NEUROSURGICAL

FOCUS Neurosurg Focus 43 (5):E5, 2017

Real-time ultrasound-guided external ventricular drain

placement: technical note
James H. Manfield, MBBS, MSc, MRCS,1 and Kenny K. H. Yu, MBBS, MRCS, PhD1,2
1
Department of Neurosurgery, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Greater
Manchester; and 2Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, The University of
Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom

In the United Kingdom, ultrasound-guided external ventricular drain (EVD) insertion is becoming the standard of care
to mitigate the morbidity associated with catheter malposition and multiple passes. Many neurosurgeons routinely use
ultrasound to check the preinsertion trajectory, although real-time visualization of ventricular cannulation is preferable
since minor deviations can be significant in patients with smaller ventricles, and live visualization further enables the
catheter tip to be adjusted away from the choroid plexus. Such real-time ultrasound navigation has traditionally been
limited by technical factors including the challenge of simultaneously manipulating the probe and inserting the catheter
within the same image plane.
The authors here describe a simple technique for precise EVD placement using a readily available bur hole ultrasound
transducer attached to a 10-gauge needle guide channel (principally used for biopsy procedures) to accommodate a
ventriculostomy catheter. The anticipated trajectory line is then projected onto the display and followed into the ipsilateral
lateral ventricle. This is illustrated with a representative case and video demonstrating this rapid, user-friendly, and reli-
able technique. The authors invite others to consider this useful technique to minimize the risks of catheter misplacement
or multiple cannulation attempts, which can be of particular benefit to junior neurosurgeons performing difficult cases
under pressured conditions.
https://thejns.org/doi/abs/10.3171/2017.7.FOCUS17148
KEY WORDS ultrasound guidance; external ventricular drain; ventriculostomy; technique

E
xternal ventricular drain (EVD) placement for ce- ries.1 Such findings have led several authors to conclude
rebrospinal fluid diversion is commonly performed that current ventriculostomy practice leaves room for im-
for conditions such as acute hydrocephalus from provement and calls for wider adoption of image-guided
any cause as well as to monitor and treat intracranial pres- insertion.1,5 The latest 2016 consensus statement guide-
sure. Although a basic procedure frequently delegated to lines on EVD insertion and management from the Neuro-
junior neurosurgeons, catheter placement in a timely and critical Care Society also recommend considering image
accurate manner is critical as it is often performed as a guidance in cases of distorted ventricular anatomy or un-
life-saving procedure in an acute setting. usually small ventricles.4
Insertion of an EVD is generally safe, though compli- Two current meta-analyses, comprising 2428 and 2829
cations such as hemorrhage and suboptimal placement cases, respectively,2,3 emphasized a wide range of estimat-
have been reported in up to 40% of cases.9 Huyette et al.5 ed bleeding risk (from 0% to over 40%), attributable to
performed a retrospective study of 90 patients and found varying definitions and study designs, with pooled overall
that just 56% of EVD catheter tips were located within the rates of 7% and 8.4%. More recent data from the random-
ipsilateral lateral ventricle and 22% in the extraventricular ized controlled Clot Lysis: Evaluating Accelerated Reso-
spaces. Two passes were required per successful insertion lution of Intraventricular Hemorrhage Phase III (CLEAR
overall, with results similar to those in other reported se- III) trial revealed a 16.8% hemorrhage rate, based on the

ABBREVIATIONS EVD = external ventricular drain; UK = United Kingdom; VP = ventriculoperitoneal.

SUBMITTED March 9, 2017. ACCEPTED July 25, 2017.
INCLUDE WHEN CITING DOI: 10.3171/2017.7.FOCUS17148.

