Placement of External Ventricular Drain: Comparison of Two Methods

Abstract

Background Insertion of a frontal external ventricular drain (EVD) is a common emergency procedure in neurosurgery. Malpositioning of the EVD and/or triggering a new intracerebral or intraventricular hemorrhage (nICVH) are typical complications. The standard procedure (SP) uses a tape measure to identify the Kocher's point for placement of a frontal burr hole. A faster alternative to determine the correct position is the freehand technique (FHT). This study compared both techniques with regard to the correct positioning of the EVD tip and the induction catheter-induced nICVH.

Methods We performed a retrospective analysis of patients who required an EVD for acute or chronic hydrocephalus between January 2013 and March 2014. The study consisted of two groups. In the first group, EVDs were placed with the FHT. In the second group the SP was used. Postoperative computed tomography scans were analyzed regarding correct positioning of the ventricular catheter, malpositioning of the tip of the EVD using a 4-point-scale, and evidence for catheter-induced nICVH.

Results A total of 95 patients could be included. The FHT was performed in 43 cases and the SP in 52 cases. No significant differences between the two groups were found regarding the correct position of the EVD tip (p = 0.38) and nICVH (p = 0.12). There was no significant difference in malpositioning of the EVD tip between the groups (p = 0.34).

Conclusion Our results show no significant differences between the two methods with regard to correct position, malpositioning, and nICVH. Thus we conclude that the FHT is a fast, safe, and effective alternative to the SP.

Keywords

external ventricular drain - accuracy - complications - technique - hydrocephalus

• References

• 1 Toma AK, Camp S, Watkins LD, Grieve J, Kitchen ND. External ventricular drain insertion accuracy: is there a need for change in practice?. Neurosurgery 2009; 65 (06) 1197-1200 ; discussion 1200–1201
• 2 Khanna RK, Rosenblum ML, Rock JP, Malik GM. Prolonged external ventricular drainage with percutaneous long-tunnel ventriculostomies. J Neurosurg 1995; 83 (05) 791-794
• 3 Miller C, Tummala RP. Risk factors for hemorrhage associated with external ventricular drain placement and removal. J Neurosurg 2017; 126 (01) 289-297
• 4 Roitberg BZ, Khan N, Alp MS, Hersonskey T, Charbel FT, Ausman JI. Bedside external ventricular drain placement for the treatment of acute hydrocephalus. Br J Neurosurg 2001; 15 (04) 324-327
• 5 Meyer B, Schaller K, Rohde V, Hassler W. Percutaneous needle trephination. Experience in 200 cases. Acta Neurochir (Wien) 1994; 127 (3–4): 232-235
• 6 Scheithauer S, Bürgel U, Ryang YM. , et al. Prospective surveillance of drain associated meningitis/ventriculitis in a neurosurgery and neurological intensive care unit. J Neurol Neurosurg Psychiatry 2009; 80 (12) 1381-1385
• 7 Arabi Y, Memish ZA, Balkhy HH. , et al. Ventriculostomy-associated infections: incidence and risk factors. Am J Infect Control 2005; 33 (03) 137-143
• 8 Lozier AP, Sciacca RR, Romagnoli MF, Connolly Jr ES. Ventriculostomy-related infections: a critical review of the literature. Neurosurgery 2008; 62 (Suppl. 02) 688-700
• 9 Dos Santos SC, Fortes Lima TT, Lunardi LW, Stefani MA. External ventricular drain-related infection in spontaneous intracerebral hemorrhage. World Neurosurg 2017; 99: 580-583
• 10 Bota DP, Lefranc F, Vilallobos HR, Brimioulle S, Vincent JL. Ventriculostomy-related infections in critically ill patients: a 6-year experience. J Neurosurg 2005; 103 (03) 468-472
• 11 Reyes MM, Munigala S, Church EL. , et al. Comparing external ventricular drains—related ventriculitis surveillance definitions. Infect Control Hosp Epidemiol 2017; 38 (05) 574-579
• 12 Abdoh MG, Bekaert O, Hodel J. , et al. Accuracy of external ventricular drainage catheter placement. Acta Neurochir (Wien) 2012; 154 (01) 153-159
• 13 Baum GR, Hooten KG, Lockney DT. , et al; EVD Best Practice Team. External ventricular drain practice variations: results from a nationwide survey. J Neurosurg 2017; 127 (05) 1190-1197
• 14 Bijlenga PD, Gautschi OP, Sarrafzadeh AS, Schaller K. External ventricular catheter placement: how to improve. Acta Neurochir Suppl (Wien) 2016; 122: 161-164
• 15 Foreman PM, Hendrix P, Griessenauer CJ, Schmalz PG, Harrigan MR. External ventricular drain placement in the intensive care unit versus operating room: evaluation of complications and accuracy. Clin Neurol Neurosurg 2015; 128: 94-100
• 16 Huyette DR, Turnbow BJ, Kaufman C, Vaslow DF, Whiting BB, Oh MY. Accuracy of the freehand pass technique for ventriculostomy catheter placement: retrospective assessment using computed tomography scans. J Neurosurg 2008; 108 (01) 88-91
• 17 Kakarla UK, Kim LJ, Chang SW, Theodore N, Spetzler RF. Safety and accuracy of bedside external ventricular drain placement. Neurosurgery 2008; 63 (01) (Suppl. 01) ONS162-ONS166 ; discussion ONS166–ONS167
• 18 Krötz M, Linsenmaier U, Kanz KG, Pfeifer KJ, Mutschler W, Reiser M. Evaluation of minimally invasive percutaneous CT-controlled ventriculostomy in patients with severe head trauma. Eur Radiol 2004; 14 (02) 227-233
• 19 Reinges MHT. External ventricular drain insertion. In: Falter F. , ed. Bedside Procedures in the ICU. New York, NY: Springer-Verlag; 2012: 183-189
• 20 Saladino A, White JB, Wijdicks EF, Lanzino G. Malplacement of ventricular catheters by neurosurgeons: a single institution experience. Neurocrit Care 2009; 10 (02) 248-252
• 21 Bogdahn U, Lau W, Hassel W, Gunreben G, Mertens HG, Brawanski A. Continuous-pressure controlled, external ventricular drainage for treatment of acute hydrocephalus—evaluation of risk factors. Neurosurgery 1992; 31 (05) 898-903 ; discussion 903–904
• 22 O'Leary ST, Kole MK, Hoover DA, Hysell SE, Thomas A, Shaffrey CI. Efficacy of the Ghajar Guide revisited: a prospective study. J Neurosurg 2000; 92 (05) 801-803
• 23 Evans Jr WA. An encephalographic ratio for estimating ventricular enlargement and cerebral atrophy. Arch Neurol Psychiatry 1942; 47: 931-937
• 24 Stein M, Luecke M, Preuss M, Boeker DK, Joedicke A, Oertel MF. Spontaneous intracerebral hemorrhage with ventricular extension and the grading of obstructive hydrocephalus: the prediction of outcome of a special life-threatening entity. Neurosurgery 2010; 67 (05) 1243-1251 ; discussion 1252
• 25 Stangl AP, Meyer B, Zentner J, Schramm J. Continuous external CSF drainage—a perpetual problem in neurosurgery. Surg Neurol 1998; 50 (01) 77-82
• 26 Ellens NR, Fischer DL, Meldau JE, Schroeder BA, Patra SE. External ventricular drain placement accuracy and safety when done by midlevel practitioners. Neurosurgery 2018; March 29 (Epub ahead of print)