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Volume 1, Issue 1
Article Type: Research Article

Risk of re-bleed in cases of aneurysmal subarachnoid hemorrhage upon external ventricular drain placement: Systematic review

Bader Ali1*; Sarah Kawtharani2; Elias Horanieh3; Houssein Darwish2

1Faculty of Medicine, University of Balamand, Beirut, Lebanon.
2Department of Neurosurgery, American University of Beirut Medical Center, Beirut, Lebanon.
3Department of Surgery, University of Balamand, Beirut, Lebanon.

*Corresponding author:  Bader Ali
Faculty of Medicine, University of Balamand, Beirut, Lebanon.
Email ID: bader.ali@std.balamand.edu.lb

Received: May 20, 2025
Accepted: Jun 06, 2025
Published Online: Jun 13, 2025
Journal: Journal of Neurology and Neurological Sciences
Copyright: Ali B et al. © All rights are reserved

Citation: Ali B, Kawtharani S, Horanieh E, Darwish H. Risk of re-bleed in cases of aneurysmal subarachnoid hemorrhage upon external ventricular drain placement: Systematic review. J Neurol Neuro Sci. 2025; 1(1): 1008.

Abstract

Background: Aneurysmal Subarachnoid Hemorrhage (aSAH) requires immediate treatment which can lead to better patient outcomes. If acute hydrocephalus is present, a drain should be placed before securing the ruptured aneurysm due to the rapid and devastating outcomes of hydrocephalus. There is still no consensus on whether ventriculostomy should be done before or after securing the ruptured aneurysm and whether ventriculostomy can lead to the re-rupture of an unsecured aneurysm. However, many studies showed that drain placement before aneurysmal treatment is associated with increased risk of rebleeding. The aim of this systematic review is to be able to assess the re-bleeding risk caused by drain placement in cases of aneurysmal subarachnoid hemorrhage before securing the aneurysm.

Methods: We searched a total of four online databases (PUBMED, EMBASE, SCIENCE DIRECT and COCHRANE LIBRARY) for papers published between March 1992 and April 2022 based on pre-defined search criteria. Main outcomes were measurement of rebleeding rate after external ventricular drain placement before securing the aneurysm, associated factors, control group comparison, mortality rate and EVD-related hemorrhage in patients on dual antiplatelet therapy.

Results: A total of 22 studies are included in this systematic review with a total number of 5492 aSAH patients. We found that the highest rebleeding rate with pre-operative CSF drainage via EVD was 53.47% while 27.8% via ELD compared to the 14.57% in the control group without pre-operative drainage. Only a few studies reported the number of mortalities among patients with pre-operative drainage and the highest mortality rate was 22%. Finally, prolongation of drainage, amount of CSF drained, and the time between drainage and securing the aneurysm were the most associated risk factors.

Conclusion: The risk of aneurysmal re-rupture in patients with CSF drainage before securing the aneurysm is higher than in patients without drainage. However, this review shows the need for further research to be able to assess the optimal timing and duration of drain placement following acute hydrocephalus in patients with aSAH, in addition to the safety of CSF drainage in such patients before securing the aneurysm.

Keywords: Aneurysmal subarachnoid hemorrhage; External ventricular drain; Re-bleed risks; Acute hydrocephalus.

