Pterion Prep CraniPro VUMC Case Prep
2026-06-27

Case Prep: External Ventricular Drain (EVD) Placement

Case / Approach Snapshot

One-Liner

[Age]yo [M/F] with [acute hydrocephalus / SAH / IVH / posterior fossa mass / TBI] presenting with [decreased consciousness / headache / CN VI palsy / upward gaze palsy] planned for emergent/urgent right frontal EVD placement.

Figures, Imaging & Video

🎥 Operative videos & resources

High-Yield Literature

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

External Ventricular Drain Placement — Fig. 1 Fig. 1. (A) The puncture position of M-EVD group. (B) The position of the drainage tube in the M-EVD group Source: Clinical characteristics and post-operative outcomes in children with purulent meningitis with hydrocephalus: 46 cases in a single center study — Italian Journal of Pediatrics 2025; CC BY-NC-ND.

External Ventricular Drain Placement — Figure 1: Figure 1:. 3D reconstruction of fractured skull. Source: Traumatic cerebrospinal fluid oculorrhea managed with an external ventricular drain — Journal of Surgical Case Reports 2018; CC BY-NC.

External Ventricular Drain Placement — Figure 2: Figure 2:. Right medial orbital wall fracture showing route of CSF leak. Source: Traumatic cerebrospinal fluid oculorrhea managed with an external ventricular drain — Journal of Surgical Case Reports 2018; CC BY-NC.

External Ventricular Drain Placement — Figure 1 Figure 1. Scoliosis standing X-ray shows significant positive balance with pronounced thoracic kyphosis (A). Sagittal CT without contrast show T12, L1, L2, and L3 compression fractures with severe… Source: Use of an External Ventricular Drain for Treatment of a Thoracolumbar Cerebrospinal Fluid Leak: A Case Report and Review of Literature — Cureus 2022; CC BY.

External Ventricular Drain Placement — Figure 2 Figure 2. Sagittal (A & B) and axial (C) pre-operative MRI show severe compression at the level of T12 and L1. Source: Use of an External Ventricular Drain for Treatment of a Thoracolumbar Cerebrospinal Fluid Leak: A Case Report and Review of Literature — Cureus 2022; CC BY.

External Ventricular Drain Placement — Figure 3 Figure 3. Post-operative X-rays show well-seated T9-L4 posterolateral instrumentation with cement augmentation. Source: Use of an External Ventricular Drain for Treatment of a Thoracolumbar Cerebrospinal Fluid Leak: A Case Report and Review of Literature — Cureus 2022; CC BY.

External Ventricular Drain Placement — Figure 4 Figure 4. Post-operative CT of the brain without contrast shows scattered subarachnoid blood with some layering on the lateral ventricles along with small amounts of pneumocephalus. Source: Use of an External Ventricular Drain for Treatment of a Thoracolumbar Cerebrospinal Fluid Leak: A Case Report and Review of Literature — Cureus 2022; CC BY.

External Ventricular Drain Placement — Figure 5 Figure 5. Coronal (A) and axial (B) CT of the brain without contrast showing proper placement of an external ventricular drain. Source: Use of an External Ventricular Drain for Treatment of a Thoracolumbar Cerebrospinal Fluid Leak: A Case Report and Review of Literature — Cureus 2022; CC BY.

External Ventricular Drain Placement — Fig 1 Fig 1. External ventricular drain (EVD) introduced posterior to retractors and left common carotid artery. Source: External ventricular drain as a nontraumatic suction device in carotid endarterectomy — Journal of Vascular Surgery Cases and Innovative Techniques 2017; CC BY-NC-ND.

External Ventricular Drain Placement — Fig 2 Fig 2. External ventricular drain (EVD) connected to regulated suction device. Source: External ventricular drain as a nontraumatic suction device in carotid endarterectomy — Journal of Vascular Surgery Cases and Innovative Techniques 2017; CC BY-NC-ND.

History of Present Illness

Imaging Review

CT Head

Labs

Surgical Planning

Case Logistics, OR Needs & Orders

Technique Selection

Kocher’s Point (Standard Right Frontal)

Key Surgical Steps

  1. Confirm indication and side — time-out
  2. Position: Supine, HOB 30 degrees, head neutral or slightly elevated
  3. Mark Kocher’s point: 11 cm posterior to nasion, 3 cm lateral to midline (right side)
    • Confirm: anterior to coronal suture (palpate)
    • Confirm: at or near mid-pupillary line
  4. Prep and drape — wide sterile field around the entry point
  5. Local anesthesia — 1% lidocaine with epinephrine at the scalp site (if bedside)
  6. Incision: Small stab incision (~2 cm) at Kocher’s point through skin and galea
  7. Drill: Twist drill or hand drill through the skull
    • Hold drill perpendicular to skull surface initially
    • “Give” is felt when inner table is penetrated — STOP advancing
  8. Coagulate and incise dura — with monopolar or #11 blade
  9. Insert catheter:
    • Pass ventricular catheter (stylet in) directed toward:
      • Ipsilateral medial canthus (coronal plane)
      • Ipsilateral tragus (sagittal plane)
    • Advance to 5-5.5 cm from the inner table of the skull (typical depth to reach frontal horn)
    • NEVER advance beyond 6-7 cm — risk of deep structure injury
    • Remove stylet — CSF should flow
    • If no CSF at 5.5 cm:
      • Withdraw catheter, redirect slightly
      • Do NOT make more than 3 passes (increases hemorrhage risk)
      • If failed: consider image-guided placement or contralateral attempt
  10. CSF return: Note color (clear, bloody, xanthochromic), opening pressure
  11. Tunnel catheter subcutaneously (~5 cm from the burr hole) to a separate exit site
  12. Connect to drainage system:
    • Calibrated drainage column
    • Set initial drainage level (typically 15-20 cm H2O above the tragus)
    • Zero the transducer at the level of the tragus (approximates foramen of Monro)
  13. Secure catheter — suture to scalp at entry and exit points
  14. Sterile dressing over all sites
  15. CT head post-procedure — confirm catheter tip position (ideally in frontal horn, near foramen of Monro)

Catheter Tip Target

Alternative Sites

Critical Anatomy & Structures at Risk

  1. Eloquent cortex — frontal lobe at entry site (Kocher’s point is chosen to avoid motor cortex)
  2. Superior sagittal sinus — entry point must be > 2 cm lateral to midline
  3. Motor cortex (precentral gyrus) — posterior to Kocher’s point; do not place too posteriorly
  4. Caudate nucleus / thalamus — if catheter advanced too deep
  5. Choroid plexus — can occlude catheter
  6. Cortical vessels — at entry site; cannot be avoided, but small caliber usually

Equipment

Potential Complications

  1. Hemorrhage — intracerebral or intraventricular (~5%); limit to <= 3 passes; correct coagulopathy
  2. Misplacement — parenchymal, extra-ventricular; CT confirms position
  3. Infection (ventriculitis) — 5-10% risk; decreases with tunneling, antibiotic-coated catheters, strict sterile technique
  4. Overdrainage — collapsed ventricles, subdural hematoma, upward herniation (posterior fossa mass); set appropriate drainage height
  5. Catheter obstruction — blood, debris, choroid plexus; may need flushing or replacement
  6. Pneumocephalus — from open drainage system; keep system closed

Operative Note Template

Preoperative Diagnosis: [Acute hydrocephalus / SAH with hydrocephalus / IVH / TBI requiring ICP monitoring]

Postoperative Diagnosis: Same

Procedure: Right frontal external ventricular drain placement via Kocher’s point

Surgeon: Anesthesia: [General / MAC / local with sedation]

EBL: Minimal Fluids: Drains: Right frontal EVD Complications: None

Indications: The patient is a [age]yo [M/F] with [indication] and CT head demonstrating [findings including ventricular enlargement]. An EVD was indicated for [CSF diversion / ICP monitoring / both].

Description of Procedure: After informed consent [was obtained / was waived due to emergent nature], a time-out was performed. The patient was positioned supine with the head of bed at 30 degrees and the head in neutral position. Kocher’s point was marked on the right side at 11 cm posterior to the nasion and 3 cm lateral to midline, confirmed to be anterior to the coronal suture and at the mid-pupillary line.

The right frontal region was prepped and draped in sterile fashion. [Local anesthesia was administered.] A [2 cm] incision was made at Kocher’s point. A twist drill hole was created perpendicular to the skull surface. The dura was coagulated and incised.

The ventricular catheter with stylet was passed aiming toward the ipsilateral medial canthus in the coronal plane and the ipsilateral tragus in the sagittal plane. CSF was obtained at a depth of [__] cm from the inner table. The stylet was removed. [Opening pressure was __ cm H2O.] [CSF appeared clear/bloody/xanthochromic.]

The catheter was tunneled subcutaneously [5 cm] from the burr hole and secured at both the entry and exit sites with 2-0 [silk/nylon] sutures. The catheter was connected to the external drainage system and set to drain at [15-20] cm H2O above the tragus. A sterile dressing was applied.

Postoperative: CT head obtained to confirm catheter tip position [in the right frontal horn / at the foramen of Monro]. ICP was noted to be [___] mmHg.

Postoperative Plan / EVD Management

Chief-Level Case Review

Use these as the senior-level mental model for External Ventricular Drain (EVD) Placement:

Common Pimp Questions

Use these to pressure-test preparation for External Ventricular Drain (EVD) Placement:

  1. What is the working CSF physiology problem: obstruction, absorption failure, overdrainage, infection, or catheter failure?
  2. Where exactly is the entry point, target, and backup trajectory?
  3. What valve, catheter, endoscope, or navigation preference does the attending use?
  4. What is the infection-prevention plan and what cultures/CSF studies are needed?
  5. What postop imaging, valve setting, drainage level, and neuro-check plan should be written?

Attending Preference Variables

Items that commonly vary by surgeon or institution: