Image-guided placement of external ventricular drains: a binational analysis

External ventricular drainage is a core neurosurgical procedure for the management of acute hydrocephalus and raised intracranial pressure, yet freehand catheter placement is associated with malposition rates. Image-guided techniques, including neuronavigation and intraoperative ultrasound, have been introduced to improve accuracy, but their real-world clinical benefit remains unclear. This binational, multicenter prospective study evaluated contemporary external ventricular drain placement across 21 neurosurgical centers in the United Kingdom and Ireland. A total of 632 drains inserted over six months were analyzed with respect to catheter tip position, drain dysfunction, and use of image guidance. Image guidance was used in 19.6% of cases, predominantly neuronavigation, while ultrasound guidance was rare. Optimal catheter placement, defined as free-floating within cerebrospinal fluid, was achieved in approximately two thirds of cases and did not differ significantly between image-guided and freehand techniques. This finding persisted in anatomically and clinically challenging subgroups, including patients with small ventricles and traumatic brain injury. Rates of drain dysfunction and revision were numerically lower with image guidance but did not reach statistical significance. Substantial interinstitutional variability in the use of image guidance was observed, ranging from routine use to complete non-use, indicating a lack of standardized practice. Most procedures required only a single catheter pass, suggesting high contemporary proficiency with freehand techniques. Overall, these findings challenge the assumption that image guidance alone improves clinical outcomes in external ventricular drain placement. They highlight the need to distinguish theoretical technical advantages from demonstrable clinical benefit and suggest that selective application, structured training, and workflow integration may be more important than routine use of guidance technologies.