Non-assisted versus neuro-navigated and XperCT-guided external ventricular catheter placement: a comparative cadaver study

Background and purpose: Accurate placement of an external ventricular drain (EVD) for the treatment of hydrocephalus is of paramount importance for its functionality and in order to minimize morbidity and complications. The aim of this study was to compare two different drain insertion assistance tools with the traditional free-hand anatomical landmark method, and to measure efficacy, safety and precision. Methods: Ten cadaver heads were prepared by opening large bone windows centered on Kocher's points on both sides. Nineteen physicians, divided in two groups (trainees and board certified neurosurgeons) performed EVD insertions. The target for the ventricular drain tip was the ipsilateral foramen of Monro. Each participant inserted the external ventricular catheter in three different ways: 1) free-hand by anatomical landmarks, 2) neuronavigation-assisted (NN), and 3) XperCT-guided (XCT). The number of ventricular hits and dangerous trajectories; time to proceed; radiation exposure of patients and physicians; distance of the catheter tip to target and size of deviations projected in the orthogonal plans were measured and compared. Results: Insertion using XCT increased the probability of ventricular puncture from 69.2 to 90.2% (p = 0.02). Non-assisted placements were significantly less precise (catheter tip to target distance 14.3 ± 7.4mm versus 9.6 ± 7.2mm, p = 0.0003). The insertion time to proceed increased from 3.04 ± 2.06min. to 7.3 ± 3.6min. (p < 0.001). The X-ray exposure for XCT was 32.23mSv, but could be reduced to 13.9mSv if patients were initially imaged in the hybrid-operating suite. No supplementary radiation exposure is needed for NN if patients are imaged according to a navigation protocol initially. Conclusion: This ex vivo study demonstrates a significantly improved accuracy and safety using either NN or XCT-assisted methods. Therefore, efforts should be undertaken to implement these new technologies into daily clinical practice. However, the accura