Rapid Pore Cranial Drilling With External Ventricular Drainage for Treatment of Intraventricular Hemorrhage: A 36-Year Case Series

Intraventricular hemorrhage (IVH) denotes a bleeding within the ventricular system of the brain. It usually results from traumatic brain injuries or hemorrhagic stroke, and the prognosis can be very poor.^1,2 Volume of IVH has been reported to be a predictor of outcome in patients with spontaneous intracerebral hemorrhage (ICH) and extension to the ventricles.^3,4 Epidemiologic data has demonstrated a strong association between the amount of blood in the ventricles and severity of outcomes including mortality, coma, and functional impairment.⁴ This finding provides substantial support for the therapeutic idea of intraventricular hematoma removal, which has been validated in animal studies. The removal of blood clot from ventricles prevents hydrocephalus and inhibits inflammation mediated progressive tissue damage.^5,6 External ventricular drainage (EVD), also known as ventriculostomy, has then been developed to remove the blood or obstructed cerebrospinal fluid (CSF) from the ventricles of the brain, which thus relieves the elevated intracranial pressure (ICP) and hydrocephalus.⁷ Efforts have been made to improve the drilling and drainage techniques. For example, the method of percutaneous needle trephination has been introduced and performed in case of emergency as a simple, low-risk, effective way to reduce ICP.^8,9 Similarly, Zhang et al first introduced a medical device named rapid pore drilling apparatus in 1975, and shortly after reported the first success using the rapid pore drilling technique to perform EVD via the frontal horn of the lateral ventricle, which saved the life of a patient with IVH and severe tonsillar hernia.^10,11 It was a fast procedure, completed within 10 minutes, and could be performed at the bedside under sterile condition. Since then, this technique has been adopted in many hospitals in Shandong Province, China. In this study, we collected and analyzed clinical data on 3773 patients who were admitted for IVH at 14 hospitals from 1977 to 2013 and received rapid pore cranial drilling with EVD. The clinical experiences, including operating procedures, duration, technical performances, and the therapeutic effect of rapid pore drilling with EVD were recorded. To our best knowledge, the present study was the biggest one that involved the largest cohort so far and summarized the clinical practice of the rapid pore cranial drilling technique over 30 years. The results indicate that the rapid pore cranial drilling technique is minimally invasive, fast, safe, and effective for treating patients with severe IVH.

Materials and Methods

Surgical method

The pistol-like drilling apparatus (Fig. 1) was designed by Dr. Qinglin Zhang and Dr. Cheng Zhang, and manufactured by Xinhua Medical Instrument Factory of Shandong Province in 1964.¹⁰ The most common puncture site was located 2 to 3 cm above the hairline and 2 to 3 cm beside the middle line, pointing to the frontal horn of the lateral ventricle. After local anesthesia of the puncture site, the scalp, skull, and dura mater were drilled directly in 1 line, and the drainage tube was inserted with a needle about 7 to 8 cm from the skin. The opening of the drainage tube was 10 to 15 cm higher than the ventricle level. Bilateral drainage was performed when the lateral ventricle was full of hematoma. The key point of the procedure was to prevent the scalp from slipping to ensure that the scalp puncture point and the skull hole were aligned.

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The CSF pulsation of the tube was checked regularly to ensure that the tube was unobstructed. If obstruction occurred, the tube was reopened by irrigation with normal saline, squeezing, or repositioned by adjustment of depth. The drainage volume was maintained at about 200 mL/d, holding 5 to 7 days. Urokinase was infused to the ventricles as early as possible to decompose the hematoma clot and prevent tube blockage, especially for patients with a ventricular cast. CT scans were performed regularly to monitor the status of hematoma and obstruction. The results from CT scans were used to determine the efficacy of EVD. Before extubation, the tube was elevated to 20 cm above the ventricle for 24 hours. If the patient's condition did not worsen, the drainage tube could be removed. In this study, the longest duration of intubation was 15 days.

Results

This study included a total of 3773 patients suffering from IVH and admitted to 14 hospitals in Shandong Province from 1977 to 2013 (Table 1). Of these patients, 2172 were male and 1601 female, with a male–female ratio of 1.36:1. Patients ranged in age from 43 days to 97 years, with a mean of 51.7 years. A total of 58.2% of patients underwent unilateral cranial drilling with EVD treatment, and 41.8% underwent bilateral treatment. The drainage tubes were held from 5 to 15 days. By the end of the treatment, 1049 patients (27.8%) experienced complete remission, 1788 (47.4%) showed improvement, and 936 (24.8%) died. Statistics indicated that the conditions such as brain stem hemorrhage, aneurysm rupture, cerebral arteriovenous malformation hemorrhage, and thalamic hemorrhage had higher mortality (>30%).

Table 1 Distribution of patients with intraventricular hemorrhage treated in 14 hospitals of Shandong Province between 1997 and 2013

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The main complications in these patients treated with rapid pore cranial drilling and EVD were intracranial infection (178, 4.7%), upper gastrointestinal bleeding (162, 4.3%), lung infection (136, 3.6%), drilling point and/or puncture tract bleeding (67, 1.8%), and others (19, 0.5%). It is worth mentioning that in this study no cases needed emergent surgical operation to remove a hematoma occurring due to puncture.

As an illustrative case, a 45-year-old male patient was admitted for sudden headache and left hemiparalysis for 2 hours with a primary diagnosis of IVH. The brain CT scan showed acute hydrocephalus and diffusive brain edema (Fig. 2). The ICP was about 360 mmH₂O (3.53 kPa). At the bedside, bilateral rapid pore cranial drilling was performed and EVD was initiated within 10 minutes. After discharge of 60 mL bloody CSF, the patient's respiration, blood pressure, and pulse became stable, consciousness improved, and pupil dilation returned to normal. The patient gained consciousness after drainage of 24 hours, and the drainage volume was about 150 to 200 mL/d. The CSF became clear within 4 days, and the CT scan showed no visible hydrocephalus and reduced hemorrhage in the ventricles (Fig. 3). Catheter of the right lateral ventricle was removed on the seventh day and the CT scan on the 11th day showed that the hemorrhage was partially absorbed (Fig. 4). The left drainage catheter was removed on day 14 following the disappearance of hemorrhage, and the patient was safely discharged after further treatment upon full recovery.

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Discussion

It has been reported that 40% of patients with spontaneous intracerebral hemorrhage (ICH) have extension of the hemorrhage into the ventricles early or late in the sequence.^4,12,13 The 30-day mortality rate for patients with IVH is nearly 5 times higher than those with ICH alone.¹⁴ We think there are several reasons for the high mortality rate and disability rate of IVH: first, a vicious cycle of acute increased ICP inducing fatal brain hernia¹⁵; second, potential triggering of cerebral vasospasm by vasoactive agents arising from or released by the hemorrhage, such as serotonin, prostaglandins, catecholamines, angiotensin, oxyhemoglobin, endothelin, calcium ion, protein kinase C, thromboxane A2 (TxA2), substance P, histamine, hypothalamus exudate, biogenic amines and peptides, fatty peroxides, and free radicals^16,17; third, secondary brain edema; and fourth, acute obstructive hydrocephalus.⁴ Whether these pathologic processes, especially the rapid increase of ICP and tissue inflammation, can be blocked or relieved is the key to successful treatment of severe IVH. Rapid pore cranial drilling is a quick and effective practice to gain the patients immediate relief from elevated ICP, stop the malignant pathologic development of brain hernia, and facilitate further treatment. Significant impact has been made in patients with very severe IVH who were in deep coma (Glasgow Coma Scale score ≤6) and/or showed unstable vital signs. More than 20% of the patients in our study belonged to this group, and most of them experienced quick remission through the immediate use of rapid pore cranial drilling drainage. A very similar procedure, percutaneous needle trephination, was introduced in the early 1980s, and demonstrated clinical efficacy.¹⁸ Although the principle of the procedure is the same as ours, the drilling technique is different and takes approximately 20 minutes to complete the procedure, which is significantly longer than ours (5 minutes for unilateral drainage). Despite these differences, the complication rates, including the rate of intracranial infection, are both low and comparable between the 2 procedures.^8,9

The rapid pore cranial drilling technique has multiple advantages over the traditional methods including the Dandy's approach. A comparison of procedures shows that the rapid pore drilling is superior to Dandy's drilling in terms of complexity of operating procedures and requirements, number of trained personnel required, operation duration and cranial injury (Table 2). Rapid pore drilling allows the initiation of unilateral EVD within 5 minutes, which greatly reduces the lethal risk of brain herniation from prolonged ICH and IVH. The scalp incision and diameter of bone hole are very small compared to that from conventional drilling (5 mm versus 40 mm and 5 mm versus 12–14 mm, respectively), which minimizes the damage to the hypothalamus and reduces the stress response from invasive surgery. The prognosis is greatly improved and better outcome is achieved. The statistic data have shown that the case fatality rate for conservative treatment of severe IVH was 78%, and it was 58% for EVD performed by conventional drilling technique.¹ In our study, the mortality rate of 3773 cases with rapid pore drilling was only 24.8%, and the mortality rate for patients with severe conditions such as aneurysm rupture and cerebral arteriovenous hemorrhage was slightly higher (>30%), yet still significantly lower than the historical comparator. However, this comparison was made from indirect observational studies using historic data. The analysis did not adjust for the differences in medical conditions of the patients, age and sex composition of the group, surgical protocols, and definition for infection. Therefore, a well-controlled study is required for direct comparison of the rapid pore cranial drilling with the conventional drilling technique and modified procedures such as percutaneous needle trephination.

Table 2 Comparison of traditional Dandy's drilling and rapid pore drilling techniques for treating intraventricular hemorrhage

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Ventricular drainage combined with fibrinolytics has been proved to improve the outcome of IVH.^19–21 In our study, fibrinolysis with urokinase was used to accelerate clot dissolution and keep the drainage tube unobstructed. In addition, lumbar puncture or lumbar catheter drainage can be used in patients in stable condition to promote the circulation of CSF and clearance of bloody CSF, thereby reducing hydrocephalus, arachnoid adhesions, cerebral ischemia, cerebral infarction and other delayed complications.²²

Intracranial infection is the major complication of external ventricular drainage and the risk of infection increases with the duration of drainage, which greatly limits its use in patients who need longer drainage. A recent study reported the use of long subcutaneous tunneling of external ventricular drainage, which uses an externalized distal catheter to increase the distance between the drainage exit site and the puncture hole on the skull in order to reduce the risk of infection.²³ Unfortunately, our rapid pore cranial drilling is not suitable to adopt this adaptation. However, other preventative measures can be taken to minimize the chance of infection, such as the use of antibiotic-impregnated catheters, strict sterile techniques, and standardized perioperative management protocols.

One limitation of this study is that it uses historic data as controls. Since our results provide very strong evidence demonstrating the effectiveness of rapid pore cranial drilling in increasing the success rate and decreasing the mortality, it is urgent to conduct a prospective controlled trial.