Received: 25.12.2012 / Accepted: 05.02.

2013
DOI: 10.5137/1019-5149.JTN.7817-13.0

Excessive External Drainage of Csf Might

Case Report

Aggravate Bacterial Ventriculitis

Aşırı Bos Eksternal Drenajı Bakteriyel Ventriküliti Şiddetlendirebilir
Song-ping Zheng, Guo-ping Lı, Chao You

West China Hospital of Sichuan University, Department of Neurosurgery, Cheng Du, China

Corresponding Author: Chao You / E-mail: [email protected]

ABSTRACT
Bacterial ventriculitis is one of the most difficult diseases of neurosurgery, if not controlled well in the early stage, it will cause empyema,
adhesion and separated infectious ventricle locules inside the ventricle. Few studies focus on the relationship between external drainage
volume and the occurrence of adhesion and separation of the ventricle. This paper reported a case of ventriculitis, and we propose that
excessive external drainage might increase the occurrence rate of the internal separation and adhesion of ventricle in patients with ventriculitis.
Choosing an appropriate drainage method and avoiding excessive drainage might be the key to the treatment of ventriculitis.
Keywords: External drainage, Lumbar drainage, Drainage volume, Ventriculitis

ÖZ
Bakteriyel ventrikülit nörocerrahideki en zor hastalıklardan biridir ve erken dönemde iyi kontrol edilmezse ventrikül içinde ampiyem, yapışma
ve ayrılmış enfeksiyöz ventrikül loküllerine yol açar. Eksternal drenaj hacmi ile ventrikül yapışması ve ayrılmasının oluşması arasındaki ilişkiye
odaklanan çok az sayıda çalışma vardır. Bu makale bir ventrikülit olgusu bildirmektedir ve aşırı eksternal drenajın ventrikülitli hastalarda
internal ventrikül ayrılması ve adezyonunun oluşma oranını arttırabileceğini düşünüyoruz. Uygun bir drenaj yöntemi seçmek ve aşırı drenajdan
kaçınmak ventriküliti önlemenin temeli olabilir.
ANAHTAR SÖZCÜKLER: Eksternal drenaj, Lumber drenaj, Drenaj hacmi, Ventrikülit

Introduction (WHO grade II). With a daily drainage volume of 350ml, the
drainage catheter was removed after 8 days. At that moment,
Being one of the most problematic diseases in neurosurgery
the CT scanning showed the ventricle was small and a small
if not controlled in the early phase, bacterial ventriculitis will
amount of subdural effusion on the left side. On the tenth
cause empyema, adhesion and separated infectious ventricle
locules inside the ventricle, which means a long course of day after the operation, the patient developed fever. The
disease, enormous expense and a high death rate. External cerebrospinal fluid (CSF) examination showed a dramatic
ventricle drainage and lumbar drainage are effective ways to increase in the white blood cells. Glucose and chloride
treat bacterial ventriculitis. However, few studies focus on the decreased significantly. The CSF culture revealed Escherichia
relationship between drainage volume and the occurrence of coli. He was diagnosed with intracranial infection and a
adhesion and separation of the ventricle. With a report about lumbar drainage operation was performed. The patient once
a ventriculitis case, we propose that excessive drainage might developed disturbance of consciousness due to excessive
increase the occurrence rate of the internal adhesion and drainage as the head CT re-examination showed that the
separation of the ventricle of patients with ventriculitis, and ventricle was contracted along with increasing subdural
conducts analysis and research on it. effusion. The patient’s condition was gradually worsened, and
empyemata and infectious separations occurred repeatedly
Case report in the ventricle (Figure 1A-C). After 15 procedures for surgical
A 22-year-old man was admitted to hospital for having debridement, separation resection, chamber shunt, etc. and
dizziness and headache for a month, and the enhanced head assisted with antibiotic and whole body supportive treatment,
MRI showed that the third ventricle and lateral ventricles his illness was cured one year later, with the sequela of mild
were occupied by a huge mass measuring about 6.5x7x7 cm, limb activity restriction and serious intellectual impairment.
accompanied with obvious hydrocephalus. With everything
Discussion
normal in the preoperative examination, we carried a tumor
resection operation. The tumor was totally removed in surgery External ventricular drainage and lumbar drainage have been
and a drainage catheter was indwelled in the lateral ventricle extensively applied in various fields of neurosurgery, such as
after operation. The pathology result was an ependymoma the treatment of hydrocephalus and intracranial infection.

