Accepted Manuscript

Keen’s Point for External Ventricular Drainage in Traumatic Brain Injury Patients: An
Uncommon Indication for an Old Technique

Kevin T. Huang, MD, Vamsidhar Chavakula, MD, William B. Gormley, MD, MPH,
MBA

PII: S1878-8750(17)30487-4
DOI: 10.1016/j.wneu.2017.03.145
Reference: WNEU 5514

To appear in: World Neurosurgery

Received Date: 9 January 2017

Revised Date: 29 March 2017
Accepted Date: 30 March 2017

Please cite this article as: Huang KT, Chavakula V, Gormley WB, Keen’s Point for External Ventricular
Drainage in Traumatic Brain Injury Patients: An Uncommon Indication for an Old Technique, World
Neurosurgery (2017), doi: 10.1016/j.wneu.2017.03.145.

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 ACCEPTED MANUSCRIPT

Keen’s Point for External Ventricular Drainage in Traumatic Brain Injury Patients: An
Uncommon Indication for an Old Technique

Kevin T. Huang, MD1*, Vamsidhar Chavakula, MD1*, William B. Gormley, MD, MPH, MBA1

1) Department of Neurosurgery
Brigham and Women’s Hospital

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Harvard Medical School
75 Francis Street
Boston, MA 02115

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*These authors contributed equally

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Corresponding Author:
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William B. Gormley, MD, MPH

Department of Neurosurgery
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Brigham and Women’s Hospital

75 Francis Street
Boston, MA 02115
P: 617-732-6600
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F: 617-734-8342

Key Words: cerebrospinal fluid diversion, external ventricular drainage, intracranial hypertension,
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Keen’s point, traumatic brain injury

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Abstract

Background

In cases of severe traumatic brain injury (TBI), cerebrospinal fluid (CSF) diversion though an external

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ventricular drain (EVD) is a proven method to assist in the control of elevated intracranial pressure (ICP).
Under normal circumstances, the EVD is placed in a frontal location. However, in cases of multifocal

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intracranial injury and swelling, collapse of the frontal horns of the lateral ventricles leads to frequent
failure of frontal CSF drainage. In this series we describe the utility of the Keen’s point EVD as a safe
alternative to maintain continuous CSF diversion for patients in whom frontal drainage is not feasible.

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Case descriptions

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Three patients (ages 30-46 years) with diffuse intracranial injury following severe trauma were admitted
to our neurointensive care unit. One of these patients had decompressive craniectomy prior to transfer,
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while the other two patients did not undergo any surgical procedures. Each of these patients had severe
refractory elevation of intracranial pressure and significant frontal swelling, ultimately necessitating
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bedside placement of a Keen’s point EVD.

Conclusions
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In all cases, we were able to reliably maintain continuous CSF diversion for an extended period of time.
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There was one mortality due to severity of initial injuries. In the remaining two patients, ICP was able to
be normalized following placement of Keen’s point EVD. The Keen’s point EVD is a viable option to
maintain continuous CSF drainage in patients with diffuse intracranial injury and should be considered in
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patients for whom frontal EVD cannot reliably maintain continuous drainage of CSF.
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Introduction

External ventricular drain (EVD) placement through percutaneous ventriculostomy is one of the
most commonly employed techniques in the treatment and monitoring of elevated intracranial pressure
(ICP). EVD placement is learned early-on in neurosurgical training and is nearly ubiquitous in modern

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neurosurgical practice, with over 20,000 catheters placed annually in the United States.1 It is commonly
employed to gain ventricular access in a variety of situations including trauma for control of intracranial
pressure (ICP), and hydrocephalus from diverse causes including subarachnoid hemorrhage, ventricular

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outlet obstruction, and intraventricular hemorrhage.

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The most frequently used technique for EVD placement at our institution, and throughout the
country, is the right frontal approach through a twist-drill burr hole at Kocher’s point. This approach

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offers a number of advantages, including relative ease of patient positioning, passage through the non-
dominant hemisphere, wide margin from eloquent cortex, and a relatively large target in the frontal horn
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of the ipsilateral lateral ventricle. Recently, however, we encountered three cases of traumatic brain
injury (TBI) at our institution that, due to the unique pattern of their intracranial injuries, could not
receive right frontal EVD placement. We report here on the use of a temporal EVD placed through
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Keen’s point in certain unique patterns of TBI.

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Case Presentation
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Case 1
This is a 30 year-old female with no known past medical history who was witnessed to
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intentionally cross in front of a moving train. Emergency medical services were immediately contacted
following the incident, she was intubated in the field, and she presented to our emergency department
soon afterwards. Upon arrival, a computed tomography (CT) scan of the head demonstrated a right
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temporal bone fracture, a left lateral orbital wall fracture, traumatic subarachnoid hemorrhage, and a 1cm
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right temporal epidural hematoma (Figure 1). Also of note, she was noted to have congenital agenesis of
the corpus callosum and colpocephaly. On exam, she was intubated, with eyes remaining closed to deep
stimulation, but with all extremities withdrawing symmetrically to painful stimuli.

Given the need for ICP monitoring and ventricular drainage in the setting of traumatic brain
injury, an EVD was placed through the right frontal approach, with good flow initially. However, less
than 24 hours after placement, the catheter ceased to drain. Due to the patient’s colpocephaly, it was felt

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that the frontal horns were too small to afford reliable ventricular diversion, and that the atrium would
provide a larger space for CSF drainage. Thus, a Keen’s point EVD was placed on the right side without
issue.

