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Nathaniel L. Whitney and Nathan R. Selden

P lacing an external ventricular drain is one of the most basic and important procedures routinely performed by neurosurgeons. 2 , 4 When used in the care of pediatric neurosurgical patients, EVDs are typically left in place for several days. 6 During this time, patient movement and transport to and from procedures and imaging studies exposes the EVD to the risk of dislodgement or complete pullout. Additional morbidity and resource utilization may result from the need to replace dislodged EVD catheters, particularly with decompressed ventricles. 1

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Behzad Eftekhar

S everal techniques have been developed in the past to improve the accuracy of external ventricular drain (EVD) insertion. Jamshid Ghajar developed his guide to improve accuracy in 1985. 1 Neuronavigation has been applied to the insertion of EVDs and has increased the accuracy. However, due to the time and resources required for these techniques and the fact that the majority of EVD placements are done by postgraduate Year 1 and Year 2 medical officers in emergency situations, 2 these techniques are not commonly used. 4 The freehand technique for EVD

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George K. C. Wong and Wayne W. S. Poon

T o T he E ditor : We read with great interest the article by Lo and colleagues (Lo CH, Spelman D, Bailey M, Cooper DJ, Rosenfeld JV, Brecknell JE: External ventricular drain infections are independent of drain duration: an argument against elective revision. J Neurosurg 106: 378–383, March, 2007). We would like to congratulate the authors for carrying out this thoughtful analysis, which concurred with the results of our randomized controlled trial. 5 Our data concurred with the authors' results that elective EVD revision did not decrease the CSF

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Carlos Velásquez, Mónica Rivero-Garvía, Maria Jose Mayorga-Buiza, María de los Ángeles Cañizares-Méndez, Manuel E. Jiménez-Mejías, and Javier Márquez-Rivas

V entriculostomy , or external ventricular drainage, is among the most common procedures in neurosurgery practice. However, it is not exempt from complications. 6 , 7 Since its first description, it has been improved with several technical advances and safer protocols. 5 , 8 Additionally, complications from the procedure have been addressed in several papers, including reports on infection 2 , 4 and misplacement 3 , 9 as the most important. Despite the better understanding we have about external ventricular drains (EVDs) and the technical advances

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Griffin R. Baum, Kristopher G. Hooten, Dennis T. Lockney, Kyle M. Fargen, Nefize Turan, Gustavo Pradilla, Gregory J. A. Murad, Robert E. Harbaugh, Michael Glantz, and The EVD Best Practice Team

T he insertion of an external ventricular drain (EVD) is a standard procedure that is performed by every neurosurgeon across the world. An EVD can be lifesaving, with the therapeutic effect visible within minutes in patients with hydrocephalus or increased intracranial pressure. The insertion procedure can be performed by any neurosurgeon, from a well-trained intern to the most experienced professor. Without question, the insertion of the EVD is as close to a universal practice that will ever be seen in neurosurgery. As with any procedure, there are known risks

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James H. Manfield and Kenny K. H. Yu

the first dot on the image puncture line is approximately 7 mm (0.3 inch) with the distance between dots being 5 mm (0.2 inch). The guide channel is angled at 8° to the transducer’s image axis. C: Real-time tracking of the EVD following the dotted line as the drain is being inserted. Once the catheter is in the correct position, it is tunneled and secured. Discussion External ventricular drain insertion can be performed either freehand using surface landmarks or with the aid of image guidance such as neuronavigation or ultrasound. Our traditional practice

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Julia Champey, Clément Mourey, Gilles Francony, Patricia Pavese, Emmanuel Gay, Laurent Gergele, Romain Manet, Lionel Velly, Nicolas Bruder, and Jean-François Payen

monitoring technology . J Neurotrauma 24 ( Suppl 1 ): S45 – S54 , 2007 (Erratum in J Neurotrauma 25:276–278, 2008) 5 Camacho EF , Boszczowski I , Freire MP , Pinto FC , Guimaraes T , Teixeira MJ , : Impact of an educational intervention implanted in a neurological intensive care unit on rates of infection related to external ventricular drains . PLoS One 8 : e50708 , 2013 10.1371/journal.pone.0050708 6 Chan KH , Mann KS : Prolonged therapeutic external ventricular drainage: a prospective study . Neurosurgery 23 : 436 – 438 , 1988

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Catherine Miller and Daniel Guillaume

premature infants . Childs Nerv Syst 13 : 369 – 374 , 1997 10.1007/s003810050102 1641110 6 Forbes KP , Pipe JG , Heiserman JE : Diffusion-weighted imaging provides support for secondary neuronal damage from intraparenchymal hematoma . Neuroradiology 45 : 363 – 367 , 2003 10.1007/s00234-003-0995-z 16206972 7 Gardner PA , Engh J , Atteberry D , Moossy JJ : Hemorrhage rates after external ventricular drain placement . J Neurosurg 110 : 1021 – 1025 , 2009 10.3171/2008.9.JNS17661 7761015 8 Harbaugh RE , Saunders RL , Edwards WH

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Cheng H. Lo, Denis Spelman, Michael Bailey, D. James Cooper, Jeffrey V. Rosenfeld, and John E. Brecknell

, version 8.1, Cerner Corporation) and from patient records. For each patient we recorded age; sex; GCS score at presentation; underlying diagnosis; and the presence or absence of an open skull fracture, diabetes mellitus, and bacteremia within 14 days of EVD insertion. The outcome measure of death prior to discharge was also recorded. Insertion of EVDs External ventricular drains (TraumaCath ventricular catheter, Integra Neurosciences) were inserted using an aseptic technique usually via a frontal twist drill craniotomy; when placement occurred in the operating

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Paul A. Gardner, Johnathan Engh, Dave Atteberry, and John J. Moossy

E xternal ventricular drain placement has been a neurosurgical treatment for many decades. It is one of the most important and common emergency procedures in neurosurgery, largely because of its role as a critical tool in the management of multiple intracranial disorders. External ventricular drain placement is indicated in the monitoring and treatment of such diverse conditions as closed head injuries, posthemorrhagic hydrocephalus, obstructive hydrocephalus secondary to tumor, ventriculoperitoneal shunt infection, postoperative CSF leakage, prophylaxis