**4. Ventriculostomy procedure**

By diverting the CSF often kept in the ventricular system, a ventriculostomy decompresses the spaces and makes it easier for ICP to return to normal. In this treatment, the ventricle is reached by guiding a flexible silastic catheter through the brain parenchyma using a hard internal stylet [16] (**Figure 2**).

In about 10–40% of cases, there are recorded complications of ventriculostomy such as bleeding and unintentional insertion in brain tissue. In order to increase the precision and effectiveness of placement, technical advancements utilizing computed tomography (CT), ultrasound, endoscopy, and stereotactic neuronavigation have been made [2]. The incidence rate of these complications thus necessities a rigorous procedure for higher efficiency.

**Equipment** to include in the basic tool set include: Non-sterile gloves, soap, a brush, a towel, a razor, and a marker pen to prepare the components and mark the location where the monitor devices will be placed. A face mask, sterile gloves and

**Figure 2.** *Closed external ventricular device.*

gown, antiseptic solution, drape, local anesthetic, 5-ml syringe, 15- or 11-number surgical blade, and ICP monitoring kit are required for the treatment itself. According to the techniques, a drill with a drill bit, a bolt, an ICP sensor, and a transducer, an aseptic dressing and suture material will be necessary.

A multidisciplinary medical team comprising of:

The brain surgeon (Neurosurgeon),

A competent assistant,

A nurse practitioner,

An anesthetist and.

A general assistance [17].

For the **procedure**, the patient is kept in the supine position with the head of the bed elevated at a 45-degree angle. It could be necessary to shave some hair with the

**Figure 3.** *(a and b) Main approaches and their trajectories for ventriculostomy.*

#### *Ventriculostomy DOI: http://dx.doi.org/10.5772/intechopen.111764*

aid of the razor and the area sterilized before the procedure. Given that it is not the dominant hemisphere for language function in >90% of patients, the right frontal cerebral hemisphere is the recommended site of entry. The reference point is that of Kocher which is located at 1–2 cm in front of the mid pupillary line's coronal suture, 11 cm behind the glabella, 3–4 cm to the side of the midline ipsilateral medial canthus, and a line going coronally from the ipsilateral tragus. The superior sagittal sinus and the motor strip of the frontal brain are avoided at this point. Other points include Keen's point which is 2.5–3 cm above the ear pinna and 2.5–3 cm posterior, Dandy's point: 2 cm laterally and 3 cm above the inion, Frazier's point: 4 cm laterally and 6 cm above the inion, Paine's point: the point of an isosceles triangle, whose two limbs each measure 2.5 cm and whose base is located along the Sylvian veins, and Tubbs' point: The trajectory points 45 degrees away from a horizontal line and 15–20 degrees medial to a vertical line, passing through the top of the orbit at a location just medial to the mid papillary point [2–4].

On the scalp, a 2 cm-tall incision is made that may be straight or horseshoe-shaped after local anesthetic has been given (**Figure 3**).

The twist drill is used to enter the skull along the path chosen for ventricular cannulation. The ventricular catheter is primed and advanced no further than 7 cm, aiming in the anteroposterior plane at a spot 1.5 cm anterior to the ipsilateral tragus, toward the ipsilateral Foramen of Monro, and in the coronal plane toward the medial canthus of the contralateral eye. After the catheter stylet has been removed, CSF flow may be seen, and it can then be transduced to determine the opening intracranial pressure. It is then connected to an external drainage system after being tunneled


#### **Table 1.**

*Approaches for ventriculostomy and EVD insertion.*

through the skin by a different incision away from the point of entry. Dissolvable stitches, which will gradually fall out over the following 7–14 days, will be used to sew the scalp back together [18] (**Table 1**).
