Ventriculostomy is one of the most common emergency based neurosurgical procedures practitioners undertake globally. The first attempt was by Claude-Nicolas Le Cat, a French anatomist. Ingraham later advocated the application of a closed draining system to minimize the infective complications.
Herophilus and Erasistratus were the first to provide the anatomical depiction of the ventricular system inside the brain. Later, Domenico Felice Antonio Cotugno described the presence of cerebrospinal fluid (CSF) within this interconnecting system.
The ventricular system develops from the cavities within the developing brain vesicles. The cavity of the rhombencephalon later forms the fourth ventricle, whereas the cavity of the diencephalon forms the third ventricle, and those of the telencephalon develop into the lateral ventricles. The cavity within the mesencephalon forms the aqueduct connecting third to the fourth ventricles.
The contraindications for ventriculostomy include :
Basic equipment sets should include the following :
A composite healthcare team comprised of :
The patient and next of kin/relatives should receive a thorough explanation regarding the indication for the procedure and the risks involved before the procedure, and written consent obtained.
Strict adherence to aseptic guidelines is a cornerstone in preventing the risk of infection and prophylactic antibiotic needs to be administered just at the beginning of the procedure.
The meticulous technique is pivotal in minimizing procedure-related complications. The patient should be well sedated, assuring patency of his airway, and local anesthetic administered at the allocated point of ventriculostomy.
The insertion of the device is aided with the placement of either a burr hole or a twist drill technique. Kocher's point is the choice for the ventriculostomy. Other points of ventricular puncture include.
Computed tomogram based grading system has been developed to assess the accuracy of the placement of ventricular catheters.
Ghajar first introduced a ventricular catheter guide for optimizing trajectory during ventriculostomy. He advocated a perpendicular trajectory relative to the skull surface.
However, the calvarial slope obviates this trajectory, especially in the coronal plane. The accuracy for the ideal placement of the ventricular tip is around 86%. Furthermore, only 3.1% of the catheters were found to be nonfunctional and requiring a replacement or reposition. The accuracy can undergo further improvement along with the application of ultrasonogram, endoscopy, neuronavigation, and adjustable Ghajar guide technique.
The complications include :
Ventricular catheters represent a “global” ICP with minimal chances of drift and influence from pressure gradients between parenchyma and ventricular system.
It is the most reliable method of achieving maximum accuracy at minimal expense. There are added therapeutic benefits of CSF drainage, instilling medications like antibiotics and thrombolytic agents.
The advantage of the ventricular monitoring device is the facility for egress of CSF in cases of a sustained rise in ICP (greater than or equal to 20 mm Hg for 5 minutes or longer), but the disadvantage is that simultaneous monitoring, as well as CSF drainage, is not possible. The amount of CSF to be drained can be guided as per the recommended target ICP (commonly set as 10 mm Hg) or can be aided with the visual guidance in the improvement in the ICP waveform analysis obtained from the concurrent application of intraparenchymal monitors or through clinical neurological examination. Care always needs to be taken in preventing paradoxical upward transtentorial herniation due to overzealous drainage of CSF.
EVD can be removed once the ICP is normalized with sustained or improved clinical neurology (motor score at least 5) for at least 48 to 72 hours without the use of any interventions by clamping, or more ideally gradual increment in its height (training of the EVD) is attained to watch for any clinical deterioration in the patient for at least 48 hours.
Strict aseptic precautions and care also need to be implemented during its removal as well. The head end should be lowered down to prevent the risk of pneumocephalus and pneumoventriculi. The tip of the catheter can be sent for bacteriological analysis in cases of persisting fever with features of meningitis. The wound is closed in layers to minimize the risk of CSF leak and infection. The patient should receive close monitoring for any signs of clinical deterioration for at least 24 hours with all preparations made for the emergency placement of a new EVD set.
To ensure better clinical outcome and to prioritize patient safety by minimizing complications, there need to be mandatory patient safety checklists to be implemented by the interprofessional team involved in the process. Following guidelines has to be adhered to :
Monitoring of intracranial pressure requires an interprofessional team approach, including physicians, specialists, and specialty-trained nurses, all collaborating across disciplines to achieve optimal patient results. Obviously, surgically-trained nurses will play a significant role in the procedure, assisting and monitoring for the surgeon performing the procedure. Deviation from these standards can result in life-threatening complications. Open communication between the interprofessional team is necessary so that the procedure achieves optimal outcomes safely. [Level V]
The nurses involved in patient care should monitor the following: 
There needs to be a strict provision of following checklists.
Maintaining a sterile environment, and stringent monitoring for foreseeing and timely troubleshooting of complications are the cornerstones in the care bundle approach in managing these patients.
|||Kohli G,Singh R,Herschman Y,Mammis A, Infection Incidence Associated with External Ventriculostomy Placement: A Comparison of Outcomes in the Emergency Department, Intensive Care Unit, and Operating Room. World neurosurgery. 2018 Feb; [PubMed PMID: 29097331]|
|||Missori P,Paolini S,Domenicucci M, The origin of the cannula for ventriculostomy in pediatric hydrocephalus. Journal of neurosurgery. Pediatrics. 2011 Mar [PubMed PMID: 21361770]|
|||Mortazavi MM,Adeeb N,Griessenauer CJ,Sheikh H,Shahidi S,Tubbs RI,Tubbs RS, The ventricular system of the brain: a comprehensive review of its history, anatomy, histology, embryology, and surgical considerations. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery. 2014 Jan; [PubMed PMID: 24240520]|
|||Lele AV,Hoefnagel AL,Schloemerkemper N,Wyler DA,Chaikittisilpa N,Vavilala MS,Naik BI,Williams JH,Venkat Raghavan L,Koerner IP, Perioperative Management of Adult Patients With External Ventricular and Lumbar Drains: Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. Journal of neurosurgical anesthesiology. 2017 Jul; [PubMed PMID: 28169966]|
|||M Das J,Zito PM, Nimodipine . 2019 Jan [PubMed PMID: 30521291]|
|||Munakomi S,M Das J, Intracranial Pressure Monitoring 2019 Jan; [PubMed PMID: 31194438]|
|||Tse Ts,Cheng K,Wong K,Pang K,Wong C, Ventriculostomy and Infection: A 4-year-review in a local hospital. Surgical neurology international. 2010 Sep 9; [PubMed PMID: 20975968]|
|||Yoon SY,Kwak Y,Park J, Adjustable Ghajar Guide Technique for Accurate Placement of Ventricular Catheters: A Pilot Study. Journal of Korean Neurosurgical Society. 2017 Sep; [PubMed PMID: 28881125]|
|||Ghajar JB, A guide for ventricular catheter placement. Technical note. Journal of neurosurgery. 1985 Dec; [PubMed PMID: 4056916]|
|||Thomale UW,Schaumann A,Stockhammer F,Giese H,Schuster D,Kästner S,Ahmadi AS,Polemikos M,Bock HC,Gölz L,Lemcke J,Hermann E,Schuhmann MU,Beez T,Fritsch M,Orakcioglu B,Vajkoczy P,Rohde V,Bohner G, GAVCA Study: Randomized, Multicenter Trial to Evaluate the Quality of Ventricular Catheter Placement with a Mobile Health Assisted Guidance Technique. Neurosurgery. 2018 Aug 1; [PubMed PMID: 28973670]|
|||Hsieh CT,Chen GJ,Ma HI,Chang CF,Cheng CM,Su YH,Ju DT,Hsia CC,Chen YH,Wu HY,Liu MY, The misplacement of external ventricular drain by freehand method in emergent neurosurgery. Acta neurologica Belgica. 2011 Mar; [PubMed PMID: 21510229]|
|||Manfield JH,Yu KKH, Real-time ultrasound-guided external ventricular drain placement: technical note. Neurosurgical focus. 2017 Nov; [PubMed PMID: 29088955]|
|||Gardner PA,Engh J,Atteberry D,Moossy JJ, Hemorrhage rates after external ventricular drain placement. Journal of neurosurgery. 2009 May; [PubMed PMID: 19199471]|
|||Huyette DR,Turnbow BJ,Kaufman C,Vaslow DF,Whiting BB,Oh MY, Accuracy of the freehand pass technique for ventriculostomy catheter placement: retrospective assessment using computed tomography scans. Journal of neurosurgery. 2008 Jan; [PubMed PMID: 18173315]|
|||Whitehead WE,Riva-Cambrin J,Kulkarni AV,Wellons JC 3rd,Rozzelle CJ,Tamber MS,Limbrick DD Jr,Browd SR,Naftel RP,Shannon CN,Simon TD,Holubkov R,Illner A,Cochrane DD,Drake JM,Luerssen TG,Oakes WJ,Kestle JR, Ventricular catheter entry site and not catheter tip location predicts shunt survival: a secondary analysis of 3 large pediatric hydrocephalus studies. Journal of neurosurgery. Pediatrics. 2017 Feb; [PubMed PMID: 27813457]|
|||Kraemer MR,Koueik J,Rebsamen S,Hsu DA,Salamat MS,Luo S,Saleh S,Bragg TM,Iskandar BJ, Overdrainage-related ependymal bands: a postulated cause of proximal shunt obstruction. Journal of neurosurgery. Pediatrics. 2018 Nov 1; [PubMed PMID: 30117791]|
|||Muralidharan R, External ventricular drains: Management and complications. Surgical neurology international. 2015; [PubMed PMID: 26069848]|