Accurate insertion of a ventricular catheter using intraoperative real-time ultrasound imaging with a burr hole–compatible transducer

OBJECTIVE The traditional freehand insertion of a ventricular catheter using surface anatomical landmarks is a basic procedure for neurosurgeons. However, this procedure involves considerable uncertainty and frequently requires multiple placement attempts. This also periodically results in improper positioning of the catheter tip. The aim of this study was to evaluate the accuracy of ventricular catheter insertion using real-time ultrasound images acquired with a burr hole–compatible transducer and to compare it with freehand insertion. METHODS This retrospective cohort study included all patients at a single institution who underwent a ventricular catheter insertion operation, including external ventricular drainage, ventriculoperitoneal shunt placement, and Ommaya reservoir insertion through a new burr hole, between January 2015 and March 2022. The data collected for each patient included age, sex, diagnosis, antiplatelet or anticoagulant use within 24 hours before or after the procedure, use of intraoperative real-time ultrasound with a burr hole–compatible transducer, site and side of the ventricular catheter placement, number of attempts required to achieve successful insertion, postoperative parenchymal bleeding, and symptomatic complications related to inaccurate catheter insertion. The Evans index was acquired from preoperative CT images, and the accuracy of ventricular catheter placement was evaluated using postoperative CT. RESULTS A total of 136 procedures were included in this study; 81 ventricular catheters were inserted using the freehand technique, and 55 were inserted using the real-time ultrasound technique. The number of catheter placement attempts was significantly lower using the real-time ultrasound technique than the freehand technique (p < 0.001), and the accuracy of the real-time ultrasound technique was significantly higher (p < 0.001). The difference in accuracy between the ultrasound and freehand techniques was augmented in posterior horn punctures (100% and 74.1%, respectively, p = 0.01). CONCLUSIONS The real-time ultrasound-guided ventricular catheter insertion technique is significantly more accurate than the traditional surface anatomical landmark–based freehand technique and results in a reduced number of puncture attempts.