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CSF leaks after brain injury, Intracernal Pressures, Subdural burr drainage system, Under EVD

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Neurologist, Surgical
Practicing since : 1996
Answered : 138 Questions
Hi Doctor..

My Son who had a brain injury almost 3 months back was hospitalized and after which he had a brain surgery. After the brain injury he had csf leaks for 2-3 weeks which after a lumbar drain got healed and since then he was under rehab. After 2 weeks we saw a small (2-3 cm) bony lymph above his ear, after doctor checkup and CT scan it was found ICP (Intracernal Pressures) got built up in his brain because of which the skull got little distorted as the pressure pulled the brain which inturn pulled the skull. Currently for las 3 days my son is under EVD (Subdural burr drainage system) where his pressures are reduced. Today they will be taking off the EVD and do the MRI and CT Scan again. I am not sure what is happening here and how much more pain my son has to go through. My son has no headaches or eye pupil problem or any kind of sign and symptoms of raised ICP.
Only good thing I can share is during EVD his right side of hand started working more as he was able to close and open fingers which was not able to earlier, may be its working. Overall I am not sure how long its going to take for my son to recover fully but based on your experience can you please tell me whats happening here and what are the chances of hiss full recovery.

Also today doctors did a MRI and they found that a small lake like structured accumulation of CSF fluid in there on brain which before EVD was 14 mm in size and After EVD its reduced to 9 mm in size. What does that mean? Is this indication of recovery.

Now Doctors have extended his EVD procedure for 2 more days at the same continous pressure (kept at a height of 25 mm) and drainage is very less almost negligible, will this help further?

What are the chances my son weill need a Shunt and if placed what are the chances it will be removed in future?

Please help me Doctor.
Posted Wed, 9 May 2012 in Brain and Spine
Answered by Dr. Praveen K Nath 13 hours later

Thanks for posting the query.

I have gone through the detailed history of your son and I feel sad for his sufferings.

Your son appears to be suffering from Post Traumatic Subdural Hygroma collection secondary to overdrainage of Cerebrospinal fluid.

Chances of full recovery after the head injury is variable. It depends upon the extent of brain damage happened due to trauma. If Neurological deficits are only related to raised intracranial pressure, it can be recovered almost to normal once the intracranial pressure is normalized either by shunt or EVD (External Ventrucular Drain).

Reduction of collection of cerebrospinal fluid from 14 mm to 9 mm is definitely sign of improvement. It might reduce further over a period of time, as the pressure become normal.

Continuation of External Ventrucular Drain for 2 more days can be useful to maintain the the normal pressure. It is kept as safety measure. It is kept above head end level so that it will drain only if pressure is more than normal.

After drainage of subdural hygroma through External Ventrucular Drain, it may or may not recollect. This can be assessed through repeat CT scans. In future, he may require shunt only if he develops raised intraranial pressure symptoms after removal of External Ventrucular Drain. But once placed, usually it will be permanent. Rarely they become shunt free.

Best assesment of removal of External Ventrucular Drain is done by the neurosurgeon after proper clinical & radiological correlation.

I hope I have answered your query. I will be available for follow up queries if any.

Wishing your son a speedy recovery.

Dr. Praveen K. Nath
Above answer was peer-reviewed by
Follow-up: CSF leaks after brain injury, Intracernal Pressures, Subdural burr drainage system, Under EVD 19 hours later
Hi Doctor ,

Just to update you , today EVD drainage was stopped and my son was put under observation. After it was stopped some CSF leaks again started happening out of the dura. Doctors said it was because some CSF leak wounds were not completely healed and XXXXXXX ICP pressures after the EVD was stopped is pushing this CSF out. They have again put my son on EVD for few more days, also they said the raised ICP pressures can be because of some scar formed on ventricle of brain which is creating this pressure beside the Subdural Hygroma.
Please guide me doctor what is happening here, will my son ever recover from these symptoms and be completely fine.

What is causing all this and how much time it takes for the brain to recover. I am bit worried doctors, please help me.

Doctors said there are 80% chances that he will be put on Shunt.

Answered by Dr. Praveen K Nath 7 hours later

I can completely understand your feeling and your growing concern over your son's neurological state.

We rarely had definite answers for questions posted by persons on neurological conditions especially ones like these. But our experiences say that most of them recover too often on a positive side with best results.

Restarting of EVD after closure means that intracranial pressure is high. We need to continue this as a temporary measure in a hope that later on when intracranial pressure is low he may be off these shunting procedures.

If it is not so, he may require a permanant shunting procedure.

It happens at times due to head injuries when cerebro spinal fluid drainage system is injured. We need to take care of infections simultaneously.

Hope for a speedy & complete recovery for your son.

