Is delayed external ventricular drain placement associated with increased in-hospital mortality? A propensity score matched analysis

Introduction: Patients with traumatic brain injury (TBI) with suspected or imminent risk of brain herniation often undergo emergency external ventricular drain (EVD) placement to decompress the cerebral ventricles. In patients without indications for immediate EVD placement, elevated intracranial pressure may develop later during hospitalization, necessitating delayed EVD placement. In these patients, it is unclear if early prophylactic placement can help reduce mortality. The purpose of this study is to evaluate if delayed EVD placement has differing in-hospital outcomes compared to early placement.

Methods: The National Trauma Dank Bank was queried from 2017-2019 for all adults with TBI who underwent EVD placement. Late placement was defined as placement longer than the 75% quantile (13.78 hours). Patients in the early and late groups were propensity score matched based on patient demographics, comorbidities, injury severity, and hospital trauma level. Group differences were compared using t-tests and chi-squared tests. Multivariable logistic regression was used to identify independent predictors of in-hospital mortality.

Results: A total of 6,249 patients meeting the inclusion criteria were identified. Of those, 4,686 underwent early placement and 1,563 underwent late placement. The late group was older (50 vs. 47, p< 0.01) and had fewer patients with GCS < 13 (63% vs. 83%, p< 0.01) than the early group. Following matching, the late group had similar ventilator duration (12 days vs 11 days, p=0.14), overall LOS (23 days vs. 21 days, p=0.09), and mortality rate (33% vs. 37%, p=0.73) compared to the early group. In the multivariable analysis, EVD timing was not an independent predictor of in-hospital mortality (OR 1, CI 0.98-1.01).

Conclusion : There were no differences in in-hospital outcomes between early and late EVD placement and EVD timing was not an independent predictor of death. Withholding prophylactic EVD placement until clearly indicated does not pose an increased risk of death in patients with TBI.