INDICATIONS AND CONTRAINDICATIONS

The injuries for which intracranial monitoring may be indicated include traumatic brain injury, ischemic
stroke, subarachnoid hemorrhage, intracerebral hemorrhage, intraventricular hemorrhage, or status
epilepticus

Before placement of invasive cerebral monitoring device, a patients coagulation status must be
assessed. Recommended coagulation values prior to beginning the procedure are:
Platelets >100.000
INR < 1.5
PTT within normal range
No history of aspirin or clopidogrel within 7 days

SETUP, PREPARATION, AND POSITIONING

After informed consent is obtained the equipment specified should be placed on a bedside table in an
ordered fashion. A Cranial Access Kit (Codman, Raynham, MA) contains most, if not all, of the
following materials:
Razor or electric shaver
Chlorhexidine prep tray
Hat, mask, eye protection
Sterile gown and gloves
Sterile clear plastic drape and burn sheet
or other large drape
Four pack of sterile towels
Sterile ruler and marking pen Sterile drill
kit and appropriate bit ( guard)
Toothed forceps, hemostat, and needle
driver
Skin knife with #11 and #15 blades,
scissors, small retractor
30 nylon suture
10-cc syringe with 24- and 18-gauge
needles
1% lidocaine with epinephrine
30 cc of sterile preservative-free saline
4 breathable transparent medical dressing

Preparation issues are:

ABCs secure the airway, monitor vital signs, and pulse oximetry
Restraints especially in an awake patient
Head of bed elevated to 3045
Head in neutral position and apex slightly off the top of the bed
Shave half of the head across midline and back to coronal suture, and down to zygomatic arch
Point of entry is Kochers point: 12 cm anterior to the coronal suture in mid-pupillary line or 11 cm
posterior from the glabella and 3 cm lateral from midline (Fig. 16-1).
Right (nondominant) frontal lobe is preferred unless:
Scalp lacerations/abrasions.
Previous craniotomy or complicated fracture with absent bone.
Large hemorrhage on right (catheter will have an tendency to clot).
Proposed future surgery on right.
Tract may go through AVM or mass.

INSERTION TECHNIQUES
Whether placing a single ICP-monitoring bolt or a LICOX with microdialysis catheter, the initial opening
technique is similar:
1. Setup, sterilize, drape, and anesthetize as described above.
2. Mark a 23 cm linear incision in the sagittal plane approximately 23 cm off midline and at least 2 cm
anterior to the coronal suture. Kochers point is commonly used for placement of external ventricular
drains and can be employed similarly for placement of neuromonitoring devices.
3. Using the 15-blade scalpel to make the skin incision.
4. Carefully sweep the periosteum away on each side to expose the calvarium. The self-retaining
retractor may be inserted at this point to maximize exposure and keep the periosteum retracted away.
The retractor is also useful in stopping any superficial scalp bleeding which occurs.
5. Attach the drill bit that is included with the monitoring device to be placed
6. Drill the bone. A nurse or assistant may be employed to stabilize the patients head from beneath the
surgical drapes while the burr hole is fashioned.
7. At the inner cortex, the drill will catch.
8. Remove bone debris from the hole using forceps, gauze, and saline irrigation.
9. A very small dural puncture is made, which is expanded bluntly using the Allen wrench.
10. At this point the desired monitoring device may be placed.

Once dural access has been obtained insertion of the monitoring device should follow manufacturer
guidelines. Techniques for several common devices are summarized below.

Ventriculostomy
Additional equipment needed:
Minimum of four sutures, preferably 30
nylon ( 3) and 20 or 0 silk ( 1)
Camino tray with bolt, drill bit, and fiber-
optic cable.
Ventriculostomy catheter and appropriate
stylet, adapter/connectors, and trochar
Buretrol burrette system (Baxter,
Deerfield, IL)
Pressure transducer
Additional 50250 cc of preservative-free
sterile saline
50 cc syringe
Additional 18-gauge needle

1. Set up a sterile field, and prepare the

ventriculostomy catheter. The dura is entered
as described above.
2. After puncturing the dura with the needle,
grab the ventriculostomy catheter and its
stylet with the right hand at the tip. The left hand should have index and thumb at 6 cm to prevent
passing it too far (Fig. 16-2). The trajectory is defined by the ipsilateral medial canthus and ipsilateral
tragus.
3. If a pop is felt at approximately 5 cm and CSF is seen, remove the stylet carefully and soft pass the
catheter to 7 cm at the skin, tunnel the device out of a subgaleal tract approximately 34 cm away
from the incision along the anesthetized tract. Use a nontoothed device to hold the catheter at the
bone and prevent movement while tunneling.
4. If there is no spontaneous flow, remove the stylet and drop the distal end of the catheter to check for
CSF.
5. Before reattempting another pass, clean out all the brain/blood material. Three passes is generally
considered the limit when trying to place a Camino or Codman device.
6. When CSF is obtained, connect the plastic connector and cap the distal end to prevent further loss of
CSF.
7. Close the incision at Kochers point using a running 30 nylon suture.
8. While taking care to avoid occluding the catheter, suture it in place using a standard drain stitch.
Create 12 loops of catheter and suture them down to create slack in case of an accidental tug.
9. Use a nylon or silk tie to secure the plastic connector to the catheter then connect the Buretrol
system and zero the transducer.