Neurocritical Care

, Volume 29, Issue 3, pp 435–442 | Cite as

Accuracy and Safety of External Ventricular Drain Placement by Physician Assistants and Nurse Practitioners in Aneurysmal Acute Subarachnoid Hemorrhage

  • Alejandro Enriquez-Marulanda
  • Luis C. Ascanio
  • Mohamed M. Salem
  • Georgios A. Maragkos
  • Ray Jhun
  • Abdulrahman Y. Alturki
  • Justin M. Moore
  • Christopher S. Ogilvy
  • Ajith J. ThomasEmail author
Original Article



In the current dynamic health environment, increasing number of procedures are being completed by advanced practitioners (nurse practitioners and physician assistants). This is the first study to assess the clinical outcomes and safety of external ventricular drain (EVD) placements by specially trained advanced practitioners.


Compare the safety and outcomes of EVD placement by advanced practitioners in patients with subarachnoid hemorrhage (SAH).


A cohort comparison study was performed from an aneurysmal SAH database selecting patients treated with EVD from a single major academic institution in the USA between June 2007 and June 2017. Safety, accuracy, and complications of EVD placement were compared between advanced practitioners and neurosurgical physicians (attending neurosurgeon and subspecialty clinical fellow). Statistical analysis was performed using the Mann–Whitney test for continuous variables and χ2 test for categorical variables, with p values set at < 0.05 for significance.


We identified 203 patients for this cohort with 238 EVD placements; eighty-seven (36.6%) placements were performed by advanced practitioners and 151 (63.4%) by neurosurgeons. Most of the ventriculostomies were placed in the emergency room (n = 114; 47.9%). Additional procedures performed concurrently with the EVD placements were significantly higher among the physicians’ group (21.8 vs. 4.6%; p < 0.001). Bedside placement and usage of Ghajar guide were significantly higher among advanced practitioner’s (58.3 vs. 98.9 and 9.9 vs. 64.4%, respectively, with a p < 0.001 for both). There were, however, no significant differences in terms of the number of attempts for insertion, intraprocedural complications, tract hemorrhages, accuracy, infection rates, catheter dislodgments, and need for repositioning/replacement of EVD.


After appropriate training, EVD placement can be safely performed by advanced practitioners with an adequate accuracy of placement.


External ventricular drain Ventriculostomy Subarachnoid hemorrhage Operative complications Nurse practitioners Physician assistants Advanced practitioners Mid-levels 


Authors Contribution

AEM conceived of the study, participated in its design and coordination, participated in data collection, performed the statistical analysis, interpretation of the data, literature review and drafted the manuscript; LCA, MMS, GAM, RJ participated in the design and coordination of the study, performed the data collection and helped to draft the manuscript; AYA, JMM, CSO and AJT conceived of the study, participated in the study design, interpretation of data and helped to draft the manuscript. All authors read and approved the final manuscript.

Source of support

This research received no specific grant from any funding agency.

Compliance with Ethical Standards

Conflict of interest

The authors report no conflict of interest concerning the material or methods used in this study, or the findings specified in this paper.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society 2018

Authors and Affiliations

  • Alejandro Enriquez-Marulanda
    • 1
  • Luis C. Ascanio
    • 1
  • Mohamed M. Salem
    • 1
  • Georgios A. Maragkos
    • 1
  • Ray Jhun
    • 1
  • Abdulrahman Y. Alturki
    • 1
    • 2
  • Justin M. Moore
    • 1
  • Christopher S. Ogilvy
    • 1
  • Ajith J. Thomas
    • 1
    Email author
  1. 1.Neurosurgical Service, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA
  2. 2.Department of Neurosurgery, The National Neuroscience InstituteKing Fahad Medical CityRiyadhSaudi Arabia

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