# Comparison of Accuracy Between Image-Guided and Freehand External Ventricular Drain Bedside Placement in Association With Time Efficacy

## TL;DR

This study compares the accuracy and efficiency of using image guidance versus freehand techniques for placing external ventricular drains in neurosurgery.

## Contribution

The study demonstrates that image-guided EVD placement is more accurate and reduces the number of passes without increasing procedure time.

## Key findings

- Image-guided EVD placement resulted in 100% single-pass optimal placement compared to 73.5% for freehand.
- Procedural times were similar between image-guided and freehand techniques.
- Image guidance reduced the risk of suboptimal placement by 11.76% and multiple passes by 26.5%.

## Abstract

A common neurosurgical procedure is the placement of an external ventricular drain (EVD), often as a time-sensitive treatment for hydrocephalus and/or increased intracranial pressure. The etiology ranges from traumatic brain injury to spontaneous intracranial hemorrhages, frequently causing change to ventricular anatomy, making them difficult targets. The goal of this study was to determine whether the use of image-guidance for bedside EVD placement improves accuracy and decreases number of passes with the same time-effectiveness.

Adult patients with bedside EVD placement for traumatic brain injury or spontaneous intracranial hemorrhages between October 2021 and December 2023 were retrospectively reviewed and dichotomized by electromagnetic image-guided or freehand EVDs. The primary outcome was the rate of suboptimal placement (defined by Kakarla score). The secondary outcomes were rates of multipass EVDs and procedural time.

Of 44 patients included, median age was 59 years (IQR 44-66), and 59.1% were men. Median midline shift was different between image-guided (3.5 mm [IQR 1.5-6.3]) and freehand (0 mm [IQR 0-5]) EVDs (P = .0013). With image-guidance, 100% of cases were completed with one pass and optimally placed (Kakarla 1). With freehand placement, 73.5% of cases were completed with one pass, and 88.2% were optimally placed. Median procedural times were similar between image-guided (55 minutes [IQR 50-60]) and freehanded (60 minutes [IQR 48.8-89.3]) placement (P = .71). Attributable risk reduction for suboptimal placement with image guidance was 11.76%. For every 9 image-guided EVDs, 1 additional suboptimal EVD placement will be prevented (number needed to treat = 9). Attributable risk reduction for multiple passes with image guidance was 26.5%. For every 4 image-guided EVDs, 1 additional patient will avoid multiple passes for EVD placement (number needed to treat = 4).

Image guidance in bedside EVD placement does not require more time in comparison with freehand EVD placement and is associated with fewer passes and higher accuracy.