13 Placement of External Ventricular Drain/Placement of Intraparenchymal ICP Monitor
13.1 Symptoms and Signs
State of confusion
Headache
Vomiting or nausea
Fatigue
Difficulty producing speech
Abnormal sleeping behavior
Difficulty maintaining balance
Blurred vision, abnormal taste/smell senses
Mood change
Memory or concentration deficiency
Depression or anxiety
Pupil dilation
Weakness/Numbness in fingers/toes
Coma
Neurologic dysfunction from cranial nerve damage
13.2 Surgical Pathology
Cranial benign/malignant trauma
13.3 Diagnostic Modalities
Physical examination
Neurological examination
Glasgow Coma Scale
CT scan of brain without contrast
MRI of brain without contrast
X-ray of brain (test for skull fractures)
13.4 Differential Diagnosis
Diffuse axonal injury (DAI)
Concussion
Contusion
Coup/Contrecoup lesion
Skull fracture
Hematoma
Epidural hematoma (bleeding between skull and dura mater)
Subdural hematoma (bleeding between dura and arachnoid mater)
Subarachnoid hemorrhage (bleeding between arachnoid mater and pia mater)
Intracerebral hematoma (bleeding into brain itself)
Degenerative brain disease from repeated or severe traumatic brain injury (TBI)
Alzheimer’s disease
Parkinson’s disease
Dementia pugilistica
13.5 Treatment Options
13.5.1 Acute Pain Control with Medications and Pain Management
13.5.2 Therapy and Rehabilitation
Physiatry
Occupational therapy
Physical therapy
Speech pathology
Neuropsychology
Rehabilitation nursing
Recreational therapy
13.5.3 If Symptomatic
In emergent cases, ensure sufficient blood and oxygen supply
Medications to reduce secondary damage (diuretics, antiseizure drugs, coma-inducing drugs)
Surgery if deemed suitable candidate
Determine overall prognosis and Karnofsky performance score
If poor surgical candidate with poor life expectancy, medical management recommended
Hematoma removal
Skull fracture repair
External ventricular drain (EVD) placement to treat hydrocephalus and reduce elevated intracranial pressure (ICP), when normal cerebrospinal fluid (CSF) flow is obstructed or intracranial swelling is noted (see ▶Fig. 13.1)
Fig. 13.1 Before placement of external ventricular drain (EVD), intracranial pressure (ICP) was elevated, cerebrospinal fluid (CSF) leakage was present, and the ventricles were enlarged (a). Postplacement imaging confirms success of EVD effect (b). Adjuncts and postoperative care. In: Stamm A, ed. Transnasal Endoscopic Skull Base and Brain Surgery: Surgical Anatomy and Its Applications. 2nd ed. Thieme; 2019
Intraparenchymal ICP monitor placement to measure ICP without CSF diversion
Craniectomy (to relieve ICP and prevent herniation) followed by cranioplasty
Unilateral or bilateral
Bifrontal or frontotemporal
Unilateral frontotemporal: Unilateral localized lesion (traumatic hematoma and cerebral swelling)
Bifrontal: Frontal contusion of brain, generalized cerebral edema without localized lesion
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