T RADITIONALLY, the development of

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1 J. Neurosurg. / Volume 3 / March, 969 Temporary Control of Cerebrospinal Fluid Volume and Pressure by Means of an Externalized Valve-Drainage 'System* ROBERT J. WHITE, M.D., PH.D., J. GEORGE DAKTERS, M.D., DAVID YASHON, M.D., AND MAURICE S. ALBIN, M.D. Division o] Neurosargery, Department o] Surgery, Case Western Reserve University School o] Medicine, and Cleveland Metropolitan General Hospital, Cleveland, Ohio T RADITIONALLY, the development of acute, sustained increases in ventricular pressure and volume resulting from cerebrospinal fluid (CSF) obstruction has been managed by repeated direct ventricular puncture 4 or the establishment of a tube ventriculostomy. 2 The method of repetitive direct needle puncture of the ventricle leaves much to be desired since it is not only damaging to brain tissue, but is basically unphysiological because it can only discontinuously affect ventricular volume and pressure. Tube ventriculostomy does offer the advantage of continuous drainage, but does not provide satisfactory hydraulic control. Its major drawback, however, is the constant danger of retrograde infection of the brain which severely limits the length of time it can be left in place. To circumvent some of the disadvantages of these techniques in the temporary management of acute increased ventricular pressure-volume states, we have used a simplified system of continuous pressure-modulated externalized ventricular drainage utilizing standard Spitz-Holter shunt equipment. ~ This report describes our clinical experience with this technique of externalized CSF shunting which we have termed the "externalized 5th ventricle" drainage system. Methods and Materials Because of the precarious condition of almost all of the patients in this series, the placement of the externalized valve-regulated drainage system was accomplished under local anesthesia. A small perforator Received for publication May 2, 968. Revision received October 8, 968. * Presented at the 36th Annual Meeting of the American Association of Neurological Surgeons (the Harvey Cushing Society), Chicago, Illinois, April 7-, opening was made in the skull at the coronal suture (anterior placement) or occasionally in the occipital area (posterior placement) as shown in Fig.. A suitable length of barium impregnated silicone rubber tubing was introduced into the ventricle and connected to a Rickham reservoir positioned in the burr hole. The reservoir was placed in series with an externalized medium or lowpressure Spitz-Holter valve connected to a short section of silicone tubing which exited from the scalp through a small stab wound (treated with local antibiotict) located about 5 cm from the burr hole. The valve, in turn, was joined to a sterile calibrated bottle or plastic bag ("externalized 5th ventricle") with an extended length of silicone tubing. The Rickham reservoir provided direct sampiing of ventricular fluid and permitted perfusion of the ventricular cavities with antibiotic solutions. Fifty-one valve-modulated externalized ventriculostomies were successfully implanted in 33 patients (Fig. 2). Each drainage system was the subject of a specially designed protocol which provided for daily estimations of CSF volume, protein concentration, cell count, and bacteriological characteristics. At the time of surgical removal the externalized shunt equipment was divided into various sections (distal tubing, valve, Rickham reservoir, and ventricular tubing) and individually cultured. Use of the plastic bag made walking possible for the patient. In fact, two children were actually safely discharged from the hospital following careful instruction of the parents regarding the technique of exchanging a full for an empty sterile collecting unit. Neosporin Aerosol (Polymyxin B-Bacitracin- Neomycin), Burroughs Wellcome & Co., Inc., Tuckahoe, N.Y.

2 Externalized CSF Valve-Drainage System 265 FIG.. Schematic representation of the externalized valve-regulated ventriculostomy displaying the anterior and posterior placement systems. Fro. 2. Photograph of a patient with the "externalized 5th ventricle" in place. The child can be mobilized both on and off the ward with this self-contained unit.

