Accuracy of Freehand Ventriculostomy in Resource-Limited Settings: Institutional Experience
Seyoum Debebe Alemu, MD1, Abenezer Tirsit Aklilu, MD, PGD, FCS(ECSA)2, Yabello Hirbo Guyolla, MD3*, Wondu Mekonnen Abebe, MD4
1Neurosurgery resident, Department of Surgery, College of Health Sciences, AAU, Addis Ababa, Ethiopia.
2Associate Professor of Neurosurgery, Department of Surgery, College of Health Sciences, AAU, Addis Ababa, Ethiopia.
3Assistant Professor of Neurosurgery, Surgery Department, Jimma University, Jimma, Ethiopia.
4General Surgeon, Bishoftu Hospital, Ethiopia.
*Corresponding Author: Yabello Hirbo Guyolla, MD, Assistant Professor of Neurosurgery, Surgery Department, Jimma University, Jimma, Ethiopia.
https://doi.org/10.58624/SVOANE.2025.06.032
Received: November 29, 2025
Published: December 30, 2025
Citation: Alemu SD, Aklilu AT, Guyolla YH, Abebe WM. Accuracy of Freehand Ventriculostomy in Resource-Limited Settings: Institutional Experience. SVOA Neurology 2025, 6:6, 187-194. doi. 10.58624/SVOANE.2025.06.032
Abstract
Background: Freehand external ventricular drain (EVD) insertion remains the standard technique for managing acute hydrocephalus, though reported accuracy varies widely.
Objective: To prospectively evaluate the accuracy of freehand EVD placement and identify predictors of catheter misplacement.
Methods: Adult patients undergoing freehand EVD insertion between December 2020 and September 2021 at two tertiary centers were prospectively studied. Pre- and postoperative CT scans were assessed for catheter tip position, Evans index, midline shift, burr hole site, intracranial catheter length, number of attempts, and operator experience. Accurate placement was defined as catheter tip within the ipsilateral lateral ventricle. Associations were analyzed using chi-square tests and odds ratios (ORs) with 95% confidence intervals (CIs).
Results: Seventy-one patients (mean age 42.2 ± 15 years; 54.9% male) were included, mostly with obstructive hydrocephalus (78.9%). Accurate placement occurred in 46/71 (64.8%) cases. Misplacements were into the contralateral ventricle (14.1%), third ventricle (9.9%), or brain parenchyma/extraventricular (11.3%). Catheter length >60 mm was strongly associated with misplacement (p < 0.001; OR 8.73, 95% CI 2.29–33.29). Smaller ventricles (Evans index <0.30) (p = 0.007; OR 5.14, 95% CI 1.67–15.82) and ≥3 insertion attempts (p = 0.007; OR 5.20, 95% CI 1.66–16.26) increased misplacement risk and postoperative complications (70.0% vs 32.3%, p = 0.0035). Burr hole site and operator experience showed no significant effect.
Conclusion: Freehand EVD achieved accurate ventricular placement in 64.8% of cases. Excessive catheter length, small ventricles, and multiple attempts predicted misplacement, underscoring the need for improved training and selective image guidance.
Keywords: External Ventricular Drain, Ventriculostomy, Kocher’s Point, Frazier’s Point, Accuracy, Evans Index
