale of about 12. In the CT scan performed today, you could see that there was no major infarction in the territory - territory of the middle cerebral artery, but you could see that there was bleeding in the cerebellum, compressing the fourth ventricle and leading to a hydrocephalus, explaining the loss of consciousness of - or the reduced consciousness of the lady. So we are going to first place an extraventricular drainage to treat the hydrocephalus, and then we are going to remove the hematoma in the cerebellum. Extraventricular drainage will be inserted using a manual drill, which, regarding the overall procedure, makes it faster than doing it with an automatic drill. One of the disadvantages certainly is that when you use a hand drill, that the burr hole is rather small - more or less just a little bit bigger than the diameter of the drainage itself. When - when you have done the drilling, you do not have that much room to adjust the angle - how it goes through the skull.
CHAPTER 2
Okay, so we do a little incision - just very quick. And then we do need the manual drill as I said before. And now we - you should, as I said before, it's helpful if you try to place already the drill in the direction you later on want to introduce the - the drainage. Because, otherwise, you might later have difficulties with it. Okay, here we go. So I have to start here. Okay, now you feel how it goes through the corticalis, and then it goes - should go quite easy. And then you will hit the other corticalis on the other side. That's when it gets hard again, which is now. Okay, now we in. Probably saw that it advanced. Take it back out. Now we are ready to take the - the extraventricular drainage system, and then... Always try to take something, which is not sharp at it's top. Shortly see and open the dura. Okay. Before introduction of the drainage system, I always like to - to moisten it or to make it a little bit wet, so that the - the rubber does not stick to the - to the medulla. Now we need to find the hole. See that you have the right angle, and then do not advance it further than 6. 6 cm. And here we go. Here you can see the liquid running, and then if you hold it close to the head, you can kind of get an impression if there's high pressure or rather low pressure. Okay, you can see that very nicely. Liquid is so - again. Insert it here. And to... Put it up like this. So you always need to make sure now - need to make sure now that you do not move the - the drainage outside. So, okay. And now we look again if it's still running, and you see it's still running very nicely. Take it here to the connector. The worst thing which can - one of the worst things which can happen to you actually would be - yeah - would be that the drainage, which the patient probably will have for at least some days to take out some fluids but also to measure the pressure - so you do not want to risk that the drainage dislocates. Therefore, you fix it using a suture. And we also do another suture... To fix it in place. So as I said, you do not want to risk that it dislocates over the next days where the patient will have it. Therefore, we fix it to the skin, using this butterfly fixation system, and now we need a little suture for the wound. Also at this point of course, you need to take care that you do not harm the drainage. One of the major advantages actually of - of doing it with a manual drill is also that you are not - that you do not have to go to the OR if you only - if you have a patient where you only need extraventricular drainage for measuring intracranial pressure and releasing some fluid. So therefore you can also, doing this way, do it on a normal Intensive Care Unit and without blocking the operating room. So now the next step will be to - to turn the patient to its belly, and then we will address the - we will address the bleeding doing a suboccipital craniotomy.
CHAPTER 3
So the major part of the bleeding is located on the - on the right side. Therefore, we are going to do the craniotomy right sided. So next we will tape down the skin a little bit, so - so the skin incision will be easier. Then we are going to locate the middle, which is here, locate the inion, which is about here, and touch - okay. And... So most probably, I think this will be enough to get - to expose the inferior fossa. Okay. So you need to prepare this for - so that you are prepared when you need the Halo ring during the surgery to fix it. Schnidt. So we are doing the skin incision first, then insert the distractor. Then we check the monopolar. Directly go down on the skull because there you have your orientation. And then you need - always try to stay - to stay in the middle, as - as the muscles - as the muscles are attached to the skull there, so if you stay in the middle, you at least, hopefully, will have rather low bleeding. However - however basically, with this approach, most of the time - most of the time, you do quite have to take care - take some care about controlling blood flow. So as I said in the beginning, we are - we will do a craniotomy on the right side only to approach the bleeding. We do not have to - to remove the muscles - you do not have to remove the muscles on the left side. Which of course, also is good for wound healing - for the wound healing and - and generate onto the musculature. So as I said, you remove the - the muscle from the skull on the - on the right side only. You must be careful not to go too deep. Dissector. With a dissector, you can very nicely see if you - how close you are to the foramen magnum. You can touch down here. So as you can see, the muscle is attached here, and also the - the bone shows you that here's the midline. So we take out all the bone from the drilling. So basically, what happened is where - that we injured the - the sinus. And then generally, it can start bleeding quite a lot as you have seen, but as there's not much pressure on it, most of the time you can just stop the bleeding by giving some counter-pressure using - using or utilizing a dura suture. So now we fix the Halo ring.
CHAPTER 4
So I'm entering or operating at the cerebellum. Most of the times, it's a little bit hard. Yeah. Because the angle is always very hard. And here we go - here's the bleeding. Okay. So this is artificial bone so to say.
CHAPTER 5
Get my Bioplate. Okay, so now we have fixed the - close the head again. That's certainly important because we do not want to have any intracranial fluids getting outside. And we always fix it with some Bioplates, which are these little titanium - titanium plates with two screws on each side.
CHAPTER 6
So taken together, we had an elderly lady with a hydrocephalus and reduced consciousness due to an overall - due to an ICH in the cerebellum. We evacuated the ICH from the cerebellum, which went quite fine, and then we closed up again the skull with artificial bone. And before we evacuated the ICH in the cerebellum, we had an implantation of an extraventricular drainage to already take some pressure from the brain, and everything went fine. So now the lady will be - will be returned to the Intensive Care Unit. We will take a CCT follow up tomorrow, and - where the aim is, of course, that she will wake up and regain consciousness - and of course, we can control the ICP due to the extraventricular drainage we implanted. That's it.