3 266 White, Dakters, Yashon and Albin Results The clinical pathological states in which temporary externalized drainage was instituted are listed in Table. The opportunity to provide continuous control of abnormal ventricular volume and pressure arose most frequently in acute hydrocephalus, with or without an associated central nervous system infection. The majority of these patients were children who had undergone numerous CSF shunting procedures with repeated system failures resulting in seriously ill, invariably debilitated individuals with occasional erosion and infection of the surgical incisions. Employment of the externalized valve-regulated ventriculostomy permitted pressure regulated drainage of the hydrocephalus, while elimination of infection from the nervous system, circulation, and operative sites was undertaken. In addition, a period of time was gained during which substantial improvement in the nutritional and clinical states of the patient was possible prior to the planned insertion of a standard internalized shunt system. The employment of the valve-controlled externalized ventricular drainage unit was found to be helpful in the management of CSF blocking lesions of the posterior fossa. Here the ventricular pressure and volume could be easily regulated before, during, and immediately following surgery. The ability to know the exact volume of ventricular drainage and to influence, that is, lower the pressure by pumping the valve was of particular TABLE Clinical states treated by externalized ventriculostomy Clinical State acute distress due to uncontrolled hydrocephalus (multiple etiologies) bacterial ventriculitis posterior fossa tumor or cyst supratentorial tumor or cyst meningitis (T. B.) meningitis (pyogenic) trauma hemorrhage (aneurysm) brain stem glioma No. Cases 2 Total 5 assistance during each of these three intervals. In addition, since the ventricular obstruction had been removed in three of these patients, the implantation of an internalized shunt prior to surgery, as suggested by Hekmatpanah and Mullan, ~ was not necessary. The opportunity for protracted shunting of ventricular fluid by means of this externalized drainage system was apparent. The average implantation time for the ventriculostomy was 2.5 days; the longest period was 76 days and the shortest 3 days. Thirty ventriculostomies were in place for more than 4 days, 2 for 2 days or less, 4 for 22 to 28 days, eight for 28 to 35 days, six for 35 to 42 days, and five for more than 49 days. Daily ventricular drainage volumes ranged from to 45 ml and protein concentrations varied from 9 to 3 mg/ ml. In 23 patients with significantly elevated CSF proteins (frequently greater than 2 mg/ ml) and in whom serious question was raised as to the proper functioning of the valve, a gratifying decrement in protein content as recorded during the period of externalized drainage. The ability to pump and replace the externally mounted valve assisted in maintaining hydraulic competence in the system handling protein-rich fluid. The reasons for removing or converting the externalized ventriculostomies are given in Table 2. In seven instances the externalized drainage system was removed because of the suspicion that an iatrogenic ventriculitis had developed (persistence of high cell counts and protein concentrations in the Rickham reservoir). However, only one example of ventriculitis directly traceable to the system was actually documented. Infection at the site of exit of the silicone tubing in the scalp occurred on three occasions and necessitated removal of the entire drainage system. Daily or bi-weekly cultures of the "externalized 5th ventricle" fluid were performed in all 5 implacements. Eventually, 38 of these systems developed positive bacterial cultures from the fluid in the collecting bags; however, at the time of shunt removal only 5 of the externalized valves demonstrated positive cultures. These statistics are influenced by five cases of ventriculitis present prior to the installation of the externalized ventricular drainage unit. These infections of