AANS, 2017 Neurosurg Focus Volume 43 November 2017 1

J. H. Manfield and K. K. H. Yu

FIG. 1. Bur hole ultrasound transducer (10 8.6 mm) with a mounted 10-gauge guide channel, with illustrated trajectory line.
Copyright BK Medical. Published with permission.

first 250 cases, with 2.4% of subjects deemed to have suf- sound scanner with bur hole transducer. At our institution,
fered clinically symptomatic bleeding.3 There is evidence we use the Flex Focus 800 (BK Medical) with a 10 8.6
that increasing the number of EVD placement attempts is mm footplate bur hole transducer (Burr-Hole 8863) onto
a risk factor for this complication.6 which is mounted a sterile single-use needle guide chan-
In the United Kingdom (UK), EVD insertion is not rou- nel (UA1346). This apparatus is principally designed for
tinely performed as a bedside procedure, but is performed biopsy needles but comes in a range of sizes from 20 to
in the operating theater unless the patient is in extremis. 10 gauge, which allows passage of the typical ventricular
Intraoperative ultrasound has gained widespread accep- catheter used in an adult population (Fig. 1). We use the
tance as it permits real-time visualization of the lateral channel designed for a 10-gauge needle (outer diameter
ventricle before and during catheter insertion. The antici- 3.404 mm), which easily accommodates the Codman Bac-
pated trajectory line can be projected on the display and, tiseal catheter (3-mm outer diameter, Codman & Shurtleff
when necessary, adjusted for optimal catheter positioning Inc.) used at our institution. Codman also manufactures
to avoid the choroid plexus or other potential obstructions a larger Bactiseal ventricular catheter, which is, to our
such as an intraventricular hematoma. This image-guided knowledge, the largest on the market, but with an outer di-
approach minimizes the likelihood that multiple passes ameter of 3.4 mm is still not greater than 10 gauge in size.
will be required to enter the ventricle, thus reducing the To accommodate the mounted ultrasound probe and
risk of hemorrhage and inadvertent injury to surrounding catheter, at least a 13-mm-diameter bur hole is required
structures. In many institutions, including our own, it is (assuming a 10-mm footplate such as ours). If a standard
standard practice to use a bur hole ultrasound probe to 14-mm perforator drill is used, it will typically produce an
check the planned trajectory prior to catheter insertion. 11-mm inner hole, which can then be enlarged to around
However, true real-time ultrasound guidancethat is, live 15 mm using Kerrison rongeurs or a cutting bur drill or
visualization of the catheter entering the ventricleis lim- via the use of 2 spectacle bur holes made with the per-
ited by technical factors, such as the size of the bur hole, forator.
and the difficulty of both manipulating the bur hole probe In an illustrative case, we performed an EVD insertion
and inserting the catheter simultaneously within the same using a standard incision over Kochers point. After scrap-
image plane. ing back the periosteum, two 14-mm bur holes are placed
Here we describe a technique of using a bur hole ultra- horizontally side by side with overlap, with the more
sound transducer along with a readily available 10-gauge medial bur hole placed over the intended EVD insertion
needle guide channel (typically used for biopsy proce- site (Fig. 2). An ultrasonic bur hole probe with the EVD
dures) to accommodate a ventricular catheter. In the lit- holding attachment is placed over the lateral bur hole, the
erature, we identified one relevant paper (10 cases) from septum pellucidum and ipsilateral lateral ventricle are
2007 describing real-time ultrasound-guided insertion of identified on ultrasound, and the exact entry point of the
ventriculoperitoneal (VP) shunt catheters in a pediatric EVD is then determined. Next, a small cruciate durotomy
cohort, all of which were positioned optimally on the first is performed with pial diathermy and incision over the in-
pass without complication,11 but no such technical notes
using contemporary imaging technology in adults. A re-
port of 3 cases, which describes the use of ultrasound to
customize EVD insertion points and trajectories to ac-
commodate distorted and dynamic anatomy, also illus-
trates a potential application of the method we describe.7
We therefore present a simple technique utilizing read-
ily commercially available equipment for precise ven-
tricular catheter placement in adults (and adolescents). We
have used this method with good results at our institution,
and we illustrate the technique with a representative case
and video.

