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J Korean Neurosurg Soc 59 (3) : 322-324, 2016 Copyright © 2016 The Korean Neurosurgical Society

Technical Note

Device for Catheter Placement of External Ventricular

Drain
Jae-Min Ann, M.D., Hack-Gun Bae, M.D., Ph.D., Jae-Sang Oh, M.D., Seok-Mann Yoon, M.D., Ph.D.
Department of Neurosurgery, Cheonan Hospital, Soonchunhyang University School of Medicine, Cheonan, Korea

To introduce a new device for catheter placement of an external ventricular drain (EVD) of cerebrospinal fluid (CSF). This device was composed of
three portions, T-shaped main body, rectangular pillar having a central hole to insert a catheter and an arm pointing the tragus. The main body
has a role to direct a ventricular catheter toward the right or left inner canthus and has a shallow longitudinal opening to connect the rectangular
pillar. The arm pointing the tragus is controlled by back and forth movement and turn of the pillar attached to the main body. Between April 2012
and December 2014, 57 emergency EVDs were performed in 52 patients using this device in the operating room. Catheter tip located in the fron-
tal horn in 52 (91.2%), 3rd ventricle in 2 (3.5%) and in the wall of the frontal horn of the lateral ventricle in 3 EVDs (5.2%). Small hemorrhage
along to catheter tract occurred in 1 EVD. CSF was well drained through the all EVD catheters. The accuracy of the catheter position and direction
using this device were 91% and 100%, respectively. This device for EVD guides to provide an accurate position of catheter tip safely and easily.

Key Words : External ventricular drain · Device · Cerebrospinal fluid.

INTRODUCTION the medical instrument and its registration number is 2009-08.

This device was made of polyoxymethylene. It was designed to
External ventricular drainage (EVD) is an important neuro- direct a ventricular catheter along a course pointing the inner
surgical procedure performing under emergent conditions. The canthus and the tragus. It was composed of three portions,
ideal target for ventricular placement is usually within the ipsi- main body, rectangular pillar and an arm pointing the tragus.
lateral frontal horn just anterior to the Monro foramen2). Even Main body shaped a large letter T which was composed of hori-
though the freehand technique using superficial anatomical zontal and vertical portions. Vertical portion has a role to direct
landmarks is traditional and generally accepted method for a ventricular catheter toward the right and left inner canthi, re-
EVD, the accuracy rate of EVD catheter placement has been re- spectively, and horizontal portion has a shallow longitudinal
ported about 39.9% to 84%3-5,7). EVD tips locating in nonven- opening to connect the rectangular pillar and move it back and
tricular space have been reported to be 8.2% to 22.4%4,5,7). forth. Rectangular pillar is 2×2×8 cm in size and has a longitu-
In 1985, the Ghajar Guide was introduced for ventricular cath- dinal central hole of 4 mm in diameter to insert an EVD cathe-
eter placement1), but it was unfamiliar with most neurosurgeon. ter into the frontal horn of the lateral ventricle. Vertical portion
Currently, navigation guided EVD may increase the accuracy of pointing the inner canthus was made to be placed coaxially with
placement of EVD, but it requires a lot of time and general anes- the central hole of the pillar. On the lateral surface of this pillar,
thesia. Thus, it is not suitable and reasonable in consideration of there is a longitudinal groove running parallel with the central
an emergent procedure and cost effectiveness of EVD. The au- hole of the pillar to insert the arm pointing the tragus (Fig. 1).
thors introduce a new device for ideal placement of EVD catheter. In order to perform an EVD at the Kocher’s point, the rectan-
gular pillar was connected with the horizontal portion of main
MATERIALS AND MATHODS body through its opening using a screw. The arm pointing the
tragus was inserted into the longitudinal groove of the pillar. To
EVD device position the tip of verticalportion toward the inner canthus, the
This study was approved by the institutional review board for main body was slightly moved from side to side centering the

• Received : August 27, 2015 • Revised : November 5, 2015 • Accepted : December 16, 2015
• Address for reprints : Hack-Gun Bae, M.D., Ph.D.
Department of Neurosurgery, Cheonan Hospital, Soonchunhyang University School of Medicine, 31 Soonchunhyang 6-gil, Dongnam-gu, Cheonan 31151, Korea
Tel : +82-41-570-3648, Fax : +82-41-572-9297, E-mail : hgbaeb@[Link]
• This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ([Link]

which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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 Device for External Ventricular Drain | JM Ann, et al.