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 You C. et al: CSF Drainage Might Aggravate Ventriculitis

A b c

Figure 1: A) Pre-operative enhanced MRI: the ventricle is largely occupied by a mass, accompanied with obvious hydrocephalus.
B) Post-operative (8 days) CT: obvious contraction of the ventricle after excessive drainage, and some subdural fluids in the left.
C) Post-operative enhanced MRI: several infectious separated loculi formed in the ventricle.

When treating intracranial infection, an early operation of disorders of consciousness, the contraction of ventricle space
lumbar drainage or external ventricular drainage is very and the reducing of CSF will increase the viscosity of fluid in
important for controlling the infection and decreasing the the ventricle and make it easier for purulent fluid to adhere
intracranial pressure if conservative treatment cannot control in the ventricle. Therefore, we believe that proper drainage of
the increasing intracranial pressure or the infection is poorly CSF is more reliable than excessive drainage, and the volume
controlled (3). Nevertheless, they may cause catheter-related of drainage might change the whole course of disease. In this
infection, which will exacerbate the infection and might even case, longtime of excessive drainage caused the contraction of
cause empyema and separation in the ventricle, making the the ventricle, possibly resulting in the formation of infectious
condition difficult to control (1). separated loculus. The patients’ illness became chronic.
Current documents mainly focus on lowering the incidence Then what volume do proper volumes of drainage refer to?
rate by improving the material (2,4), such as antibiotic-im- There is no answer yet. Lacking enough clinic evidence, we
pregnated catheters, reducing the frequency of cerebrospinal suggest perform draining in a conservative way in the early
fluid sampling from extraventricular drains (5) and decreasing phase. After intracranial hypertension was mitigated, we may
the drainage time. However, few documents probe into the gradually increase the volume. Paying close attention to check
relationship between lumbar drainage, external ventricular whether the patient has the manifestation of intracranial
drainage and the empyema and separation in the ventricle hypotension, and observing the change of the ventricle size
caused by ventriculitis. That is caused by various factors, like according to the recheck of CT scan, we could confirm the best
malnutrition and improper antibiotic treatment. We believe drainage volume by the principle that the ventricle will not
that unlike common surgical infection, the volume of drain- be contracted. This not only realizes the purpose of sufficient
age is a very significant factor in such a special path as the drainage, but also avoids the possibility of adherence in the
circulation path of CSF. ventricle caused by the ventricle contraction. In this case, a
daily drainage volume of 350ml led to obvious intracranial
The ventricle depends on continuous generation of CSF to
hypotension.
maintain its state. When ventriculitis occurs, a certain amount
of CSF can not only dilute sticky inflammatory fluid, but also Besides, we believe that whether to choose external ventricular
keep a certain distance between intraventricular structures drainage or lumbar drainage is related to the separation in
that prevents viscous substance from adhering between the ventricle, and external ventricular drainage is more likely
ventricles to form separated loculi. After we perform external to cause adherence and separation in the ventricle. On one
CSF drainage, on one hand, if the drainage volume is too small, hand, external ventricular drainage discharges the infectious
CSF can’t be discharged effectively, which weighs against the CSF in the ventricle, changes the flowing direction of the CSF
control of intracranial infection and intracranial pressure. On in part of the subarachnoid space and cistern, and then the
the other hand, with excessive drainage and the neglect of infectious CSF outflows along with the drainage catheter
certain symptoms as patients who suffer intracranial infection after it enters into the ventricle. That makes it easier for the
sometimes cannot report symptoms themselves due to meningitis of the dorsolateral surface and cistern to spread in

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You C. et al: CSF Drainage Might Aggravate Ventriculitis

the ventricle, increasing the possibility of the deterioration of References

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