External Ventricular Drain in Midline Hemorrhagic Stroke
Place an external ventricular drain (EVD) immediately in patients with midline hemorrhagic stroke who have hydrocephalus causing decreased level of consciousness, as this is a Class 1 indication that reduces mortality. 1, 2
Primary Indication: Hydrocephalus with Altered Consciousness
The American Heart Association establishes EVD as a Class 1 recommendation specifically for intracerebral hemorrhage (ICH) or intraventricular hemorrhage (IVH) when hydrocephalus develops and causes decreased consciousness—this directly reduces mortality. 1, 2 The mechanism is straightforward: hydrocephalus is an independent predictor of death after hemorrhagic stroke, and EVD rapidly decreases intracranial pressure secondary to obstructed CSF flow. 2
The critical decision point is whether hydrocephalus is present AND causing neurological decline. 1, 2
Patient Selection Based on Glasgow Coma Scale
EVD placement follows a clear GCS-based algorithm:
- GCS >3 with hydrocephalus and decreased consciousness: Place EVD immediately—this is where mortality benefit is proven. 3, 2, 4
- GCS ≤8 with moderate-to-severe ICH/IVH: Consider EVD for ICP monitoring and treatment to reduce mortality. 1, 2
- GCS 4-5: Gray zone where survival is possible but functional recovery is highly unlikely—EVD may reduce mortality but functional benefit is uncertain. 3
- GCS ≤3: Do NOT place EVD—these patients have universally poor prognosis regardless of intervention. 3, 2
Independent predictors of EVD placement include GCS ≤8, Graeb score >5 (indicating severe IVH), and non-lobar ICH ≤30 cc. 4
Timing and Technical Considerations
Place EVD early—delaying placement in patients with hydrocephalus and decreased consciousness increases mortality. 2 For patients undergoing surgical intervention, install the EVD in the operating room immediately before starting the procedure. 5
Before insertion, evaluate and correct coagulation abnormalities to minimize hemorrhagic complications. 2
Enhanced Therapy: Adding Intraventricular Thrombolysis
For patients with GCS >3 who have primary IVH or IVH extension from supratentorial ICH <30 mL requiring EVD, adding intraventricular thrombolytic (alteplase or urokinase) to the EVD is safe and reasonable compared to EVD alone, as it further reduces mortality. 1, 2 This represents a Class 2a recommendation from the American Heart Association based on the CLEAR III trial. 1
The thrombolytic hastens clot removal, improves CSF circulation, and shows no increased risk of symptomatic hemorrhage—in fact, it demonstrates lower ventriculitis rates. 1
Expected Outcomes and Realistic Expectations
EVD reduces mortality but functional outcome benefit remains uncertain. 3, 2 In patients with hydrocephalus on presentation and GCS >3, EVD placement is independently associated with reduced mortality at hospital discharge after controlling for ICH and IVH severity. 4
Median GCS typically increases within 48 hours post-EVD placement. 4 However, infection rates can reach 27.6%, and 8.9-48% of survivors may progress to permanent shunt dependency. 3, 1
Common Pitfalls to Avoid
- Do not delay imaging when clinical worsening occurs—urgent CT is essential to assess for catheter obstruction, new hemorrhage, or evolving hydrocephalus. 1
- Do not place EVD in patients with GCS 3—this represents futile care with no survival benefit. 3, 2
- Do not assume all neurological decline is from hydrocephalus alone—consider concurrent issues like rebleeding, herniation, or seizures. 1
- Do not continue ineffective EVD management—if standard drainage fails and IVH is present, escalate to intraventricular thrombolysis. 1
Management Protocol
Implement a bundled EVD protocol addressing insertion technique, aseptic management, proper skin preparation, catheter selection, dressing changes, CSF sampling frequency, healthcare professional training, and infection rate monitoring to reduce complications from potentially 45% down to <1%. 1