Gigante Paul, Hwang Brian Y, Appelboom Geoffrey, Kellner Christopher P, Kellner Michael A, Connolly E Sander
College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, 710 West 168th Street, New York, NY 10032, USA.
Br J Neurosurg. 2010 Dec;24(6):625-32. doi: 10.3109/02688697.2010.505989. Epub 2010 Sep 20.
External ventricular drain (EVD) placement is standard of care in the management of aneurysmal subarachnoid haemorrhage-associated hydrocephalus (aSAH). However, there are no guidelines for EVD placement and management after aSAH. Optimal EVD insertion conditions, techniques to reduce the risk of EVD-associated infection and aneurysmal rebleeding, and methods of EVD removal are critical, yet incompletely answered management variables. The present literature consists primarily of small studies with heterogeneous populations and variable outcome measures, and suggests the following: EVDs may increase the risk of rebleeding; EVDs are increasingly placed by non-neurosurgeons with unclear results; intraparenchymal ICP monitors may be safely considered (with or without spinal drainage) in the setting of difficult EVD placement; the optimal timing and manner of EVD removal has yet to be defined; and the efficacy of prophylactic systemic antibiotics and antibiotic-coated EVDs needs further investigation. Nevertheless, there are no definitive practice guidelines for EVD placement and management techniques in aSAH patients. Large prospective randomised trials are needed to definitively address important gaps in our understanding of EVD management principles in the neurocritical care setting.
外置脑室引流管（EVD）置入是动脉瘤性蛛网膜下腔出血相关性脑积水（aSAH）治疗的标准护理措施。然而，目前尚无关于aSAH后EVD置入及管理的指南。最佳的EVD置入条件、降低EVD相关感染和动脉瘤再出血风险的技术以及EVD拔除方法是关键问题，但这些管理变量尚未得到充分解答。现有文献主要由针对异质性人群且结局指标各异的小型研究组成，结果表明：EVD可能会增加再出血风险；越来越多的EVD由非神经外科医生置入，但其效果尚不清楚；在EVD置入困难的情况下，可安全考虑使用脑实质内颅内压监测器（无论是否进行脊髓引流）；EVD拔除的最佳时机和方式尚未明确；预防性全身使用抗生素和抗生素涂层EVD的疗效有待进一步研究。尽管如此，目前尚无针对aSAH患者EVD置入和管理技术的确切实践指南。需要开展大型前瞻性随机试验，以明确解决我们在神经重症监护环境中对EVD管理原则理解方面的重要差距。