A B C
Fig. 1. A : Device for external ventricular drain (EVD). T-shaped main body, screw, rectangular pillar having a longitudinal central hole, an arm pointing
the tragus and EVD catheter are visible. Both tips of vertical portion of the main body has a role to direct a ventricular catheter toward the right and
left inner canthi, respectively. Horizontal portion has a shallow longitudinal opening to connect the rectangular pillar and move it back and forth. B and
C : EVD procedures in dummy, respectively. Arrows indicate medial canthus and tragus in both hemispheres.

subarachnoid hemorrhage, respectively. Postoperative comput-

ed tomographic scans were examined in all patients.

RESULTS

All ventricular punctures were accomplished at one time. Cath-

eter tip located in the frontal horn in 52 EVDs and in the 3rd
ventricle in 2, in the wall of the frontal horn of the lateral ventricle
in 3. Small hemorrhage along to catheter tract occurred in 1 EVD.
Even though 3 EVD catheters located in the wall of the frontal
horn of lateral ventricle, CSF was well drained.
Fig. 2. Photograph showing an EVD procedure on the left head using the
device. Assistant is holding the arm pointing the left inner canthus.
Operator is holding the arm pointing the left tragus and inserting the DISCUSSION
EVD catheter through the longitudinal central hole of rectangular pillar.
Even though freehand insertion of an EVD using superficial
burr hole. The direction of the arm pointing the tragus was also anatomical landmarks is the most common method practiced
controlled by back and forth movement and turn of the pillar by young neurosurgical trainees, the catheter tip locations have
attached to the main body. EVD catheter through the central been reported to be unsatisfactory. EVD catheter placement has
hole of the pillar was finally inserted into the ventricle in depth been reported to be 39.9–84% in the ipsilateral frontal horn4-7),
of 5.5 cm from the dura mater (Fig. 2). If the thick blood had 2.7–12.4% in the contralateral frontal horn4,5,7), 18% in the later-
been pushed out of the ventricle through the EVD catheter due al ventricle body7), 1.8–10.4% in the subarachnoid space5,7), ap-
to the increased intracranial pressure in a case of intraventricular proximately 10% in the brain parenchyme5,7), 1.8–22.4% in the
hemorrhage (IVH), IVH was aspirated using a syringe of 10 cc. extraventricular space4,5), and 8.2–19.5% in the third ventricle4,5,7).
Toma et al.7) reported that 40% required EVD revision or reinser-
Patients for EVD tion procedure. They recommended to use neuronavigation, ul-
Between April 2012 and December 2014, 57 emergency EVDs trasonography, or other guidance techniques to position the cath-
were performed in 52 patients using this device in the operating eter tip accurately in the frontal horn of the lateral ventricle. To
room. Admission diagnoses in 52 patients were aneurysmal sub- increase the accuracy of ventriculostomy at Kocher’s point, Gha-
arachnoid hemorrhage in 21, intracerebral hemorrhage (ICH) jar guide was introduced in 19852). It was designed to direct a
associated with IVH in 21 (thalamus 15, caudate nucleus 5, pons catheter along a course that lies at a right angle to the cranial
1), pure IVH in 2, moyamoya disease in 2, cerebellar infarction surface. This device is rigid and consists of three equal-length
in 2, meningitis in 1, ventriculitis in 1, ruptured arteriovenous standards that are applied to the patient’s scalp and a central
malformation in 2. Bilateral EVDs were performed in 5 patients tube at the apex of the formed pyramid for passage of the cathe-
who had thalamic hemorrhage and ruptured AVM, aneurysmal ter. However, Ghajar guide is not familiar with neurosurgeons

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J Korean Neurosurg Soc 59 | May 2016

and is not popularly used. Currently, navigation guided EVD particularly in beginners. If the neurosurgical residency use this
may increase the accuracy of placement of EVD, but it requires a device more than several times during the training course, the
lot of time, room for procedure and frequent general anesthesia. accuracy of EVD by freehand technique will be also improved
In consideration of an emergent procedure and cost effectiveness because of the familiar direction of EVD device for ventricular
of EVD, navigation guided EVD is not suitable. In this presenta- puncture. This device for EVD guides to provide an accurate
tion, EVD device could be used very conveniently and quickly. position of catheter tip safely and easily.
When performing EVD using this device, the location of EVD
catheter tip can’t be reach enough in the frontal horn due to the • Acknowledgements
slight backward movement of the catheter in the process remov- This research was supported by the Soonchunhyang University Research
ing the device after ventricular puncture or due to the sight mid- Fund.
line shift. In this study, 3 patients showed that catheter tip located
in the ventricular wall of the frontal horn. However, In all pa- References
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