Extraventricular Drainage and Hematoma Evacuation to Treat Hydrocephalus Following Lysis of MCA Embolism

This is a clinical case of an elderly female patient who developed signs of hydrocephalus after receiving systemic thrombolysis for a middle cerebral artery (MCA) embolism, which was followed by intra-arterial thrombolysis a day before. The procedures were assessed as successful. Later on, despite the initial success, she was found exhibiting impaired consciousness. A follow-up head computed tomography (CT) revealed hemorrhaging of the cerebellum leading to the compression of the fourth ventricle and subsequent hydrocephalus. A decision was made to place an external ventricular drain (EVD), followed by a suboccipital craniotomy and evacuation of the cerebellar hematoma. The placement of an EVD is widely considered to be one of the most frequent and crucial life-saving interventions in the neurologic intensive care unit.¹ An EVD is a temporary catheter specifically designed to drain cerebrospinal fluid (CSF) and facilitate the monitoring of intracranial pressure (ICP).²

While considering these interventions, it is imperative to evaluate potential contraindications. For EVD, significant bleeding disorders that may increase hemorrhage risk during placement and active infection at the insertion site must be ruled out. Similarly, suboccipital craniotomy is contraindicated in patients who are hemodynamically unstable or have severe comorbidities that render them unsuitable for surgery. Additionally, if the hematoma is deeply located or surrounded by critical structures, making surgical access too risky, this procedure would also be contraindicated.^1,7

This video provides a detailed overview of the key steps involved in the EVD placement and hematoma evacuation, offering critical insights from skin incision to wound closure. The procedure begins with EVD placement. The patient is positioned supine with the head in a neutral position to avoid any distortion of anatomical landmarks. Hair is removed, and the scalp is prepared in a sterile fashion. A linear small incision is made at the Kocher’s point through the skin and down to the bone, and the periosteum is carefully retracted. Kocher's point is a commonly chosen entry site on the frontal bone for inserting CSF drainage catheters. It is located 2–3 cm lateral to the midline at the level of mid-pupillary line, 11 cm posterior to the nasion (or 10 cm posterior to the glabella). Following the skin incision, a burr hole is drilled. Then, after the dura is carefully incised, the catheter is placed. The catheter is advanced about 6 cm into the skull. It is directed in a vertical plane towards the inner corner of the ipsilateral eye and in the horizontal plane, posteriorly towards a point 1.5 cm in front of the ipsilateral earlobe. The aim is to place the catheter at the foramen of Monro. Common complications of this procedure are hemorrhage and catheter displacement.¹ To prevent displacement and ensure stability, the drainage system is secured to the scalp using sutures․ Care is taken to avoid excessive tension on the scalp tissues, as this can impair blood flow and compromise wound healing. Proper fixation of the drainage system is essential to facilitate effective CSF drainage and mitigate the risk of postoperative complications. Finally, the incision site is closed with sutures. Hemostasis is confirmed, and the wound is dressed in a standard fashion to minimize the risk of infection.

Subsequently, to manage the intracranial hemorrhage (ICH) a suboccipital craniotomy is performed. The patient is placed in the prone position with the head flexed, ensuring the manubriomental distance is two fingerbreadths. First, the external occipital protuberance is identified. This serves as a prominent landmark guiding the surgical approach to the inferior fossa. The patient’s back skin is taped to retract it and facilitate the incision. Following the marking of anatomical landmarks, a midline skin incision is made to access the underlying structures. The overlying musculature on the right side is dissected and retracted to expose the underlying skull. Care is taken to avoid excessive depth. Two burr holes are drilled to facilitate the creation of a bone flap. A craniotome is employed to carefully cut out the bone flap, providing access to the underlying intracranial structures. In this case, a cerebral venous sinus is accidentally injured, and bleeding is observed. A dura suture is promptly placed to exert counter pressure, effectively controlling the hemorrhage. The placement of the dura suture is crucial for ensuring hemostasis. Injury to the sinuses can lead to rapid blood loss and serious morbidity or mortality if not promptly handled.³

Following craniotomy, a head frame is secured to the skull to provide stabilization and support during the surgical intervention. The next part of the video focuses on the alleviation of the cerebellar hematoma. Profuse bleeding is observed upon entry of the hematoma sac, necessitating immediate initiation of hematoma suction. The next step involves the insertion of a wire mesh. Additionally, a dural sealant is applied on wire mesh to enhance tissue adhesion and prevent CSF leakage. Finally, a synthetic bone substitute is carefully placed and secured with titanium plates and two screws on each side to ensure the structural integrity of the vault. The wound is meticulously closed using sutures, and a sterile dressing is applied. Care is taken to achieve optimal wound apposition and hemostasis to promote effective healing.
The special equipment, materials, and instruments used throughout the case include manual and automatic drills, a craniotome, an extraventricular drainage kit, self-retaining wound retractors, a Freer elevator, wire mesh, dural sealant spray, synthetic bone putty, and a titanium Bioplate cranial fixation system.

Hemorrhagic transformation (HT) is a potentially life-threatening complication of acute ischemic stroke that is particularly common following thrombolytic therapy.⁴ Systemic thrombolysis is associated with a 6–8% risk of intracerebral hemorrhage (ICH).⁵ Attention should be paid to identifying the patients who are at elevated risk of HT.⁶ To ensure timely discovery of occult HT, head CT should be performed in patients at risk. This video is a valuable step-by-step demonstration of the surgical approach in similar clinical scenarios.