Medical Student Penn State College of Medicine Hershey, Pennsylvania, United States
Introduction: External ventricular drain (EVD) placement is the most common lifesaving neurosurgical procedure. Freehand insertion, which approximates anatomical landmarks to achieve percutaneous lateral ventricle access, bodes a complication risk as high as 40%. Neuronavigation is widely used for neurosurgical procedures; however, its use for EVD has been inadequately explored. We hypothesize that neuronavigation-guided EVD insertion will increase accuracy and decrease associated morbidity.
Methods: This single-institution retrospective cohort study included all EVD procedures performed from 2021-2022. Electronic medical records were reviewed for operative details, neuroimaging findings, and clinical status. Primary outcomes were malposition and number of passes for ventricular access. Secondary outcomes included postoperative ventricular enlargement, hemorrhage, and edema. Outcomes were compared using risk ratios (RR; 95% CI) and independent t-tests.
Results: Forty-seven patients with a total of 49 EVDs were included in this study. Seventeen were inserted with neuronavigation and 32 were inserted freehand, all placed by neurosurgical trainees. Patients were predominantly male (63.3%), white (73.5%), and adults (69.4%). EVD indications included hemorrhage (53.1%), tumor (30.6%), infection (8.2%), and others (8.2%). Malposition was observed in 1 (5.9%) patient in the neuronavigation group compared to 6 (18.8%) in the freehand group (RR, 1.16; 0.94-1.42). Average number of passes was lower in the neuronavigation cohort compared to the freehand cohort (mean[SD]; 1[0] vs. 1.29[0.99]; p=0.16). On post-operative neuroimaging, ventricular enlargement was seen in 1 (5.9%) patient in the neuronavigation cohort, compared to 3 (9.4%) in the freehand cohort (RR, 0.59; 0.67-5.29). Frequencies of new, post-operative hemorrhage (5.9% vs. 18.8%; RR, 0.31; 0.04-2.40) and edema (0% vs. 6.3%) were both lower with neuronavigation. Finally, 30-day mortality was lower with neuronavigation (5.9% vs. 25%; RR, 0.24; 0.032-1.73).
Conclusion : Neuronavigation-guided external ventriculostomy offers a promising, accessible, and bedside-ready approach to minimize morbidity and mortality. Neuronavigation may also help trainees achieve safe and reliable access, while honing technical excellence.