Introduction

Intracranial saccular aneurysms, also known as berry aneurysms, are out-pouching vascular lesions that most commonly occur at the bifurcation of arteries in the anterior or posterior circulation of the Circle of Willis [1]. There are several risk factors associated with the formation of saccular aneurysms reported in literature and include: family history of a first degree relative, smoking, hypertension, female sex, and medical history of connective tissue disorders (e.g., Marfan syndrome, Ehlers-Danlos syndrome type IV) [1-3]. Patients with cerebral aneurysms can be asymptomatic or can present with headache or neurologic deficits depending on the location and size of the aneurysm. Aneurysms are weak spots in the walls of an artery, hence, they pose a risk of rupture being 0.05% every year for aneurysms less than 1 cm, whereas aneurysms larger than 1 cm or located in the posterior circulation have a higher risk [2]. Ruptured aneurysms lead to Subarachnoid Hemorrhage (SAH) referred to as aneurysmal subarachnoid hemorrhage (aSAH) with an incidence rate estimated to be 1 per 10,000 cases of ruptured aneurysms in the United States [3]. 20-30% of the time, SAH can lead to Hydrocephalus (HCP) due to the disruption of the arachnoid granulation impending proper Cerebrospinal Fluid (CSF) resorption, which in turn can lead to neurologic deterioration and necessitates the need for either a permanent ventricular shunt or an External Ventricular Drainage (EVD) for CSF diversion to decrease Intracranial Pressure (ICP) [4].

Hydrocephalus is well known to be a serious complication of SAH that can occur within the first few days [4]. The neurologic dysfunction and clinical deterioration of a patient following HCP requires urgent intervention [5,6]. Although ventriculostomy remains the mainstream treatment of hydrocephalus in the cases of aSAH, there is still no consensus on whether ventriculostomy should be done before or after securing the ruptured aneurysm and whether ventriculostomy can lead to the re-rupture of an unsecured aneurysm [6,7]. A study by Voldby and Enevoldsen showed that active drainage contributed to a re-rupture [8]. Pare, et al concluded that the risk of rebleeding with active drainage increased to 30% compared to an 8% rebleed risk in patients without drainage [8]. These results could not be confirmed by another study by Hellingman et. al. as their data showed 7 out of 34 patients with HCP had rebleeding after EVD insertion compared to 7 out of 34 patients with HCP without EVD insertion [6,9-11]. Therefore, this systematic review aims at reviewing the published data to assess the re-bleeding risk associated with CSF drainage in patients with aSAH.

Search strategy

We searched a total of four online databases (PUBMED, EMBASE, SCIENCE DIRECT and COCHRANE LIBRARY) for papers published between March 1992 and April 2022 based on predefined search criteria. Search keywords included ‘aneurysmal subarachnoid hemorrhage’, ‘acute hydrocephalus’, ‘preoperative drain placement’ ‘external ventricular drain’ and ‘risk of rebleeding’. We identified eligible publications using a (title, abstract, full-article and conclusion) screening method. At each step, two reviewers screened the published articles.

Inclusion and exclusion criteria

We focused on studies that (1) included aSAH patients with acute hydrocephalus, (2) compared rates of rebleeding between patients who had preoperative drain placement and patients who did not have any drains placed, (3) investigated the potential risk of rebleeding in patients with drain placement before securing the aneurysm, (4) reported any measurement of association, (5) assessed the risk of EVD-related hemorrhage in patients on antiplatelets therapy.

We excluded studies that (1) included conditions other than aSAH, (2) did not evaluate rebleeding risk in patients with preoperative drain placement, (3) irrelevant publications, (4) review articles without any data.

Data extraction

Two reviewers extracted data independently from eligible manuscripts using a pre-designated format. Reviewers met to discuss and discrepancies in data were resolved.

Synthesis of the results

We listed findings of qualified studies, calculated rates of bleeding, stratified by whether preoperative drain was placed, and type of drain used. We also determined the mortality rate after drain placement before securing ruptured aneurysm. A meta-analysis was not possible due to the heterogeneity of the date in the studies regarding the use of different methodological approaches and sources of data. As a result, the findings are presented as a narrative systematic review.

Results

Study selection

Overall, 22 studies have been included in this systematic review with a total number of 5492 aSAH patients.

Study characteristics

Findings of included studies are demonstrated in Table 1. In total, 10 studies (45.45%) [6-8,10,14,15,19,20,21,28] presented the number of patients who had rebleeding after drain placement before securing ruptured aneurysm as a primary focus of their research. Seven studies (31.81%) [6-8,14,15,20,21] compared this number to a control group who had rebleeding without any drain placement, and only 4 studies (18.18%) [14,19,20,21] reported the number of deaths after preoperative drain placement.

