Real-time ultrasound-guided external ventricular drain placement: Technical note

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 reliable 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.