Equipment and Methods FIG. 2. Two spectacle bur holes are placed over Kochers point to ac-
commodate both the EVD catheter and the ultrasound transducer (US).
This technique requires a portable neurosurgical ultra- L = left; R = right.

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 Real-time ultrasound-guided EVD placement

FIG. 3. Intraoperative coronal ultrasound images demonstrating the target ventricles. A: The lateral ventricles are identified by
first locating the septum pellucidum, and the adjacent hypoechoic spaces are the lateral ventricles (outlines with asterisks). Note
the hyperechoic choroid plexus at the level of the foramen of Monro. Small dots represent the anticipated trajectory projected on
the monitor. B: The distance from the guide channel entrance to the first dot on the image puncture line is approximately 7 mm
(0.3 inch) with the distance between dots being 5 mm (0.2 inch). The guide channel is angled at 8 to the transducers image
axis. C: Real-time tracking of the EVD following the dotted line as the drain is being inserted.

tended EVD insertion site, and the probe along with the well-designed retrospective analysis of 249 cases that
EVD is secured within the attachment and is directed un- identified the use of the freehand technique as the only risk
der real-time ultrasound guidance into the ventricle (Fig. factor for inaccurate placement.12 The recent Neurocritical
3 and Video 1). Care Society evidence-based consensus statement on EVD
VIDEO 1. Video clip demonstrating intraoperative ultrasound using insertion and management now advises clinicians to con-
a bur hole transducer for image-guided cannulation of the right lat- sider image guidance for difficult cases (that is, those with
eral ventricle. Copyright James Manfield and Kenny Yu. Published small ventricles or distorted anatomy).4 Ultrasound has a
with permission. Click here to view. clear advantage over stereotactic neuronavigation in terms
Once the catheter is in the correct position, it is tunneled of speed of setup and avoidance of the additional imag-
and secured. ing sequences typically required for registration. For VP
shunts, to which our technique is equally applicable, ac-
Discussion curate positioning of the proximal catheter has been found
to be among the most important variables predicting shunt
External ventricular drain insertion can be performed
either freehand using surface landmarks or with the aid longevity.10 Given the widespread availability of ultra-
of image guidance such as neuronavigation or ultrasound. sound machines, EVD insertion using ultrasonic guidance
Our traditional practice entails the use of an ultrasound has become the expected standard of care in most UK
probe to identify and confirm the catheter trajectory prior institutions. With practice, the described technique adds
to freehand insertion. However, since the attempted ven- only minimally to the operating time, which is more than
triculostomy is not performed under direct visualiza- recouped by those occasions in which multiple ventricu-
tion, there may be deviations from the intended trajec- lar catheter passes may have otherwise been necessary. By
tory, which can be particularly significant in patients with enabling the surgeon to be confident of the catheter loca-
smaller ventricles. Furthermore, confirming the final posi- tion, the procedure may also preclude the need to obtain
tion of the catheter following placement (by reintroducing a postoperative CT scan. The only potential drawback to
the ultrasound probe) is often difficult because the cath- this technique is the need to enlarge the bur hole slightly,
eter itself obscures the ultrasound waves. In comparison, which we do not believe adds any significant morbidity
the use of a fixed guide channel with the expected trajec- when weighed against the advantages. It is estimated that
tory projected on the display image means that the depth in the United States alone, approximately 500,000 EVDs
of the tip is always clearly shown. In our experience, the were inserted between 1988 and 2010.8 Given such a case
simplicity of our technique makes it robustly error proof, volume, it follows that even marginal refinements in tech-
which is a particular advantage for a procedure frequently nique are likely to translate into improved outcomes for a
performed by junior staff under pressured conditions, and significant number of patients.
especially useful for challenging cases in which ventricles We recognize that in the United States most ventricu-
are not enlarged or distorted. lostomies are performed at the bedside in a critical care
Although intuitively apparent, there is no Class I evi- unit setting by using a twist drill bur hole and that the rou-
dence to date that image-guided catheter insertion leads tine use of ultrasound would warrant a significant change
to better clinical outcomes. However, a number of stud- to current practice, unlike in the UK where the above
ies have evaluated image guidance in the context of both technique would be easily adopted. However, Phillips et
EVDs and ventricular shunt catheters, including a recent al. have described a series of 3 challenging cases in the

Neurosurg Focus Volume 43 November 2017 3

J. H. Manfield and K. K. H. Yu

FIG. 4. Proposed clinical algorithm for the management of patients with hydrocephalus requiring EVD insertion. Head CT scans
are first reviewed to assess ventricular size and anatomy. In units where image-guided insertion is not part of the standard EVD
insertion protocol, bedside cannulation is performed for patients with large ventricles and normal anatomy. For technically difficult
cases with small ventricles and/or distorted anatomy, ultrasound (US)guided insertion is advised. In addition, patients who have
had multiple failed attempts at insertion should proceed to US-guided insertion in the operating room (OR).

United States in which ultrasound guidance was used for cases with difficult or distorted anatomy or in which there
bedside EVD insertion in a critical care setting after a bur have been multiple unsuccessful ventricular catheter pass-
hole had been made using a handheld battery-powered es. We therefore suggest a putative treatment algorithm as
drill with a 14-mm perforator drill bit and then enlarged seen in Fig. 4.
with a side-by-side twist drill bur hole and/or a Kerrison
rongeur, as we describe.7 Although we do not have experi-
ence with this approach, it does suggest the feasibility of Conclusions
applying our technique at the bedside, if the appropriate Traditional freehand EVD insertion is associated with
equipment is available, as well as in the operating room. suboptimal placement and hemorrhage in a significant
We would, however, anticipate that in the United States number of cases. Given its ready availability, ultrasound
setting this technique would be reserved for challenging guidance is increasingly becoming the standard of care in

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 Real-time ultrasound-guided EVD placement

many institutions including our own. We describe the use ance: report of three cases. Neurocrit Care 17:255259,
of a biopsy needle guide adapter, which, when mounted 2012
on a bur hole ultrasound transducer, facilitates the accu- 8. Rosenbaum BP, Vadera S, Kelly ML, Kshettry VR, Weil RJ:
Ventriculostomy: frequency, length of stay and in-hospital
rate real-time placement of ventricular catheters in a rapid, mortality in the United States of America, 19882010. J Clin
user-friendly, and reliable manner. We believe this useful Neurosci 21:623632, 2014
technique minimizes the risk of complications related to 9. Sarrafzadeh A, Smoll N, Schaller K: Guided (VENTRI-
catheter misplacement or multiple attempts at ventricular GUIDE) versus freehand ventriculostomy: study protocol for
cannulation. It has minimal disadvantages and may be of a randomized controlled trial. Trials 15:478, 2014
particular benefit to junior neurosurgeons operating in 10. Wan KR, Toy JA, Wolfe R, Danks A: Factors affecting the
pressured conditions or on challenging cases. Further ef- accuracy of ventricular catheter placement. J Clin Neurosci
ficacy studies are needed to assess the intuitively plausible 18:485488, 2011
11. Whitehead WE, Jea A, Vachhrajani S, Kulkarni AV, Drake
hypothesis that image-guided ventricular catheter inser- JM: Accurate placement of cerebrospinal fluid shunt ven-
tion leads to improved clinical outcomes. tricular catheters with real-time ultrasound guidance in older
children without patent fontanelles. J Neurosurg 107 (5
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3. Dey M, Stadnik A, Riad F, Zhang L, McBee N, Kase C, et The authors report no conflict of interest concerning the materi-
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Neurosurg Focus Volume 43 November 2017 5