Dr. Praveen Nath.
Above answer was peer-reviewed by
Follow-up: CSF leaks after brain injury, Intracernal Pressures, Subdural burr drainage system, Under EVD 2 days later
Dear Doctor,

Right now only complication which my son has is these raised ICP due to subdural hygroma and a scar on the ventricle. Also doctors are saying that csf fluid is not getting absorbed with the rate it is getting formed for a reason unknows. How long it will take for these complications to go away, so my son get back to school.

Also are there any medicines for controlling CSF. Usually such kind of problems in head take how long to recover?

Answered by Dr. Praveen K Nath 24 hours later
Hope your son is showing recovery now
there is no fixed timeframe for recovery in these patients.
there are few medicines like acetazolamide to decrease production of csf .but decrease in raised icp is mainly secondary to natural recovery in drainage system of csf or secondary to a functioning shunt system in situ.

hoping to see your son going to school as early as possible

Dr Praveen K Nath XXXXXXX Consultant Neurosurgeon
Above answer was peer-reviewed by
Follow-up: CSF leaks after brain injury, Intracernal Pressures, Subdural burr drainage system, Under EVD 13 hours later
Dear Doctor,

Just one last question when EVD was started few days back in my son he was having drainage of 25 ml daily at a fixed height and now after few days drainage is 10 - 11 ml daily at the same height. Does that mean he is recovering and ICPs are equalizing?

Answered by Dr. Praveen K Nath 21 hours later
Dear sir,

Hope your son is recovering well.

Decrease in amount of cerebrospinal fluid drainage per day is a positive sign of recovery ,if EVD patency is ok .

Gradually EVD may be partially blocked and later may be removed , if associated clinical recovery is seen .

Cerbrospinal fluid secretion & absorption mechanism is very complicated ,it does not follow simple mathematics .

If on repeat CT(computerised tomography) scans ,subdural hygroma is reduced , one may try removing EVD , followed by wait & watch policy.

Hope to hear good news soon.

Dr XXXXXXX k XXXXXXX XXXXXXX consultant neurosurgeon
Above answer was peer-reviewed by
Follow-up: CSF leaks after brain injury, Intracernal Pressures, Subdural burr drainage system, Under EVD 17 days later
Dear Doctor..

After EVD was removed from my Son his Pressures were initially monitored and they came to be raised at 20-30 mm hg (in between they went to 40 mmhg doctors said they were because of anesthesia medicine).. after a weeks time his pressures were again monitored and they came to be 20-30 mmhg again (This time they did see a raise at 35+ for a small time , there was no reason).. now they will monitor the pressure again after 2 weeks. Will ICPs reduce with time on there own.. what will happen to my son?

Also he is currently in Rehab and recovering well. He is showing very good progress in Leg improvement but his fingers are showing no improvement as per the doctor flexor are working fine but extensors are not working as of now. What does that mean?

Overall in a nut shell my son is having raised ICP at 20-30 mmhg avg. His Right leg is showing improvement but right hand fingers are still not showing recovery.. his subdural hygroma is persisted at 9mm size.
Answered by Dr. Praveen K Nath 13 hours later

Nice to hear a recovery update of your son.

Hope to see him back in action soon.

After EVD removal, its not always necessary to monitor raised ICP through invasive devices,
patient may be monitored clinically & with repeated CT scans or MRIs. Too close monitoring will always reveal few spikes of high pressures.

Initial leg improvement & late upper limb power improvement is a known phenomenon. You should not worry about this. keep continuing with physiotherapy. Continue all rehab measures.

Wishing you good luck for a speedy recovery.


Dr Praveen k Nath XXXXXXX consultant neurosurgeon
Above answer was peer-reviewed by
Follow-up: CSF leaks after brain injury, Intracernal Pressures, Subdural burr drainage system, Under EVD 6 hours later
Dear Doctor,

Its my doctor who has recommended this technique of closely monitoring the child for raised ICPs. As per him his exact statement was while doing the last monitoring that while doing the ICP monitoring for 30 - 40 minutes whenever the child was asleep his ICPs were ranging between 20-30 mm and whenever he was waking in between they used to enter some 30s mm. I am not sure what he means and are these much pressures XXXXXXX for my sons health .. main thing is he is having non of the symptoms of high and raised ICPs, he is walking talking and playing and even enjoying his rehab. Only thing I am concerned about is will his ICP getting normalized? and his current ICP behaviour is working fine.

Good part is his rehab doctor is happy with his leg improvements.
Answered by Dr. Praveen K Nath 37 hours later
Dear sir ,
Thanks for the follow up.

Nice to hear about your son walking ,talking & enjoying physiotherapy sessions .

Gradually his intracranial pressure fluctuations will also heal naturally & later he will not require any intracranial pressure monitoring .

The only thing to monitor is clinical recovery & repeat MRI(magnetic resonance imaging) of brain .

Continue good physiotherapy & medications advised by your neurosurgeon.

Wishing your son a speedy recovery .

Dr XXXXXXX k XXXXXXX XXXXXXX consultant neurosurgeon
Above answer was peer-reviewed by
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