External Ventricular Drainage (Ventriculostomy) placement  
Pitman Mbabazi, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
External Ventricular Drainage is placement 
of a closed system for drainage of cerebrospinal 
fluid. It involves a catheter placed into the lateral 
cerebral ventricle, connected to an external 
collecting system. It can be used in cases of raised 
intracranial pressure including but not limited to intra 
ventricular hemorrhage, meningitis, hydrocephalus, 
and traumatic brain injury.  The procedure requires a 
drainage set. The Chhabra system, available from 
Surgiwear 
(http://www.surgiwear.co.in) 
is 
an 
example of a system that is commonly used in low-
resource settings. Also required are a Hudson Brace 
or electrical craniotome, a leveling device (also 
called a precision spirit leveler,) and the standard 
drapes.  
The procedure is usually performed under 
general anesthesia. However, depending on the 
prevailing patient status, it can be performed under 
local anesthesia with or without sedation.  
Confirm that all the components of the 
system are available and functional beforehand. 
Flush the catheter and ensure it has a seamless flow. 
 
Ventricular drainage kit containing a catheter and stylet 
(Yellow circle) and a 3-way stopcock (Red circle) to be used as 
described below. Source: 
http://www.surgiwear.co.in/files/index/download/id/14557907
51  
 
 
External ventricular drain placement can be 
divided into three major steps.  
● Site location and burr hole placement.  
● Placement of ventricular catheter.  
● System set up and closure. 
 
Steps: 
1. With the right patient, review of the CT scan 
images is key to plan for the catheter placement 
site. The EVD catheter is commonly placed in the 
anterior horn of the lateral ventricle via Kocher’s 
point, or the posterior horn of the lateral ventricle 
via an occipital entry point. 
 
Axial CT scan images showing a large right intraventricular 
hemorrhage in a patient with longstanding untreated 
hypertension. We chose to place a drain into the anterior horn 
of the left ventricle, bearing in mind that the left ventricle was 
compressed by the hemorrhage on the right.  
 
2. With patient in supine position, a head ring is 
used to stabilize the head, land marks are clearly 
labelled. Kocher’s point is located as shown in 
the image below: its is located about 2cm anterior 
to the coronal suture, 2-3cm lateral to the midline 
in the sagittal plane. Also, an intersection 
between a line though the mid-pupillary line and 
a line 2cm anterior to the tragus is an acceptable 
landmark of entry.  
External Ventricular Drainage (Ventriculostomy) placement  
Pitman Mbabazi, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The coronal suture is usually palpable through the scalp, 
especially if the head is shaved or the hair is thin. Sometimes, 
by positioning the overhead light exactly right, it can be seen 
as a shadow on the scalp, as in this photo (Black arrow.) This 
is a 4 year old child with longstanding hydrocephalus; even in 
children with enlarged heads, the landmarks described here 
still apply.  
 
 
As  shown here, a vertical line can be drawn from 2cm anterior 
to the tragus or external auditory meatus. This line will very 
nearly intersect with the coronal suture (Black arrow.) If you 
can not palpate the coronal suture, draw this line and use it as 
described in the next picture. Be sure to find the coronal suture 
after incising the scalp if you use this technique. 
 
 
A line extending posteriorly along the midline from the nose is 
drawn. A line passing through the pupil, parallel to the midline, 
is then drawn. A point 2cm anterior to where the mid-pupillary 
line crosses the coronal suture is then shown (marked by an 
“X” in this photo.) 
 
3. The right side is usually the preferred side of 
placement however, the contra-lateral side is 
acceptable depending on the circumstances.  
 
Another view of a line extending posteriorly from the glabella 
(just above the “bridge” of the nose) and another line passing 
through the mid-pupillary line, parallel to the midline. The 
surgeon is palpating the coronal suture with an index finger.  
 
External Ventricular Drainage (Ventriculostomy) placement  
Pitman Mbabazi, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Having drawn another dotted line along the coronal suture, the 
surgeon then marks the incision so that the burrhole will be 2 
cm anterior to the coronal suture. Use betadine rather than 
alcohol-chlorhexidine for sterile preparation so that the line 
remains visible. 
 
4. Standard draping is done with aseptic technique. 
Infiltrate local anesthetic agent with epinephrine 
the planned incision site 
 
Injecting epinephrine-containing anesthetic into the planned 
incision: the sooner this is done before the actual incision, the 
less bleeding there will be.  
 
An “amateur” neurosurgeon is wise to drape in such a way that 
the eyebrow and the upper earlobe can be seen, to make 
orientation more obvious. This is especially true if the 
previously made marks are washed away by the preparation 
solution.  
 
5. The surgeon and assistant stand at the head of the 
patient. A 3-4 cm longitudinal incision is made at 
the 
Kocher’s 
point 
through 
skin 
and 
subcutaneous tissues. Complete the incision to 
the bone with a diathermy to minimize bleeding 
from the scalp vessels. At this point, confirm that 
you are anterior to the coronal suture.  
6. A periosteal elevator is used to adequately dissect 
the periosteum off the bone. It is paramount to 
locate the coronal suture line and be sure the 
burrhole is anterior to it. Then a self retaining 
(such as Weitlaner) retractor is placed to 
maintain exposure.   
 
External Ventricular Drainage (Ventriculostomy) placement  
Pitman Mbabazi, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
After incision through the skin, galea, and pericranium, the 
pericranium is elevated with a periosteal elevator. Palpate the 
coronal suture and make sure your burrhole will be 2 cm in 
front of it. Place a self-retaining retractor to hold all these 
layers out of the way.  
 
7. The site placement is located and marked 2-3 cm 
anterior to the suture line. A burr-hole is drilled 
(see Burrhole Craniostomy.)  
 
As shown here, the table is lowered to about the level of the 
surgeon’s waist. An assistant then steadies the head while the 
surgeon makes the burrhole with the Hudson brace. Continuous 
slow irrigation with normal saline prevents the bone from 
overheating. Check the depth periodically to make sure you are 
not in danger of plunging the perforator through the bone into 
the brain.  
 
 
Occasionally the bit will pass through a venous sinus within the 
bone. If this occurs, use a small (Penfield) elevator to apply 
sterile bone wax to the area of bleeding. If you do not have a 
small elevator, use the opposite end of a small forceps, as 
shown here.  
 
8. Once the dura is visible, confirm that your dural 
incision will not lacerate a blood vessel and make 
a cruciate incision in the dura, being careful not 
to damage the brain underneath.  
 
After the burrhole is made, use a small scalpel blade to make a 
cruciate incision in the dura. Be careful to cut only the dura, as 
the brain will be very close underneath it, especially if 
intracranial pressure is elevated.  
 
9. The catheter is held perpendicular to the skull in 
all planes. Verify that there is a perfect 90 degree 
angle between the catheter and the skull before 
advancing it. It is then advanced through cerebral 
tissue until a “give” or “a pop” is felt as it 
perforates the ventricular wall. Usually this 
occurs when the catheter is at 5 to 7 cm into the 
brain parenchyma. At this time backflow of CSF 
is noted through the catheter, around the stylet. 
Advance the catheter gently over the stylet no 
more than 1cm. Then the stylet is carefully 
removed while holding the catheter at its current 
depth. Opening pressures can be measured if 
indicated or CSF samples collected if necessary.  
External Ventricular Drainage (Ventriculostomy) placement  
Pitman Mbabazi, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Detail of the tip of the catheter with the stylet inside. When the 
catheter is held properly, with some tension on the stylet, the tip 
of the stylet is contained within the tip of the catheter. If the 
catheter and stylet are not held properly (inset,) the stylet can 
come out of one of the side holes of the catheter and cause 
damage. 
 
 
Hold the catheter and stylet as shown, with the index finger 
keeping gentle pressure on the stylet while the thumb and other 
fingers pull the catheter upwards as you advance it.  
 
 
When the catheter enters the ventricle, a small amount of fluid 
should come through the catheter around the stylet. Advance 
the catheter about 1cm without withdrawing the stylet, then 
remove the stylet without allowing the catheter to move. You 
should then get clear or slightly bloody cerebrospinal fluid 
through the catheter. If fluid does not come out, gently pull the 
catheter back, about 3-5mm at a time, until fluid comes out. 
Repeat catheter insertion if necessary.  
 
10. The catheter is tunneled under the skin and 
exteriorized 3-4cm from the incision site. The 
ventricular system is anchored to skin with a non 
absorbable suture and connected to the drainage 
system. Confirm CSF flow before closure.  
 
Using the provided trocar, the catheter is passed under the 
galea and skin to exit separate from the incision site.  
 
11. The incision is closed in layers: galea with 
absorbable 2-0 suture and Nylon 1 for skin. 
Avoid entrapping the catheter in the suture and 
check again for flow after closure.  
External Ventricular Drainage (Ventriculostomy) placement  
Pitman Mbabazi, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
A view of the wound before closure, showing the catheter just 
deep to the galea and skin. Take care not to entrap the catheter 
the sutures as you close. Recheck flow after wound closure.  
 
12. Secure the drain to the skin well, preferably in 
three places. Insert a 3-way stopcock to allow the 
drain to be closed later, or aspirated and irrigated 
(using strict sterile technique.) Check the flow 
again after securing the drain. Loosen and redo 
any suture that constricts the tubing. 
 
The drain is secured in several places. Note that a 3-way 
stopcock should be inserted in between the catheter and the 
tubing, in the area indicated by the Red circle. This allows you 
to gently flush and aspirate the catheter, under sterile 
conditions, to unblock it if necessary.  
 
13. Nurse the patient with awareness of the drip 
chamber of the collecting system. The drip 
chamber functions as the level of the drainage, as 
follows:  
● Initially, keep the tubing open and the drip 
chamber at the same level as the tragus of the 
patient’s ear. Use the precision spirit leveler 
to obtain the zero position relative to the 
patient's ear. 
● Alternatively, measure intracranial pressure 
by placing the bottom of the ruler at the level 
of the tragus and raising the drip chamber to 
the level where fluid no longer comes out. It 
is also possible to raise the drip chamber to a 
level less than 20, to maintain intracranial 
pressure in this range while avoiding 
overdrainage. 
● As the patient improves and no longer 
requires ventricular drainage, clamp the tube 
intermittently using the stopcock. One 
technique is to open it for 10 minutes every 6 
hours. If the patient deteriorates, return it to 
continuously open. If the patient remains 
stable and the output is minimal, the catheter 
can be removed.  
 
A ventricular drain collecting system with the ruler set up 
vertically, with “zero” at the level of the tragus of the patient’s 
ear. The drip chamber can be raised and lowered as described 
above. Source: Rmosler2100, CC BY-SA 3.0 via Wikimedia 
Commons 
 
External Ventricular Drainage (Ventriculostomy) placement  
Pitman Mbabazi, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Pitfalls 
● Bleeding from the scalp can be remarkable, 
hence precise hemostasis should be achieved. 
Placement of a self-retaining (Weitlaner) 
retractor can tamponade the bleeding vessels.  
● Injury to the premotor or motor cortex: assuring 
that the burrhole is placed anterior to the coronal 
suture assures that the catheter will pass into the 
anterior portion of the frontal lobe.  
 
Illustration of the left cerebral cortex, demonstrating the motor 
(Red) and premotor (Pink) cortexes. Place the burrhole 
anterior to the coronal suture, to assure that the catheter passes 
through the frontal lobe and damage to cerebral motor 
structures is avoided. 
 
● Failure to cannulate the ventricle. Avoid over 
advancing the catheter beyond 8-9cm. If there is 
no CSF flow, withdraw the catheter and adjust 
the angle of approach.  If the first attempt, 
perpendicular to the skull, does not succeed, on 
the second attempt aim towards the medial 
canthus of the contralateral eye.  
● Blockage of the catheter: this is more likely with 
bloody fluid. If a catheter stops working, either 
immediately after insertion or later on in the 
ward, try to gently irrigate  it with sterile saline 
and then aspirate it. If fluid enters but does not 
exit, the catheter may be blocked, or it may be 
malpositioned. If you are not able to dislodge it 
and the patient still needs ventricular drainage, 
you must place a new one. This should be done 
in the operating room, under sterile conditions. If 
catheter infection is not suspected, place the new 
drain through the same burrhole. Alternatively, 
make a new burrhole on the contralateral side.  
● Overdrainage: if the drip chamber, or the entire 
collecting system, is left below the level of the 
patient’s head for a long time, it can overdrain the 
cerebrospinal fluid. Severe headache will result. 
Return the drip chamber to the proper level and 
allow the fluid to reaccumulate.  
● There is a very high risk of dislodging: ensure the 
catheter is anchored to the skin appropriately and 
be careful when shifting or transporting the 
patient.  
 
Pitman Mbabazi, MBChB FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
March 2023 
