====== Ventricular catheter placement ======

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[[External ventricular drain]] (EVD) [[insertion]] is a [[neurosurgical procedure]] in which a [[catheter]] is placed into the brain's [[ventricular system]] to drain [[cerebrospinal fluid]] (CSF). This [[procedure]] is commonly performed to relieve [[intracranial pressure]] (ICP) caused by conditions such as [[hydrocephalus]], [[traumatic brain injury]], or [[hemorrhage]], and to monitor [[ICP]] or sample [[CSF]] for diagnostic purposes.

===== Key Components =====

Purpose:

To reduce elevated intracranial pressure by draining excess CSF.
To monitor and measure ICP in real-time.
To sample CSF for infection, hemorrhage, or other diagnostic evaluations.
Procedure:

Performed in a sterile environment, often in the operating room or at the bedside in critical care settings.
The surgeon identifies the appropriate site for catheter insertion, commonly at Kocher's point (a standard entry point on the skull).
A small burr hole is drilled in the skull, and the catheter is carefully guided into the lateral ventricle using anatomical landmarks or image guidance.
Once in place, the catheter is connected to an external drainage system.
Equipment:

Catheter: A flexible tube that allows drainage of CSF.
External Drainage System: Includes a graduated chamber for collecting and measuring CSF.
Monitoring Equipment: For continuous ICP monitoring.
Indications:

Acute hydrocephalus.
Subarachnoid or intraventricular hemorrhage.
Traumatic brain injury with raised ICP.
Infections such as meningitis requiring CSF sampling.
Risks and Complications:

Infection (e.g., ventriculitis or meningitis).
Hemorrhage or damage to brain tissue.
Catheter misplacement or blockage.
Overdrainage, leading to complications like subdural hematoma.
Post-Procedure Care:

Frequent monitoring of the drainage system and CSF output.
Adjusting the height of the drainage chamber relative to the patient’s head to regulate CSF flow.
EVD insertion is a critical, life-saving procedure in neurosurgery that provides both therapeutic and diagnostic benefits in managing various intracranial pathologies.
 

===== Indications =====
[[Ventricular catheter]] placement, also known as [[ventriculostomy]], is the [[gold standard]] for managing [[acute hydrocephalus]] and for [[intracranial pressure monitoring]]. Common indications of [[EVD]] are hydrocephalus due to [[subarachnoid hemorrhage]] (SAH), [[intracerebral hemorrhage]] (ICH), or [[intraventricular hemorrhage]] (IVH) and [[traumatic brain injury]] (TBI). EVD was described as early as the 1950s
((Bogdahn U, Lau W, Hassel W, Gunreben G, Mertens HG, Brawanski A. Continuous-pressure controlled, external ventricular drainage for treatment of acute hydrocephalus--evaluation of risk factors. Neurosurgery. 1992;31(5):898-904. doi:10.1227/00006123-199211000-00011)).

===== Techniques =====

[[Ventricular drainage placement techniques]].

===== 🧠 Postoperative Imaging After Ventricular Catheter Placement =====

see [[Postoperative Imaging After Ventricular Catheter Placement]]

===== Complications =====

[[Ventricular catheter placement complications]].



===== Training =====

[[Ventricular catheter placement training]].


===== Experimental animal studies =====

Daniel et al. introduce a new [[concept]] of a [[cranial fixation device]] for [[insertion]] of EVDs, that reduces [[reliance]] on [[freehand]] [[placement]] and [[drilling]] techniques and provides a simple, [[minimally invasive]] [[approach]] that provides strong [[fixation]] to minimal thickness skulls.

An [[experimental]] device for [[catheter insertion]] and fixation was designed and tested in both ex-vivo and in-vivo conditions to assess accurate cannulation of the ventricle and to test the strength of fixation to the [[skull]]. The ex-vivo experiments were conducted at Ben-Gurion University of the Negev (BGU) in Be'er Sheva, [[Israel]]. These experiments included functionality bench testing and pullout force measurements for the ball mechanism and catheter fixation. For the in-vivo experiments the fixation device was initially tested at the Cincinnati Children's Hospital Medical Center (CCHMC) in Cincinnati, Ohio on one day of life 1 (DOL 1) male control [[lamb]]. Additional experiments were conducted on 3 hydrocephalic DOL 0 lambs (1 male 2 female) at the Jesús Usón Minimally Invasive Surgery Centre (JUMISC) in Caceres, Spain. The hydrocephalic [[animal model]] used for this study was created with in utero intracisternal injection of [[BioGlue]] in fetal lambs. The catheter insertion trajectory was determined using MR imaging to assess the device's impact on the placement accuracy. The fixation device was evaluated on reaching the ventricle and enabling extraction of CSF for all 7 fixations placed. For 5 of the fixation devices, post-mortem pullout force was measured. The general functionality of the device was also evaluated.

In the experiments, 7/7 (100%) catheter trajectories successfully reached the ventricle without any apparent complications related to the device or the procedure. The cranial fixation device base demonstrated significant strength in withstanding an average pull-out force of 4.18kgf (STD[Formula: see text]0.72, N = 5) without detachment from the subject's skull for all 5 devices included in this test. Additionally, the EVD catheter pull test was conducted with the addition of a safety loop which did not allow movement of the EVD to a force of 3.6kgf. At this force the catheter tore but did not release from its fixation point.

The newly designed experimental device demonstrates initial [[proof of concept]] from [[ex vivo]] and in vivo testing. It appears suitable for accurate ventricular catheter placement and cranial fixation
((Daniel A, Coronel M, Peer S, Grinshpan B, Duru S, Peiro JL, Leach JL, Abellán E, Doerning CM, Zarrouk D, Mangano FT. A novel minimally invasive neurosurgical cranial fixation device for improved accuracy of intraventricular catheter placement: an experimental animal study. Patient Saf Surg. 2024 Dec 18;18(1):36. doi: 10.1186/s13037-024-00420-0. PMID: 39696369.)).
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The experimental cranial fixation device by Daniel et al. shows promise as a minimally invasive, reliable, and accurate tool for EVD placement. The proof-of-concept data is encouraging, but the study’s limitations, particularly in sample size, long-term outcomes, and human applicability, highlight the need for further research. If validated through larger and more rigorous trials, the device has the potential to significantly improve neurosurgical care, particularly for vulnerable populations such as neonates and infants.
===== References =====