Safety and effectiveness of bolt-mounted versus tunnelled external ventricular drains: A systematic review, meta-analysis and trial-sequential analysis.

Publication/Presentation Date

3-1-2026

Abstract

BACKGROUND: External ventricular drains (EVDs) are fundamental to neurocritical care, yet substantial procedural heterogeneity persists, particularly regarding bolt-mounted versus tunnelled catheter fixation. The relative safety and effectiveness of these approaches remain unclear, with conflicting data from observational studies and a lack of trial-level evidence.

OBJECTIVE: To compare bolt-mounted and tunnelled EVDs across accuracy, reoperation, and key safety outcomes using systematic review, meta-analysis, and trial-sequential analysis.

METHODS: Following PRISMA guidelines, PubMed, Embase, and CENTRAL databases were searched (November 2025) for randomised or observational studies comparing bolt-mounted with tunnelled EVDs in adults. Two reviewers independently screened studies, extracted data, and assessed risk of bias. Primary outcomes were optimal catheter placement (Kakarla Grade I) and reoperation for EVD-related complications. Secondary outcomes included iatrogenic intracranial haemorrhage (ICH), cerebrospinal fluid (CSF) infection, CSF leak, catheter obstruction or malfunction, accidental discontinuation, and drainage duration. Random-effects meta-analyses were conducted using restricted maximum likelihood estimation. Heterogeneity was quantified, and certainty of evidence was assessed using GRADE. Trial-sequential analysis was performed for reoperation to determine whether available data met required information size thresholds.

RESULTS: Ten studies encompassing 2008 patients (800 bolt-mounted, 1208 tunnelled) were included. Bolt-mounted EVDs demonstrated significantly higher optimal catheter accuracy (RR 1.27; 95% CI: 1.06-1.51; P <  0.01; I

CONCLUSIONS: Bolt-mounted EVDs were associated with higher catheter accuracy, reduced CSF leak, and improved mechanical reliability without increased infection or haemorrhage. Although reoperation may be lower with bolt-mounted systems, current evidence remains underpowered for firm conclusions. These findings challenge historical assumptions regarding tunnelled catheters and may inform context-specific device selection in contemporary neurocritical care.

Volume

145

First Page

111860

Last Page

111860

ISSN

1532-2653

Disciplines

Business Administration, Management, and Operations | Health and Medical Administration | Management Sciences and Quantitative Methods

PubMedID

41534165

Department(s)

Administration and Leadership

Document Type

Article

Link to Full Text

Share

COinS