External Ventricular Drainage in Intracerebral Hemorrhage

Primary Indication: Hydrocephalus with Decreased Consciousness

• The American Heart Association recommends External Ventricular Drainage (EVD) as a Class 1 indication for patients with intracerebral hemorrhage (ICH) or intraventricular hemorrhage (IVH) and hydrocephalus causing decreased level of consciousness, as it reduces mortality 1, 2
• Hydrocephalus is an independent predictor of mortality after ICH, and EVD rapidly decreases intracranial pressure (ICP) secondary to hydrocephalus, with a strong evidence level 1, 2, 3, 4
• EVD placement is an independent predictor of reduced mortality at hospital discharge in patients with Glasgow Coma Scale (GCS) score >3 who present with hydrocephalus, based on high-quality evidence 1, 3

Secondary Indications: Severe ICH with Reduced Consciousness

• For patients with moderate to severe ICH/IVH with reduced level of consciousness, ICP monitoring and treatment via EVD might be considered to reduce mortality and improve outcomes, with a moderate evidence level 1, 2

Specific Clinical Parameters

• Patients with GCS score ≤8 may benefit from ICP monitoring and treatment, with a moderate evidence level 1, 2, 3
• Clinical evidence of transtentorial herniation may justify EVD placement, based on low-quality evidence 6, 7

EVD Plus Intraventricular Fibrinolysis

• For patients with GCS >3 and primary IVH or IVH extension from supratentorial ICH <30 mL requiring EVD, minimally invasive IVH evacuation with EVD plus thrombolytic is safe and reasonable compared with EVD alone to reduce mortality, with a high evidence level 5
• The addition of intraventricular fibrinolysis hastens clot removal and results in further mortality reduction, based on high-quality evidence 5, 8

Important Clinical Caveats

• EVD should be placed early in patients with hydrocephalus and decreased consciousness, as delaying placement increases mortality, with a high evidence level 1, 2
• Before EVD insertion, evaluate and correct coagulation status, based on moderate-quality evidence 6
• Do NOT place EVD in patients with GCS score of 3, as these patients have extremely poor prognosis regardless of intervention, with a high evidence level 1, 3

What EVD Does NOT Improve (Based on Current Evidence)

• Functional outcomes remain uncertain, while EVD reduces mortality, the benefit for improving functional outcomes is not well established, with a low evidence level 2, 5
• Routine ICP monitoring in all ICH patients is not supported, based on high-quality evidence 1, 3, 4