Table 1: Study characteristics in the selected papers.
Author Country Total number of aSAH patients Study design Study period Presenting rebleeding after PDP Comparing to a control group Reporting mortality after PDP
Bruder et al. [12] Germany 444 Retrospective 2007-2013 No No No
Lenschow et al. [5] Germany 328 Retrospective 2009-2021 No No No
Sims-Williams et al. [13] UK 1 Retrospective 2014 No No No
Ruijs et al. [14] Netherlands 107 Retrospective 1995-1997 Yes Yes Yes
Pare et al. [7] Canada 128 Retrospective 1983-1990 Yes Yes No
Lu et al. [15] USA 471 Retrospective 2001-2016 Yes Yes No
Oppong et al. [16] Germany 939 Retrospective 2003-2016 No No No
Kirmani et al. [17] India 55 Prospective 2012-2015 No No No
Zachariah et al. [18] USA 241 Retrospective 2001-2014 No No No
Hellingman et al. [6] Netherlands 546 Retrospective 1993-2001 Yes Yes No
Rajshekhar et al. [19] USA 194 Retrospective 1982-1989 Yes No Yes
Lu et al. [20] China 152 Retrospective 2006-2010 Yes Yes Yes
van den Berg et al. [21] Netherlands 126 Retrospective 2000-2007 Yes Yes Yes
Maas et al. [22] USA 211 Prospective 2006-2018 No No No
Evans et al. [23] UK 355 Retrospective 2015-2018 No No No
Leschke et al. [24] USA 93 Retrospective 2005-2014 No No No
Scholz et al. [25] Germany 27 Retrospective 2007-2009 No No No
Gard et al. [26] USA 112 Retrospective 2012-2014 No No No
Lim et al. [10] Korea 122 Retrospective 2010-2017 Yes No No
Hudson et al. [27] USA 443 Retrospective 2009-2016 No No No
Kawai et al. [28] Japan 93 Retrospective 1990-1994 Yes No No
Mclver et al. [8] USA 304 Retrospective 1990-1997 Yes Yes No

Measurment of rebleeding rate after preoperative drain placement

We calculated rebleeding rates in 10 studies [68,10,14,15,19,20,21,28] that documented the number of aSAH patients with acute hydrocephalus who had rebleeding after drain placement before securing ruptured aneurysm (Table 2). Studies used different types of drains, sometimes more than one. The percentage of rebleeding varied between the studies. The highest rebleeding rate, 53.57%, was seen in a retrospective study where external ventricular drain (EVD) was placed preoperatively [28]. Average rebleeding rates varied between 30% and 13.46% measured using the following 8 studies [68,14,15,19,20,21]. EVD were used in all these studies except one study where an external lumbar drain was used and the rebleeding rate was 27.8% [14]. The Lowest rates, 4.44% (EVD) and 4.76% (LP), were seen in two retrospective studies [8] and [6] respectively.

Associated factors

We identified 3 factors affecting rebleeding rate in aSAH patients after drain placement before surgery in 3 studies [14,19,21] only (Table 2). In one study, prolonging the drainage more than 24 hours was found to be associated with increased risk of rebleeding [19]. An additional factor was excessive CSF drainage found in another study [14]. On the other hand, we identified a study where no significant association was found between the amount of CSF drained and rates of rebleeding [7]. Added research concluded that in aSAH patients limited to WFNS grade V, delayed aneurysmal repair is associated with higher risk of rebleeding after drain placement due to less stable aneurysmal wall [21]. Another study showed that increased risk of rebleeding and degree of ventriculomegaly are not related [28]. Four studies [6,8,10,28] found no evidence of association between preoperative drain placement and increased risk of rebleeding. Two studies highlighted the increase in transmural pressure around the aneurysmal wall as a possible mechanism of rebleeding during CSF drainage [15,28].

