Risk factor analysis of long-term outcomes in patients with large intracerebral and intraventricular hemorrhage treated primarily with combined external ventricular drainage and intraventricular thrombolysis.

PURPOSE: Surgical outcomes are typically poor for patients with spontaneous large intracerebral hemorrhage (ICH) complicated by intraventricular hemorrhage (IVH). The optimal treatment strategy remained undetermined -either external ventricular drainage (EVD) alone or in combination with craniotomy. Here, we evaluated shunt-related complications of such patients treated primarily with EVD combined with intraventricular thrombolysis, aiming to provide evidence that may lead to future treatment guidelines.

MATERIALS AND METHODS: From January 2010 to December 2021, a total of 114 patients with spontaneous large ICH (> 30 mL) extending into the ventricular system treated only primarily with EVD and intraventricular thrombolysis were retrospectively enrolled. Hematoma and ventricular volumes were assessed based on imaging data. Cerebrospinal fluid (CSF) parameters-including biochemistry and cell counts-were analyzed in relation to permanent shunt dependency and one-year mortality.

RESULTS: The mean age of the patients was 67.6 ± 11 years, with a male-to-female ratio of 1.7:1. Their mean best Glasgow Coma Scale (GCS) motor score was 3.7 ± 1.9. Mean ICH/IVH volume was 70.9 ± 47 mL. Average daily CSF drainage was 104 ± 52.2 mL, with a mean drainage duration of 16.5 ± 9.4 days. The average number of EVD replacements was 1.9 ± 0.8. WBC/RBC counts(/mm3) in CSF were 110.4 ± 250.3/28997.8 ± 104,400.2 at the first EVD procedure and 5.4 ± 9.0/532 ± 761.9 at the last procedure. Multivariate analysis identified the narrower width of the temporal horn (p < 0.01) and CSF lymphocyte count at the initial EVD procedure (p < 0.05) as independent risk factors for needing a permanent shunt. One-year mortality was significantly associated with pupil size (p < 0.01), daily CSF drainage volume (p < 0.05), and presence of periventricular lucency (p < 0.05). The primary predictor of central nervous system (CNS) infection was CSF WBC count at the final EVD procedure (p < 0.05).

CONCLUSION: The prolonged and repeated use of external ventricular drainage (EVD) in patients with large intracerebral hemorrhage (ICH) complicated by intraventricular hemorrhage (IVH) appears to be a practical and recognizable treatment approach. Early identification of imaging and CSF markers would likely help optimize management strategy for this high-risk population.