External ventricular drainage

External ventricular drainage or ventriculostomy is a common neurosurgical technique and accurate placement of the intraventricular catheter is one of the most important variables in the longevity of shunt survival 1) 2).

Ventriculostomy is a neurosurgical procedure that involves creating a hole (stoma) within a cerebral ventricle for drainage. It is done by surgically penetrating the skull, dura mater, and brain such that the ventricle of the brain is accessed. When catheter drainage is temporary, it is commonly referred to as an external ventricular drain, or EVD.

When catheter drainage is permanent, it is usually referred to as a shunt. There are many catheter-based ventricular shunts that are named for where they terminate, for example, a ventriculoperitoneal shunt terminates in the peritoneal cavity, a ventriculoatrial shunt terminates within the atrium of the heart, etc. The most common entry point on the skull is called Kocher's point, which is measured 11 cm posterior to the nasion and 3 cm lateral to the midline. EVD ventriculostomy is done primarily to monitor the intracranial pressure as well as to drain cerebrospinal fluid (“CSF”), primarily, or blood to relieve pressure from the central nervous system (CNS).

Strictly speaking, “ventriculostomy” does not require the use of tubing. For example, a “third ventriculostomy” is a neurosurgical procedure that creates a hole in the floor of the third ventricle and usually has no indwelling objects.

Other types ventriculostomy include ventriculocisternostomy developed by the Norwegian doctor Arne Torkildsen.

Ventriculostomy is one of the most common emergency based neurosurgical procedures practitioners undertake globally.

On 15th October 1744, the French surgeon Claude-Nicolas Le Cat (1700-1768) introduced a specially invented cannula into the lateral ventricle of a newborn boy with hydrocephalus. The cannula was used as a tap and was left in place for 5 days, until the death of the child. This procedure should be seen as the first documented description of a device for repeated ventricular taps in the treatment of hydrocephalus. 3).

There have been numerous changes in technique, materials used, indications for the procedure, and safety. The history of EVD is best appreciated in 4 eras of progress: development of the technique (1850-1908), technological advancements (1927-1950), expansion of indications (1960-1995), and accuracy, training, and infection control (1995-present). While EVD was first attempted in the 18th century, it was not until 1890 that the first thorough report of EVD technique and outcomes was published by William Williams Keen. He was followed by H. Tillmanns, who described the technique that would be used for many years. Following this, many improvements were made to the EVD apparatus itself, including the addition of manometry by Adson and Lillie in 1927, and continued experimentation in cannulation/drainage materials. Technological advancements allowed a great expansion of indications for EVD, sparked by Nils Lundberg, who published a thorough analysis of the use of intracranial pressure (ICP) monitoring in patients with brain tumors in 1960. This led to the application of EVD and ICP monitoring in subarachnoid hemorrhage, Reye syndrome, and traumatic brain injury. Recent research in EVD has focused on improving the overall safety of the procedure, which has included the development of guidance-based systems, virtual reality simulators for trainees, and antibiotic-impregnated catheters 4).

Ingraham advocated the application of a closed draining system to minimize the infective complications 5).

Plain catheter

Antibiotic impregnated catheter: Bactiseal.

Silver impregnated catheter.

Bolt-connected external ventricular drainage.

Ventriculostomy entry sites are commonly selected by freehand estimation of Kocher's point or approximations from skull landmarks and a trajectory toward the ipsilateral frontal horn of the lateral ventricles.

Endoscopic third ventriculostomy.

see Frontal ventriculostomy.

see Fourth ventriculostomy.

Tunneled external ventricular drainage.

Standard external ventricular drainage.

The Infectious Diseases Society of America (IDSA), the Neurocritical Care Society (NCS), and The Society for Neuroscience in Anesthesiology & Critical Care (SNACC) have published recommendations for the management of EVD-Associated Ventriculitis. The objective of this study was to assess the methodological quality and reporting clarity of these recommendations using the AGREE-II tool. We found that the overall quality of the published clinical practice guidelines is acceptable. However, continuous updates and external validation should be implemented 6)

A study design of a single center, prospective, randomized controlled trial to investigate whether guided ventriculostomy is superior to the standard freehand technique. One strength of this study is the prospective, randomized, interventional type of study testing a new easy-to-handle guided versus freehand ventricular catheter placement. A second strength of this study is that the power calculation is based on catheter accuracy using an available grading system for catheter tip location, and is calculated with the use of recent study results of our own population, supported by data from prominent studies 7).

Wan KR, Toy JA, Wolfe R, Danks A. Factors affecting the accuracy of ventricular catheter placement. J Clin Neurosci. 2011 Apr;18(4):485-8. doi: 10.1016/j.jocn.2010.06.018. Epub 2011 Jan 20. PubMed PMID: 21256029.
Tuli S, Drake J, Lawless J, Wigg M, Lamberti-Pasculli M. Risk factors for repeated cerebrospinal shunt failures in pediatric patients with hydrocephalus. J Neurosurg. 2000 Jan;92(1):31-8. PubMed PMID: 10616079.
Kompanje EJ, Delwel EJ. The first description of a device for repeated external ventricular drainage in the treatment of congenital hydrocephalus, invented in 1744 by Claude-Nicolas Le Cat. Pediatr Neurosurg. 2003 Jul;39(1):10-3. PubMed PMID: 12784070.
Srinivasan VM, O'Neill BR, Jho D, Whiting DM, Oh MY. The history of external ventricular drainage. J Neurosurg. 2014 Jan;120(1):228-36. doi: 10.3171/2013.6.JNS121577. Epub 2013 Jul 26. PMID: 23889138.
Munakomi S, M Das J. Ventriculostomy. 2019 Jul 26. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from http://www.ncbi.nlm.nih.gov/books/NBK545317/ PubMed PMID: 31424901.
Brotis AG, Karvouniaris M, Tzerefos C, Gatos C, Fountas KN. Guidelines on the use of external ventricular drain and its associated complications: do we “AGREE II”? Br J Neurosurg. 2021 Dec;35(6):689-695. doi: 10.1080/02688697.2021.1958153. Epub 2021 Aug 9. PMID: 34365868.
Sarrafzadeh A, Smoll N, Schaller K. Guided (VENTRI-GUIDE) versus freehand ventriculostomy: study protocol for a randomized controlled trial. Trials. 2014 Dec 5;15:478. doi: 10.1186/1745-6215-15-478. PubMed PMID: 25480528; PubMed Central PMCID: PMC4289205.
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