Control group comparison

In addition to aSAH patients who had rebleeding after preoperative drain placement, 7 studies [6-8,14,15,20,21] included the number of aSAH patients who had rebleeding without any drains. This subset of patients was used as our control group throughout the review. We compared the rate of bleeding in control group to the rate of rebleeding in patients with preoperative drain placement. In six studies (85.7%) [6,7,14,15,20,21] the rate of bleeding was lower in the control group. It was slightly higher in only one study (5.4%) compared to (4.44%) in patients who had rebleeding after drain placement before surgery. In one study [6], the results were heterogenous. We found that the rate of rebleeding in control group (14.54%) was higher than in patients who had lumbar puncture (4.76%) but lower than in patients who had EVD insertion (20.5%) (Table 2).

Mortality rate

Four studies [14,19,20,21] reported the number of deaths in aSAH patients after drain placement before undergoing aneurysmal repair. The highest mortality rate (22.2%) was calculated using a retrospective study [14] where external lumbar drain was used. 1.92% was found to be the lowest mortality rate after EVD placement in a different study [19] (Table 2).

EVD-related hemorrhage in patients on dual antiplatelet therapy

Although not the primary goal of our study, we identified 7 studies [5,12,18,23,24,25,27] among qualified publications that assessed the risk of EVD-related hemorrhage in patients on dual antiplatelet therapy who are candidates for aneurysmal repair surgery as a major outcome of their research. Four studies showed that EVD placement before endovascular coiling and DAPT/Aspirin loading is associated with lower risk of EVD related hemorrhage [5,12,18,23]. However, two different studies concluded that EVD placement before or after endovascular procedure and ADAPT/Aspirin loading is generally safe with no significant risk factor of EVD-related hemorrhage [24,27]. A single study demonstrated that the hemorrhage rate is the same irrespective of the timing of antiplatelet therapy [25].

Table 2: Primary findings.
Author Total nb of patients with aSAH (n=5492) Acute hydrocephalus Pre-op drain placement Type of drain Rebleeding after drain placement in patients with unsecured aneurysm (%) Potential risk of rebleeding in patients with pre- op drain placement Rebleeding in patients without drain placement (%) Post-op drain placement Mortality rate after drain placement before securing (%)
Bruder et al. [12] 444 444 418 EVD# NAⵜ _ _ _ _
Lenschow et al. [5] 328 328 114 EVD# NAⵜ _ _ 84 _
Sims-Williams et al. [13] 1 1 1 EVD NAⵜ _ _ _ _
Ruijs et al. [14] 107 18 18 ELD 5/18 (27.8%) Excessive CSF drainage 44/324 (13.85%) _ 4/18 (22.2%)
Pare et al. [7] 128 49 201 EVD 6/20 (30%) No significant relation between the amount of CSF drained and rates of rebleeding 9/108 (8.33%) _ _
Lu et al. [15] 471 NA 147 EVD 22/147 (14.96%) Increase in transmural pressure around the aneurysm wall 11/324 (3.39%) _ _
Oppong et al. [16] 939 921 _ EVD NAⵜ _ _ 663‡ _
Kirmani et al. [17] 55 9 9‡ EVD NAⵜ _ _ _ _
Zachariah et al. [18] 241 241 241‡ EVD# NAⵜ _ _ _ _
Hellingman et al. [6] 546 271 551 34/EVD 21/LP 7/34 (20.5%)
1/21 (4.76%)		 No evidence of association 16/110 (14.54%) _ _
Rajshekhar et al. [19] 194 52 52 EVD 7/52 (13.46%) Prolonging the drainage more than 24 hours _ _ 1/52(1.92%)
Lu et al. [20] 152 27 102 EVD 4/19** (21.05%) _ 4/19** (21.05%) _ 4/19**(21.05%)
van den Berg et al. [21] 126* 71 103 EVD 23/103 (22.33%) -Less stable aneurysms in WFNS grade V patients.
-Delayed securing		 3/24 (12.5%) _ 6/103 (5.82%)
Maas et al. [22] 211 _ 146 EVD _ _ _ _ _
Evans et al. [23] 355 130 104 EVD# NAⵜ _ _ 26 _
Leschke et al. [24] 93 93 93 EVD*# NAⵜ _ _ _ _
Scholz et al.[25] 27 27 _ EVD ICP gauge EVD+ICP gauge NAⵜ _ _ 17/EVD## 7/ICP gauge 3/EVD+ICP gauge _
Gard et al. [26] 112 112 112 EVD NAⵜ _ _ _ _
Lim et al. [10] 122 55 67 EVD 19/67 (28.35%) Pre-op EVD placement did not increase the risk of rebleeding _ 55 (Rebleed- ing in 23 patients) 23/55 (41.81%) _
Hudson et al. [27] 443 298 298‡ EVD*# NAⵜ _ _ _ _
Kawai et al. [28] 93* 28 28 EVD 15/28 (53.57%) -Increase in transmural pressure around the aneurysm wall
-No significant relation between the degree of ventriculomegaly and increase rebleeding rates		 _ _ _
Mclver et al.[8] 304 45 45 EVD 2/45 (4.44%) No evidence of association between pre-op EVD and increase rebleeding rates 14/259 (5.4%) _ _

*: Limited to patients with WFNS grade V only; **: In this study 4 out of 19 patients had rebleeding (10/19) with EVD and 9/19 without EVD); 1: The rest of patients have been monitored or their acute hydrocephalus has resolved spontaneously; 2: In this study 7 patients underwent FLT during clipping and only one patient needed a VPS placement after surgery; #: This study shown that EVD placement before endovascular coiling and ADAPT/Aspirin loading is associated with lower risk of EVD-related hemorrhage; *#: This study has shown that EVD placement before or after endovascular procedure and ADAPT/Aspirin loading is generally safe with no significant risk factor of EVD-related hemorrhage; ##: This study has shown that EVD-related hemorrhage rates are the same before or after anticoa/antiplatelet therapy with endovascular coiling; ⵜ: These studies did not aim to investigate EVD-related rebleeding of an unsecured ruptured aneurysm; ‡: Data on the exact timing of EVD placement were missing.

Discussion

Aneurysmal rupture can be followed with serious complications including subarachnoid hemorrhage which in turn has its own complications. aSAH induced HCP is a serious complication that requires urgent medical intervention with CSF drainage due to the elevation of the ICP and decrease in cerebral perfusion before the securing the aneurysm. EVD is used to manage elevated ICP [11]. As seen from the literature review, CSF drainage can differ in type and timing. Among the 22 relevant papers, we found that the highest rebleeding rate with pre-operative CSF drainage via EVD was 53.47% while 27.8% via ELD compared to the 14.57% in the control group without pre-operative drainage. Only 1 out of the 22 papers assessed the rebleeding rate with drainage via ELD (Table 2) so further studies should be done to evaluate the difference between ventricular and lumbar CSF drainage when it comes to patient safety and risk of re-bleed. Only a few studies reported the number of mortalities among patients with pre-operative drainage and the highest mortality rate was 22%.

There are several risk factors that can be associated with the risk of rebleeding. However, no significant statistical data was reported by any of the studies. It was theorized that the prolongation of drainage, amount of CSF drained, and the time between drainage and securing the aneurysm were the most associated risk factors [7,14]. The mechanism for the rebleed is theorized to be the difference in pressure across the aneurysmal wall leading to the re-rupture. More studies should be done to evaluate the rate of CSF drainage and the maximum safe time delay before securing the aneurysm.

Conclusion

The risk of aneurysmal re-rupture with CSF drainage can reach up to 53.47% compared to 14.57% without drainage. The mortality rate can reach up to 22% based on the limited data reported. More studies should be done to assess the safety profile of EVD vs. Lumbar drainage. It was also shown that dual antiplatelet therapy has no significant risk of causing EVD associated hemorrhage. According to what was observed in the literature, CSF drainage in cases of aSAH before securing the aneurysm could be safe with decreased risk of re-bleed if CSF drainage was done minimally in order not to cause any tension on the aneurysmal that could induce its rupture; however, more data is needed to prove that, and to indicate the adequate amount of CSF drainage per hour.

Abbreviations: aSAH: Aneurysmal Subarachnoid Hemorrhage; CSF: Cerebrospinal Fluid; EVD: External Ventricular Drain; ELD: External Lumbar Drain; FLT: Fenestration of Lamina Terminalis; HCP: Hydrocephalus; ICP: Intracranial Pressure; NA: Not Available; PDP: Preoperative Drain Placement; VPS: Ventriculoperitoneal Shunt; WFNS: World Federation of Neurological Surgeons.

References

  1. Tawk RG, Hasan TF, D’Souza CE, Peel JB, Freeman WD. Diagnosis and Treatment of Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage. Mayo Clin Proc. 2021; 96: 1970-2000.
  2. D’Souza S. Aneurysmal Subarachnoid Hemorrhage. J Neurosurg Anesthesiol. 2015; 27: 222-40.
  3. Brisman JL, Song JK, Newell DW. Cerebral aneurysms. N Engl J Med. 2006; 355: 928-39.
  4. Chen S, Luo J, Reis C, Manaenko A, Zhang J. Hydrocephalus after Subarachnoid Hemorrhage: Pathophysiology, Diagnosis, and Treatment. Biomed Res Int. 2017; 2017: 8584753.
  5. Lenschow M, von Spreckelsen N, Telentschak S, Kabbasch C, Goldbrunner R, Grau S. Ventriculostomy-related intracranial hemorrhage following surgical and endovascular treatment of ruptured aneurysms. Neurosurg Rev. 2022; 45: 2787-2795.
  6. Hellingman CA, van den Bergh WM, Beijer IS, et al. Risk of rebleeding after treatment of acute hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Stroke. 2007; 38: 96-9.
  7. Pare L, Delfino R, Leblanc R. The relationship of ventricular drainage to aneurysmal rebleeding. J Neurosurg. 1992; 76: 422-7.
  8. McIver JI, Friedman JA, Wijdicks EF, et al. Preoperative ventriculostomy and rebleeding after aneurysmal subarachnoid hemorrhage. J Neurosurg. 2002; 97: 1042-4.
  9. Cagnazzo F, Gambacciani C, Morganti R, Perrini P. Aneurysm rebleeding after placement of external ventricular drainage: a systematic review and meta-analysis. Acta Neurochir (Wien). 2017; 159: 695-704.
  10. Lim YC, Shim YS, Oh SY, Kim MJ, Park KY, Chung J. External Ventricular Drainage before Endovascular Treatment in Patients with Aneurysmal Subarachnoid Hemorrhage in Acute Period: Its Relation to Hemorrhagic Complications. Neurointervention. 2019; 14: 35-42.
  11. Gigante P, Hwang BY, Appelboom G, Kellner CP, Kellner MA, Connolly ES. External ventricular drainage following aneurysmal subarachnoid haemorrhage. Br J Neurosurg. 2010; 24: 625-32.
  12. Bruder M, Schuss P, Konczalla J, El-Fiki A, Lescher S, Vatter H, et al. Ventriculostomy-related hemorrhage after treatment of acutely ruptured aneurysms: the influence of anticoagulation and antiplatelet treatment. World neurosurgery. 2015; 84: 1653-1659.
  13. Sims-Williams HP, Weinberg D, Jadun CK, Brydon HL. Ventriculostomy associated haemorrhage: a complication of anti-platelet therapy during coiling. Br J Neurosurg. 2014; 28: 782-784.
  14. Ruijs A, Dirven C, Algra A, Beijer I, Vandertop WP, Rinkel G. The risk of rebleeding after external lumbar drainage in patients with untreated ruptured cerebral aneurysms. Acta Neurochir. 2005; 147: 1157-1162.
  15. Lu VM, Graffeo CS, Perry A, Carlstrom LP, Casabella AM, Wijdicks EF, et al. Subarachnoid hemorrhage rebleeding in the first 24 h is associated with external ventricular drain placement and higher grade on presentation: Cohort study. Journal of Clinical Neuroscience. 2020; 81: 180-185.
