Proposed Simple, Efficient Free Hand Technique for Frontal External Ventricular Drain (EVD) in Case of Small Ventricle: A Report of New Technique

摘要

Background: EVD is a common procedure done in neurosurgery and the residents should master it and this is what exactly means that it should be simple, safe, fast and accurate. EVD can be done through many entry points to the different part of the lateral ventricle but the famous site is the anterior horn of the lateral ventricle which is commonly approached through Kocher’s point which is a famous point for all neurosurgeon by its measurements of allocation. The commonest problem with EVD insertion into the anterior horn is the navigation of the ventricular cavity with the right trajectory and so the location of the catheter tip in the right place near the foramen of monro to ensure CSF draining. Size of the ventricle plays significant role in the success of the procedure especially free hand technique. The more dilated ventricle, the more chance to hit the ventricular cavity especially from the first trial and vice versa. In case of small ventricle, the procedure with free hand technique seems more complicated and the chance to hit the ventricle from the first trial may reduce especially with non-expert surgeon but may succeed in the following trials with increased risk of complications with more trials. Purpose: Most EVD’s are placed with freehand technique which depends on the operator skills to navigate the ventricle with right trajectory and hit the ventricle from the first trial, because many trials may complicate the procedure and produce undesirable side effects. So the key in this free hand technique is how to ensure the success from the first trial. In case of small anterior horn of the lateral ventricle, the procedure is even more difficult with the free hand technique and the classic Kocher point needs an expert to get the right trajectory to navigate such small ventricle. Our point idea came from this prospective and aimed at raising the success of the procedure especially in the first attempt with simple technique. Method: It is a new entry point for EVD insertion through frontal burr hole gained by the intersection of two lines: the first is running vertically from the ipsilateral medial canthus downward and the second is running horizontal along the coronal suture which is usually palpable as ridge on the scalp extended lateral from the bregma. Burr hole is done just anterior to this intersection and catheter is placed in a perpendicular trajectory toward the ventricular cavity. Result: It has been used in about (n = 50 cases) fulfilling the criteria of radiological small ventricle as defined and they were candidates for EVD insertion by free hand technique. Only 3 cases (6%) out of the 50 cases failed in the first attempt but succeeded in the following trial. So high rate of success in first trial is seen in the most of cases using this technique during a period of one year of our practice without significant side effects seen. Conclusion: Our study is not conclusive and needs further studies for more evaluation. It was a suggested point other than the classic Kocher point in case of free hand EVD insertion in small ventricle. We recommend to try it and report any advantages or disadvantages to the literature.