**6.1 Blocked stoma**

In cases of infective or post haemorrhagic pathologies there is often the presence of blood clot formation which favors the stoma closure. Also, in cases of rapid tumor progression or the presence of secondary membranes (liliquist) [26]; there is a high risk for the formations of plugs which block the stoma.


**Table 2.** *Protocol for prevention of EVD-related infections.*

#### **6.2 Hypothalamic damage**

This could be caused by ventriculostomy done away from the midline or thick wall perforation by blunt instrument. This could be manifested by endocrine disorders such as hypothyroidism, precocious puberty etc.

#### **6.3 CSF leak**

Which could be precipitated by persistent increased intracranial pressure or early suture removal. In infants with ventriculomegaly it has been noted that a thin cortical mental is associated with cerebrospinal fluid leakage. Moreover, this can delay wound healing, hence increasing risk for infection; and has been shown to be a sign of failure of the third ventriculostomy [27] (**Table 2**).

### **7. Clinical relevance of ventriculostomy**

Subarachnoid hemorrhage (SAH) and Intracranial hemorrhage (ICH) are common complications which occur secondary to stroke and traumatic brain injury (TBI). These conundrums can cause massive intraventricular hemorrhage resulting into acute obstructive hydrocephalus and elevated intracranial pressure which may cause critical morbidity and mortality. Despite the management of ICP with medications such as sedatives and osmotic diuretics, always it is not effective to reduce the ICP thus necessitating the institution of external ventriculostomy also known as external ventricular drain (EVD). The existing body of evidence has revealed a significant difference of outcomes, the arm treated with conservative management had higher fatality rate compared to the arm subjected to the EVD management [28, 29].

Despite the feasibility of EVD placement it is not without flaws when misplaced, this can cause serious complications such as EVD associated hemorrhage and infections. Numerous factors contribute to increased risk of EVD associated hemorrhage including institutional and individual's practice pattern, timing of the CT scan, coagulation indices thresholds, platelet infusion practice for patient subjected to antiplatelet therapy or blood thinners, access site, drill bit size and thread distance, aggressive drilling, the use of irrigation saline. Removal of bone fragments prior to dura opening, sharp or blunt dura penetration, sharp or blunt pia opening, slow or fast access of frontal horn, removal of stylet at ventricular entry or upon advancement to the foramen of Monro and tightness of scalp closure [28–30].

The incidence of EVD related infections have been reported ranging from 0 to 22%, this has opened the mandatory use of prophylactic antibiotic regimen through the entire course of the EVD period. The contemporary use of antibiotic impregnated catheters has dramatically reduced the risk of ventriculostomy associated infections.

#### **8. Conclusion**

One of the most significant and often used techniques in pediatric neurosurgery is EVD implantation. Many pathological disorders, including those that pose a threat to life, are treated with it.

*Ventriculostomy DOI: http://dx.doi.org/10.5772/intechopen.111764*

Since infection appears to be the most significant and well-researched issue with this procedure, EVD insertion and care protocols are required to prevent the difficulties that are connected with it.