  16. Oppong MD, Buffen K, Pierscianek D, Herten A, Ahmadipour Y, Dammann P, et al. Secondary hemorrhagic complications in aneurysmal subarachnoid hemorrhage: when the impact hits hard. J Neurosurg. 2019; 132: 79-86.
  17. Kirmani AR, Sarmast AH, Bhat AR. Role of external ventricular drainage in the management of intraventricular hemorrhage; its complications and management. Surgical neurology international. 2015; 6.
  18. Zachariah J, Snyder KA, Graffeo CS, Khanal DR, Lanzino G, Wijdicks EF, et al. Risk of ventriculostomy-associated hemorrhage in patients with aneurysmal subarachnoid hemorrhage treated with anticoagulant thromboprophylaxis. Neurocritical care. 2016; 25: 224-229.
  19. Rajshekhar V, Harbaugh RE. Results of routine ventriculostomy with external ventricular drainage for acute hydrocephalus following subarachnoid haemorrhage. Acta Neurochir. 1992; 115: 8-14.
  20. Lu J, Ji N, Yang Z, Zhao X. Prognosis and treatment of acute hydrocephalus following aneurysmal subarachnoid haemorrhage. Journal of Clinical Neuroscience. 2012; 19: 669-672.
  21. van den Berg R, Foumani M, Schröder RD, Peerdeman SM, Horn J, Bipat S, et al. Predictors of outcome in World Federation of Neurologic Surgeons grade V aneurysmal subarachnoid hemorrhage patients. Crit Care. 2011; 39: 2722-2727.
  22. Maas MB, Jahromi BS, Batra A, Potts MB, Naidech AM, Liotta EM. Magnesium and risk of bleeding complications from ventriculostomy insertion. Stroke. 2020; 51: 2795-2800.
  23. Evans D, Flood R, Davies O, Wareham J, Mortimer A. Impact of Intravenous Aspirin Administration on Ventriculostomy-Associated Hemorrhage in Coiled Acute Subarachnoid Hemorrhage Patients. Neurointervention. 2021; 16: 141-148.
  24. Leschke JM, Lozen A, Kaushal M, Oni-Orisan A, Noufal M, Zaidat O, et al. Hemorrhagic complications associated with ventriculostomy in patients undergoing endovascular treatment for intracranial aneurysms: a single-center experience. Neurocritical Care. 2017; 27: 11-16.
  25. Scholz C, Hubbe U, Deininger M, Deininger MH. Hemorrhage rates of external ventricular drain (EVD), intracranial pressure gauge (ICP) or combined EVD and ICP gauge placement within 48 h of endovascular coil embolization of cerebral aneurysms. Clin Neurol Neurosurg. 2013; 115: 1399-1402.
  26. Gard AP, Sayles BD, Robbins JW, Thorell WE, Surdell DL. Hemorrhage rate after external ventricular drain placement in subarachnoid hemorrhage: time to heparin administration. Neurocritical Care. 2017; 27: 350-355.
  27. Hudson JS, Prout BS, Nagahama Y, Nakagawa D, Guerrero WR, Zanaty M, et al. External ventricular drain and hemorrhage in aneurysmal subarachnoid hemorrhage patients on dual antiplatelet therapy: a retrospective cohort study. Neurosurgery 2019; 84: 479-484.
  28. Kawai K, Nagashima H, Narita K, Nakagomi T, Nakayama H, Tamura A, et al. Efficacy and risk of ventricular drainage in cases of grade V subarachnoid hemorrhage. Neurol Res. 1997; 19: 649-653.
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