Is image guidance essential for external ventricular drain insertion?

Fisher, Benjamin A, Soon, W C, Ong, J Y W, Chan, T, Chowdhury, Y A, Hodson, James and White, Anwen (2021) Is image guidance essential for external ventricular drain insertion? World neurosurgery. ISSN 1878-8769.

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This study aimed to compare the EVD placement accuracy and complication rates, between neuronavigation-guided, ultrasound-guided and free-hand techniques in our single centre cohort, and through an additional meta-analysis of the currently available literature.


A retrospective review of patients who underwent EVD insertion from January 2016 to April 2019 was conducted. Information regarding demographics, indication, Evan's index, use of image guidance, accuracy of catheter tip placement and procedural complications were extracted from electronic records and imaging systems. The accuracy of the EVD tip placement was classified according to the Kakarla grading system into optimal, suboptimal or misplaced based on its proximity to the Foramen of Monro and involvement of non-eloquent/eloquent structures.


In total, 221 patients (mean age of 51.6 years) underwent EVD insertion during the study period. 108 catheters were placed free-hand, 70 Neuronavigation-guided and 43 ultrasound-guided; and the mean Evan's ratios were 0.34, 0.30 and 0.32 respectively. EVD placement was significantly more accurate with neuronavigation guidance versus free-hand placement (89.4% versus 79.2% respectively, p=0.0035). Meta-analysis of three studies demonstrates a statistically significant reduction in suboptimal EVD placement when compared to free-hand placement with a pooled OR of 0.50 (95% CI: 0.32 - 0.77, p=0.002). Surgeon seniority and other procedural related factors had no significant impact on EVD placement accuracy or complications.


Image-guided EVD placement significantly reduced the rate of suboptimally placed EVD's. We conclude in appropriately selected cases, image-guided EVD insertions will improve accuracy of catheter placements and reduce associated complications of the procedure.

Item Type: Article
Subjects: WL Nervous system. Neurology
Divisions: Emergency Services > Neurology
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Depositing User: Mrs Caroline Tranter
Date Deposited: 01 Oct 2021 13:48
Last Modified: 01 Oct 2021 13:48

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