Comparative outcomes of three cerebrospinal fluid drainage strategies in primary and secondary intraventricular haemorrhage with hydrocephalus: a prospective cohort study

Background Intraventricular haemorrhage (IVH) complicated by acute hydrocephalus carries high morbidity and mortality. External ventricular drainage (EVD), Ommaya reservoir with intermittent aspiration, and Ommaya reservoir with free continuous drainage are all used clinically, but comparative data on drainage efficiency, infection risk, and functional outcome are limited. Objective To compare CSF drainage efficiency, radiological clot clearance, catheter-related complications, and 90-day functional outcomes among three CSF diversion strategies in patients with primary or secondary IVH and hydrocephalus. Methods Sixty consecutive patients with IVH and hydrocephalus were allocated, non-randomly according to institutional protocol and treating-surgeon preference, to Group A (standard lateral ventricular EVD, n = 20), Group B (Ommaya reservoir with repetitive CSF taps, n = 20), or Group C (Ommaya reservoir with free continuous drainage into a closed bag via a butterfly cannula, n = 20). Baseline severity (Graeb, modified Graeb, LeRoux scores, Evans and bicaudate indices, GCS), drainage metrics, serial CSF cytochemistry, catheter complications, shunt dependency, and 90-day modified Rankin Scale (mRS) and Glasgow Outcome Scale (GOS) were recorded. Results The three groups were well matched for age, admission GCS, haemorrhage volume, and baseline radiological severity scores (all p > 0.05). Mean daily CSF output and total CSF drained were significantly higher with the two continuous-drainage strategies (Group A 184.0 ± 33.3 mL/day, Group C 171.2 ± 28.5 mL/day) than with intermittent Ommaya tapping (Group B 95.6 ± 11.6 mL/day; p < 0.001), while duration of catheter drainage was similar across groups (~ 9.7–10.3 days, p = 0.77). Radiological clot clearance (modified Graeb score reduction) and clot clearance rate did not differ significantly between groups ( p = 0.57–0.67). Catheter-related infection/ventriculitis was numerically higher in Group A (45%) than Group B (20%) or Group C (20%), but this difference did not reach statistical significance (Fisher’s exact p = 0.16). Two of the culture-positive patients grew Candida species on cerebrospinal fluid culture, and both died of fungal ventriculitis. Shunt dependency (45% vs. 45% vs. 25%) and 90-day mRS, GOS, and mortality (~ 35–40%) were statistically similar across the three strategies (all p > 0.05). Conclusion Continuous free drainage via an Ommaya reservoir achieved CSF output and radiological clearance comparable to standard EVD, with a numerically lower (though not statistically significant) infection and shunt-dependency rate, while intermittent tapping minimised daily CSF loss. Adequately powered randomised trials are needed to determine whether reservoir-based free drainage can match the efficacy of EVD while reducing catheter-related morbidity.