Extra Ventricular Drainage

Extra ventricular drainage procedure

Extra Ventricular Drainage (EVD) is a surgery where a catheter is inserted into the Ventricles of the brain to remove excess cerebrospinal fluid (CSF). It is usually applied in treating conditions such as:

• Hydrocephalus (obstructive or communicating)
• Intraventricular hemorrhage
• Increased intracranial pressure (ICP).
• Preoperative infections or CSF diversion.

Indications

• Acute hydrocephalus
• Far-severe traumatic brain injury with increased ICP.
• Ventricular obstruction and intraventricular bleeding.
• Diagnosis Diagnosis of infection or hemorrhage by sampling of CSF.
• Transient CSF diversion pre-VP shunt.

Pre-procedure Preparation

Clinical assessment:

• Neurological (GCS score, pupillary response)
• Signs of raised ICP

Imaging:

• CT or MRI to determine the size of the ventricles and the best place of insertion.

Informed consent:

• Talk about such dangers as infection, hemorrhage, and lost catheters.

Laboratory tests:

• Coagulation test (INR, platelet count)
• Blood counts

Procedure Steps

Positioning:

• Patient in the supine position with her head raised (~30°).
• Head can be turned to contralateral.

Anaesthesia:

• In combination with sedation or general anaesthesia (particularly in children) local anaesthesia + sedation.

Marking:

• Characteristic point of entry: the point of Kocher.
• 2–3 cm lateral to midline
• Approximately one centimeter before the coronal suture.

Incision and burr hole:

• Minor scalp incision, which is then succeeded by burr holes in the skull.

Catheter insertion:

• Insert a sterile EVD catheter to the lateral ventricle.
• The depth is typically 5-6 cm of cortical surface.

Confirmation:

• CSF flow confirms placement
• Alternatively, position can be checked by intraoperative imaging (ultrasound or CT).

Drain connection:

• Catheter linked to an adjustable closed CSF drainage.

Fixation:

• Scalp catheter sutured on and dressed with sterile.

Post-procedure Management

• Neurological: GCS, pupils, movement of limbs.
• ICP monitoring if attached
• CSF drainage: Regulated to prevent high rate of decompression (typically 10-20 mL/h)

Infection prevention:

• Strict sterile handling
• Regular dressing changes
• Semi-prophylaxis antibiotics in certain facilities.

Imaging:

• CT scan to ensure the catheter is in place and excludes hemorrhage.

Factors Affecting Extra ventricular drainage cost India

The following are the significant variables that influence the extent to which the EVD procedure will cost in India:

Type and infrastructure of the hospital

• Most private tertiary hospitals with developed neurosurgery units are much more expensive. 
• Availability of an ICU, high-level imaging (CT/MRI), neurosurgery facilities, and 24-hour neurosurgical cover are cost-increasing factors.
• In case the hospital is NABH/JCI accredited, this can be at the cost of increased fees.

Geographic location

• The cost of hospitals in big metros (Delhi, Mumbai, Bengaluru, Chennai) is higher than in cities of tier 2/3. 
• Patient and attendant(s) travel, accommodation, and subsistence can be an additional cost in case you are out of town.

Experience of surgeon and team skills

• A skilled neurosurgeon or expert in critical brain/ intracranial surgery will usually be charged more. 
• Availability of multidisciplinary team (neuro-intensive care, neuro-anaesthesia) has a cost impact.

Complicatedness and status of the patient

• Emergency vs elective cases: EVD can be performed in emergency (e.g., intracranial hemorrhage, hydrocephalus), which can increase the cost. 
• Other circumstances (risks of infections, increased intracranial pressure, ventilation requirement) contribute to monitoring, ICU, and length of stay => increased costs.
• The complexity of the processes can be predetermined by the nature of the underlying cause (trauma, hemorrhage, tumour).

Pre‑ and post‑operative care

• Preoperative (CT, MRI, blood work, imaging) diagnostics. 
• The cost is determined by the length of hospital stay, ICU stay, monitoring, complication management. 
• Follow-ups (in case), post-operative rehabilitation, and other interventions further raise the expense.

Hospital stay and use of ICU

• The longer the stay in ICU/ ward, the higher the charges (room, nursing, consumables). 
• In the event of complications and the extension of stay is required, the price will increase.

Consumables & devices used

• The drainage catheter system, monitoring equipment, disposables, as well as any other neurosurgical aids are money consuming.
• High technology or less invasive procedure (in case) can add to the cost.

Extra ventricular drainage risks and complications

The following is an account of the complications and dangers of Extra Ventricular Drainage (EVD):

Infection

• Ventriculitis or Meningitis: Majority of serious complication.
• The longer the catheter is the greater the risk.
• Symptoms: Fever, stiffness of the neck, disturbed sensorium, turbid CSF.
• Prevention: Aseptic technique, frequent changes of dressings, minimum handling of catheters, prophylactic antibiotics in certain protocols.

Hemorrhage

• Intracerebral or Intraventricular Bleeding in the insertion of a catheter.
• Risk factors: Multiple insertion attempts, Coagulopathy, brain tissue trauma.
• Most of them tend to be small, yet might lead to neurological decline or surgical procedure.

Catheter Misplacement/Migration

• Catheter can be wrongly placed, not in the ventricle, or too deep.
• Outcomes: poor drainage, chronic hydrocephalus or damage to the brain structures.
• Prevention: Landmarks (point made by Kocher), imaging guidance (CT or ultrasound).

Over-drainage of CSF

• This would result in subdural hematoma or ventricular collapse or headaches of low pressure due to rapid drainage.
• This can be avoided by controlled drainage (1020 mL/hr), and monitoring height of drainage bag.

Blockage of Catheter

• Blockage of CSF may happen through blood clots, debris or infection.
• Symptoms: Increased ICP, headache, vomiting, and confusion.
• May need to flush (carefully) or change catheters.

Neurological Complications

• Neurological injuries of the brain tissue, temporary or permanent.
• Uncommon, but can contain hemiparesis, cranial nerve palsies, or seizures.

CSF Leak

• The very appearance of the CSF may leak through the site of insertion leading to the development of subgaleal collections or risks of infection.

Seizures

• Catheter local irritation can trigger seizures, but rarely.

Other Risks

• Pneumocephalus: Air that gets in ventricles during insertion.
• Catheter dislodgement: Unintentional motion causing insufficient drainage or tissue damage.
• Requirement of re-use of procedures: In case of complication or catheter failure.

Extra ventricular drainage recovery time

The following is the specific recovery following Extra Ventricular Drainage (EVD):

Short-term Post-Operative Rehabilitation

• Hospitalization: 5-10 days (usually), depending on the underlying condition and complications.
• ICU Monitoring: The initial 24-72 hours are used to monitor most of the patients in the neuro-ICU.
• Vital Signs/Neurological Checks: The general check of GCS, response of the pupils, limbs movement, and ICP (in case of measurement).
• CSF Drainage: Regulated drainage to avoid excess drainage; typically 1020 mL/hour, depending on ICP and condition of patient.

Short-Term Recovery

• Duration of Catheters: 3-7 days, and in some cases longer in case underlying hydrocephalus, or patient waiting VP shunt.
• Mobility: Restricted at first; progressive as the patient becomes stable.
• Diet & Hydration: Recommenced normal diet, hydration to maintain CSF balance.

Long-Term Recovery

• EVD removal: Catheter is removed when the ICP is stable and the flow of the CSF is sufficient.
• Potential To VP Shunt: In patients having chronic hydrocephalus, VP shunt can be inserted following the removal of EVD.
• Follow-Up Imaging: CT or MRI to make sure ventricles are normalized and no complications.

Extra ventricular drainage in neurosurgery

Extra Ventricular Drainage (EVD) is a neurosurgical operation involving the insertion of a catheter to debride the ventricular system of the brain to remove cerebrospinal fluid (CSF), relieves intracranial pressure (ICP), or to monitor the pressure of CSF.

It is a form of therapy and diagnosis procedure, and is widely applied in the acute neurosurgical practice.

Markers in Neurosurgery

• Obstructive or communicating acute hydrocephalus.
• Intraventricular hemorrhage (IVH).
• Shocking traumatic brain injury with elevated ICP.
• CSF diversion after brain surgery.
• Infections that need CSF (ventriculitis, meningitis).
• Provisional CSF diversion prior to presentation surgery (e.g., VP shunt)

Procedure Overview

• Positioning of the patient: Supine, head elevated 30, head turned slightly.
• Anaesthesia: Local anaesthesia with or without sedation or general.
• Entry point: Penetration is usually Kocher point (23 cm lateral to the midline, 1 cm anterior to the coronal suture).
• Burr hole creation in skull.
• Introduction of catheters into the lateral ventricle (depth) of about 56 cm.
• OS: CSF flow or imaging (CT/ultrasound).
• Drainage connection: Catheter connected to closed CSF drainage system.
• Fixation & dressing: Sterile dressing, sutured catheter.

Role in Neurosurgery

• ICP Management: EVD assists in quick alleviation of intracranial pressure.
• CSF Diversion: It is used to prevent the enlargement of ventricles during hydrocephalus or following hemorrhage.
• Diagnostic: Provides the possibility to sample the CSF to study either infection or hemorrhage.
• Bridge to Definitive Surgery: Provision of CSF management temporarily, until VP shunt or endoscopic third ventriculostomy (ETV) can be done.

Advantages

• Rapid relief of raised ICP
• Less invasive than permanent placement of shunts.
• The feature enables a CSF to be sampled and monitored.
• It can be done as an emergency measure.

Best hospital for extra ventricular drainage India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Extra Ventricular Drainage (EVD) is a life-saving neurosurgical intervention which offers temporary cerebral spinal fluid (CSF) and intracranial pressure (ICP) diversion and monitoring. It is primarily reported in acute hydrocephalus, intraventricular hemorrhage, traumatic brain injury and post-operative CSF management. Although EVD is minimally invasive, highly effective, it bears the risks of infection, hemorrhage, catheter misplacement, and over-drainage that have to be carefully monitored and aseptic precautions followed strictly. The recovery is considered to be short-term, yet it largely depends on the background condition and any complication. EVD is currently used as a treatment and diagnostic modality in neurosurgical practice and usually serves as a temporary treatment option before more permanent interventions such as ventriculoperitoneal (VP) shunting. When done in good procedures, it greatly decreases morbidity and enhances patient outcomes.

Extra ventricular drainage in India with GetWellGo

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• Language Support
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• Case manager assigned to every patient to provide seamless support in and out of the hospital like appointment booking
• Local SIM Cards
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FAQ

1. What is the length of catheter stays?

• Typically 37 days, with ICP control and patient state.
• Perhaps more so when waiting to have definite surgery

2. Will additional surgery be required following EVD?

• VP shunt or Endoscopic third ventriculostomy might be necessary to patients when the hydrocephalus continues.
• EVD is normally transitory and serves as an intervention to definitive treatment.

3. How is infection prevented?

• Stringent sterility at insertion
• Limited manipulation of catheter
• Regular dressing changes
• Preventive antibiotics in the chosen cases

4. Can I move or walk after EVD?

• It has restricted mobility in the beginning.
• The patient is given time to stabilize and control ICP by gradual movement.

5. How is drainage monitored?

• CSF production is regulated (typically 10-20 mL/hr)
• ICP monitoring controls changes.
• Frequently checked neurological status