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Iatrogenic Vascular Complications Associated With External Ventricular Drain Placement: A Report of 8 Cases and Review of the Literature

Kosty, Jennifer MD*,‡,§; Pukenas, Bryan MD*,‡,§; Smith, Michelle MD‡,§; Storm, Phillip B. MD‡,§; Zager, Eric MD‡,§; Stiefel, Michael MD; LeRoux, Peter MD‡,§; Hurst, Robert MD‡,§,‖

doi: 10.1227/NEU.0b013e318279e783

BACKGROUND: Placement of an external ventricular drain (EVD) is a commonly performed and often lifesaving procedure. Although hemorrhage is one of the commonest complications associated with the procedure, ventricular catheter--induced vascular injury is rarely reported.

OBJECTIVE: To describe 9 cases of EVD-related vascular trauma: 7 arteriovenous fistulas and 2 traumatic aneurysms.

METHODS: During a 3-year period, 299 patients had EVDs placed. Eight patients (2.75%), 3 male and 5 female (mean age, 48 ± 20 years), developed vascular lesions associated with EVDs. Six patients developed arteriovenous fistulas and 2 patients developed a traumatic aneurysm. The arterial feeders of 5 superficial draining fistulas arose from the middle meningeal artery, and the arterial feeder of a deep-draining fistula originated from a lenticulostriate artery. One traumatic aneurysm arose from a distal branch of the anterior cerebral artery, and the second from a branch of the superficial temporal artery. Four of the superficial fistulas were treated with transarterial embolization.

RESULTS: Two superficial fistulas and the deep-draining fistula resolved spontaneously after EVD removal. The intracranial aneurysm was embolized with Onyx18, and the superficial temporal artery aneurysm was managed conservatively. There were no hemorrhages associated with any of these vascular lesions and no complications after treatment.

CONCLUSION: Our data suggest that iatrogenic vascular trauma associated with EVD insertions (2.75%) may be more common than is currently appreciated. Endovascular treatment is effective and may be necessary when these lesions do not resolve spontaneously.

ABBREVIATIONS: AVF, arteriovenous fistula

EVD, external ventricular drain

MMA, middle meningeal artery

SAH, subarachnoid hemorrhage

VEGF, vascular endothelial growth factor

Departments of Radiology,

§Neurosurgery; and

Neurology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania;

Department of Neurosurgery, West Chester Medical Center, Valhalla, New York

Correspondence: Bryan Pukenas, MD, Department of Radiology, University of Pennsylvania Medical Center, 219 Dulles Bldg, 3400 Spruce St, Philadelphia, PA 19104. E-mail:

* These authors have contributed equally to this article.

Received June 11, 2012

Accepted October 02, 2012

Copyright © by the Congress of Neurological Surgeons