External Ventricular Drain Management in Aneurysmal Subarachnoid Hemorrhage: Perspectives and Practices From Low-Income and Middle-Income Countries

Abhijit V Lele; Hemanshu Prabhakar; Victor Lin; Indu Kapoor; Charu Mahajan; Umeshkumar Athiraman; Nophanan Chaikittisilpa; Ananya Abate Shiferaw; Jorge H Mejia-Mantilla; Peter Tan; Samuel Blacker

doi:10.7759/cureus.83265

External Ventricular Drain Management in Aneurysmal Subarachnoid Hemorrhage: Perspectives and Practices From Low-Income and Middle-Income Countries

Cureus. 2025 Apr 30;17(4):e83265. doi: 10.7759/cureus.83265. eCollection 2025 Apr.

Affiliations

¹ Neurocritical Care and Anesthesiology, Harborview Medical Center, Seattle, USA.
² Neuroanaesthesiology and Neurocritical Care, All India Institute of Medical Sciences, New Delhi, New Delhi, IND.
³ Neurology, Harborview Medical Center, Seattle, USA.
⁴ Anesthesiology, Washington University School of Medicine, St. Louis, USA.
⁵ Anesthesiology, Mahidol University, Bangkok, THA.
⁶ Anesthesiology, Addis Ababa University, Addis Ababa, ETH.
⁷ Neurointensive Care, Fundación Valle del Lili, University Hospital, Cali, COL.
⁸ Anesthesiology and Intensive Care, Sarawak General Hospital, Kuching, MYS.
⁹ Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, USA.

Abstract

Objective: This study aimed to evaluate the current practices, challenges, and quality improvement (QI) opportunities related to external ventricular drain (EVD) care in aneurysmal subarachnoid hemorrhage (aSAH) across low- and middle-income countries (LMICs). The findings were compared to international guidelines, including those by the American Heart Association (AHA), Neurocritical Care Society (NCS), and Society for Neuroscience in Anesthesiology and Critical Care (SNACC).

Methods: A cross-sectional survey was conducted between September and December 2024 using a 57-item questionnaire distributed to healthcare providers in LMICs. Data on EVD insertion and management, infection prevention, intracranial pressure (ICP) monitoring, transport practices, and QI metrics were analyzed descriptively, with thematic analysis of free-text responses.

Results: Complete responses were received from 89 participants across 24 countries. Hydrocephalus was the primary indication for EVD insertion (96%), performed mainly in operating rooms (96%) by attending neurosurgeons (73%). Infection-related metrics were reported by 71% of respondents. Key areas for improvement included education, infection prevention, and standardized protocols. The adherence to AHA/NCS/SNACC recommendations was as follows: hydrocephalus as an indication for EVD insertion (96%), sterile technique (91%), EVD clamp trials (81%), indication-based CSF sampling (67%), pre-procedure antibiotics (61%), tunneling catheter (40%), use of anti-microbial-impregnated EVD (17%), and ICP during patient transport (13%). Conclusions: Significant gaps in EVD care in LMICs highlight the need for tailored QI initiatives. Leveraging campaigns like the SNACC EVD Safety Campaign can drive education, standardization, and improved outcomes. Future efforts should focus on context-specific guidelines and scalable QI practices in resource-limited settings.

Keywords: aneurysm; evd; guidelines; subarachnoid hemorrhage; transport; ventriculostomy; xternal ventricular drain.