4 Externalized CSF Valve-Drainage System 267 the ventricles were all successfully treated by use of the appropriate systemic antibiotics and on occasion intraventricular antibiotic instillation (Ampicillin in two cases and Amphotericin-B in one). In Table 3 are recorded the bacterial studies conducted on the various elements composing the external shunting system. The differences displayed between the culture findings in the Rickham reservoir and the ventricle proper were influenced by the varied times of sampling; nevertheless, we believe that on occasion organisms may be grown from the Rickham reservoir when the ventricle has been cleared of the organisms. In spite of the expected high incidence of Staphlococvus Albu~ contamination of the silicone equipment, no example of ventriculitis caused by this bacterium was documented. In 2 additional patients suffering from troublesome collections of subdural fluid previously subjected to needle and/or burr hole drainage, the institution of an identical externalized valve-regulated shunting system incorporating a low-pressure valve into the subdural space resulted in the elimination of the fluid volume and collapse of the subdural space in all but one case. Six of these patients were elderly adults ranging in age from 7 to 95 years, and six were children ranging in age from 3 months to 4 years. In the adult group four unilateral and two bilateral subdural hematomas were drained for an average time of 7 days. Average daily drainage approximated 4 cc per day (range 5 to 25 cc). Protein values varied from a maximum of 3 mg/ cc to a minimum of 76 mg/ cc. In the pedi- TABLE 2 Reasons for discontinuing externalized ventriculostomies Reasons for Discontinuation internalization of CSF shunt drainage no longer needed accidentally pulled out or disconnected scalp infection at exit wound occluded ventricular catheter (revision) died suspected ventriculitis due to "5th ventricle" (collecting bag) * Proven bacterial ventriculitis in only. No. Cases * Organism Staph Albus Enterococcus Streptococcus Staph Aureus E. Coli HereUia Pseudomonas B. Proteus Kiebsiella H. Influenzae Candida Alb. B. Subtilis TABLE 3 Bacterial culture of externalized ventriculostomy components Distal Tubing Valve Contents Proximal Tubing (Rickham Reservoir) 2 Ventricle " " 2* " " * Five of these had ventriculitis due to the above bacteria prior to ventriculostomy drainage. atric patients, four required bilateral and two unilateral external drainage. The subdural external shunts were in place from 2 to 5 days, with daily fluid output ranging from 2 to 8 cc averaging 26 cc per day. One child eventually required the insertion of bilateral vane-regulated shunts into the peritoneal cavity to eliminate the subdural collections of fluid. Subdural proteins in these children varied from 22 to 4 mg/ cc. Discussion We have been impressed with the ease of instrumenting a seriously ill patient suffering from pressure hydrocephalus, with an externalized valve-regulated ventriculostomy and charting the clinical response to an improvement in the ventricular dynamics. The added opportunities to accurately measure the CSF drainage and to determine the cellular, chemical, and bacteriological properties of this fluid during an extended period of time has been of considerable assistance in the management of hydrocephalus associated with infection and in potentially reversible ventricular obstruction caused by tumor. Our clinical experience suggests that this method is useful in the temporary control of

5 268 White, Dakters, Yashon and Albin ventricular pressure and volume in the infected or debilitated hydrocephalic child as well as in the patient harboring a posterior fossa CSF blocking lesion. In the former situation the individual may be more safely studied from below by means of pneumoencephalography and benefit from a few days of regulated ventricular drainage prior to definitive surgery. In other cases (Table ) the availability and simplicity of the technique of valve-controlled external drainage offers the surgeon the opportunity of temporarily influencing (reducing) ventricular pressure without resorting to surgically implanting a standard shunt system. The bacteriological studies presented here indicate a high incidence of eventual infection in the distal tubing system, including the Spitz-Holter valve. The remarkably low incidence of bacterial contamination of the Rickham reservoir and the ventricle via retrograde movement of the bacteria indicates that the valve, even though itself contaminated, serves as a barrier to further cephalad propagation of the organisms. Nevertheless, we advise that when the externalized shunt system becomes infected it should be replaced. Infection, particularly septicemia, continues as the most serious complication of ventriculovenous shunting for hydrocephalus. la,~ Some authors, notably Sayers, ~ have redesigned the equipment to significantly reduce the incidence of associated bacterial involvement. Unfortunately, once an internalized shunt system has become infected, management of the hydrocephalic patient becomes complex, necessitating not only continued control of ventricular pressure and volume but also the elimination of the infection. Schimke, et al., ~ have been able to sterilize the shunt system, left in situ after colonization by Staph. Albus, by using massive doses of penicillin. Perrin and McLaurin ~ have managed this complication by immediate removal of the infected shunt and replacing it with a new one. These authors placed great reliance on the administration of both systemic and intraventricular antibiotics to clear the body tissues of infection and keep the new ventriculojugular shunt from becoming contaminated. We have found it relatively easy to man- age similar patients by removing the entire Spitz-Holter system and implanting a new valve-regulated externalized ventriculostomy. With an appropriate antibiotic regimen, we have been able to clear the infection in these patients as well as sterilize the ventricles in the five cases with ventriculitis. Equally important was the opportunity to select an ideal time for the re-insertion of a new internalized shunting unit after the general condition of the patient had improved, the previous wounds had healed well and the individual had become completely free of infection. Use of this externalized drainage equipment has been of assistance in our management of persistent collections of fluid in the subdural space. Admittedly, our initial experience is still small, but the elimination of the need for permanent shunting procedures 3,9 or craniotomy 6,7 in these few patients has been impressive. Sunimaty We have reviewed our clinical experience in 5 externalized valve-regulated ventriculostomies for the control of ventricular pressure and volume in 33 selected patients. In an additional 2 patients we have briefly recorded our experience with this system for protracted drainage of subdural collections of fluid. The following valuable characteristics of this simplified system of ventricular drainage have been emphasized: ) rapidity of implementation; 2) minimal distortion of the brain; 3) continuous, pressure controlled CSF drainage; 4) prevention of retrograde infection; 5) availability of ventricular fluid for analysis; 6) opportunity for infusion of intraventricular antibiotics; and 7) ease of equipment removal or conversion. References. ALBIN, M. S., WHITE, R. J., YASHON, D. (Unpublished data.) 2. BERING, E. A. JR. A simplified apparatus for constant ventricular drainage. J. Neurosurg., 95, 8: COLLINS, W. F., and PuccI, G.L. Peritoneal drainage of subdural hematomas in infants. J. Pediat., 96, 58: HAYNES, I. S. Congenital internal hydrocephalus. Its treatment by drainage of the cisterna magna into the cranial sinuses. Ann. Surg., 93, 57:

6 Externalized CSF Valve-Drainage System HEKMATPANAH, J., and MULLAN, S. Ventriculo-caval shunt in the management of posterior fossa tumors. J. Neurosurg., 967, 26: INGRAtqAM, F. D., and HEYL, H.L. Subdural hematoma in infancy and childhood. J. Am. Med. Ass., 939, 2: INORAHAM, F. D., and MATSON, D. D. Subdural hematoma in infancy. J. Pediat., 944, 24: PERRIN, J. C. S., and MCLAURIN, R. L. Infected ventriculoatrial shunts: a method of treatment. I. Neurosurg., 967, 27: POSNIKOFF, J. Technique for transfontanelle subdural peritoneal shunting in subdural fluid collections in infancy: technical note. J. Neurosurg., 968, 28: SAYERS, M. P. (In discussion with Nulsen, F. E., and Becker, D. P. The control of progressive hydrocephalus in infancy by valueregulated venous shunt.) In: Workshop in hydrocephalus. Shulman, K., Ed., Pennsylvania: University of Pennsylvania, 966, 9 pp. (See pp ). SCHIMKE, R. T., BLACK, P. H., MARK, V. H., and SWARTZ, M.N. Indolent staphylococcus albus or aureus bacteremia after ventriculoatriostomy. Role of foreign body in its initiation and perpetuation. New Engl..L Med., 96, 264: WHITE, R. J., DAKTERS, J., YOUNG, H., YA- SnON, D., VEROURA, J., and ALtoN, M. S. Continuous control of CSF volume and pressure with an externalized valve-drainage system. Trans. Am. Soc. artif, intern. Organs, 967, 3: YASHON, D., and SUGAR, O. Today's problems irt hydrocephalus. Archs Dis. ChiMh., 964, 39: YASHON, D., JANE, J. A., CASSELL, S., CAMERON, G., and SUGAR, O. Cerebrospinal fluid diversion in infantile hydrocephalus: progress report. Archs Neurol., Chicago, 966, 5: