Strategic Placement of Bedside Ventriculostomies Using Ultrasound Image Guidance: Report of three Cases

Abstract

The blind free-hand technique for external ventricular drain (EVD) placement sometimes requires multiple attempts, and catheter location is often less than ideal. Our institution has adapted an intraoperative ultrasound-guided ventriculostomy technique for the placement of EVDs at the bedside. Our experience with ultrasound at the bedside has proven to be invaluable in certain circumstances. We present three cases of strategic EVD catheter trajectories that were made possible at the bedside with the use of ultrasound. Illustrative cases were chosen from a larger prospective study investigating the ultrasound-guided EVD technique. A portable ultrasound with a "burr hole" probe was used with modification of the standard surgical technique for placement of EVDs at the bedside. Case 1 describes an unexpected re-hemorrhage that was first realized by the ultrasound image obtained during the bedside EVD placement procedure. The catheter was purposefully directed across midline to the more prominent ventricle on the contralateral side based on this real-time finding. Case 2 describes how ultrasound was used to salvage the failed free-hand procedure and cannulate an extremely small ventricular space at the bedside. Case 3 describes an unconventionally placed burr hole that provided a customized trajectory in which the EVD catheter was placed just laterally and inferior to a large frontal hematoma. Ultrasound-guided bedside EVD placement allows EVD trajectories to be customized based on real-time information to accommodate for distorted and dynamic anatomy of the brain and its ventricles.