The patient went on to have a prolonged ICU course, including a long period of intracranial

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hypertension requiring both continued cerebrospinal fluid (CSF) drainage through the EVD catheter and
standing hyperosmolar therapy. The EVD put out consistent drainage during this period (output range:
120-230 cc/day, mean: 178 cc/day), without need for replacement or revision. She subsequently did not

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develop ICP refractory to medical treatment, and required no further neurosurgical procedures. The EVD
was removed 21 days later, after the patient had demonstrated resolution of her ICP issues. At no point

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during her admission did she demonstrate any signs or symptoms of central nervous system infection.
She was discharged to a rehabilitation facility in stable condition one month after her initial injury.

Case 2
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A 46 year-old woman was involved in a high-speed motor vehicle accident and suffered
numerous injuries, including a right-sided hemopneumothorax, a left-sided hemothorax, a liver laceration,
and several lower extremity fractures. Her past medical history was notable only for hypertension,
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fibromyalgia, and rheumatoid arthritis. She was initially evaluated and treated at an outside hospital,
where reports indicate that a right frontal fiberoptic ICP monitor was placed, and when pressures were
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noted to be greater than 40 mmHg, a left-sided hemicraniectomy was performed. She was subsequently
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transferred to our Neurosurgical intensive care unit for further management.

Upon transfer, she was intubated, with equal and symmetrically reactive pupils. Her eyes
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remained closed to painful stimulus, but her bilateral upper extremities localized briskly and her bilateral
lower extremities withdrew. A repeat CT scan upon arrival noted multiple intraparenchymal and
subarachnoid hemorrhages with subcortical infarcts of the parietal, frontal, and temporal lobes (Figure 2).
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Initially the patient was managed with hyperosmolar therapy, but progressively worsened
clinically over the next 48 hours to where she began extensor posturing in the bilateral upper extremities.
It was felt that she would require CSF drainage for management of her ICP, and given the extensive
frontal and contralateral swelling, the only ventricular access points available were the trigone and
occipital horn of the left lateral ventricle. A Keen’s point EVD was placed without problem, and allowed
for continued CSF diversion for the rest of the patient’s inpatient admission (output range: 35-170 cc/day,
mean: 110.5 cc/day over five days). However, due to the extensive nature of her initial injury, her family

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decided to transition to comfort measures only, and she ultimately expired eight days after initial
presentation.

Case 3

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A 41 year-old man with no known past medical history was involved in a head-on motor vehicle
accident. He was intubated at the scene of the accident and transferred to our institution for further care.
On presentation, he had an open left elbow fracture and a large occipital scalp laceration. To noxious

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stimuli, his eyes remained closed but he withdrew all of his extremities. A CT scan of the head revealed
extensive bilateral multi-compartmental hemorrhages, the most prominent of which was a large

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hemorrhagic contusion of the right basal ganglia (Figure 3).

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A left frontal EVD was initially placed but the catheter experienced frequent occlusions, requiring
flushing on a daily basis. Three days later, given the continued problems with the EVD and the
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worsening of the patient’s ICP, a right frontal EVD was attempted. This second drain proved more
complicated than the first and became rapidly and repeatedly obstructed with bloody clot-like material.
Finally, a right Keen’s point EVD was placed without complication. This drain was utilized for
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continuous CSF drainage for the next 27 days (output range: 120-286 cc/day, mean: 173.5 cc/day) with
combined with aggressive medical ICP management including hyperosmolar therapy, cooling, paralysis,
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and barbiturate coma with titration to burst suppression. The patients ICP did not become refractory to
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medical therapy and no decompressive procedure was required.

The patient’s intracranial hypertension eventually subsided, and the EVD was discontinued
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without issue. The patient was subsequently discharged to a rehabilitation facility in stable condition, 52
days after his initial injury.
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Technique
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Originally described by William Williams Keen in 1890, Keen’s point was the first described
reliable access point for ventricular drainage.2, 3 The point is located 3cm superior and 3cm posterior to
the pinna, lying in the posterior squamous portion of the temporal bone near the posterior bend of the
squamosal suture (Figure 4). Once the area has been adequately prepped and draped, a small vertical
incision (~1-2 cm in length) is made at the site down to the level of the periosteum.4 The periosteum is
dissected away, and a standard twist-drill burr hole is made perpendicular to the outer table of the

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cranium. Care must be exercised in the placement of these burr holes as the thin squamous temporal bone
is traversed much more quickly than the thicker frontal bone that many may be more used to. Once the
burr hole has been established, the dura can be punctured in standard fashion using a spinal needle or
sharp dural knife. The catheter is then passed perpendicular to the cerebral cortex, to the depth of 4-5 cm
aligned with the outer table of the skull. Once ventricular access has been confirmed, the catheter stylet

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can be removed and the ventricular catheter can be further advanced to allow for deeper positioning of the
catheter. The catheter can then be tunneled posteriorly and secured in standard fashion.5, 6

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Discussion

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In this study, we revisited the Keene’s point ventriculostomy as a tool for management of ICP in
cases of malignant intracranial hypertension and present a case series of patients admitted to our

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neurocritical care unit following severe traumatic injury. The particular problem faced in this series of
patients was collapse of the frontal horns from frontal lobe swelling, leading to frequent EVD failure as
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the catheter drainage fenestrations became frequently obstructed by debris or collapsed ventricular
ependyma. In severe neurotrauma cases, these patients can develop refractory elevation of intracranial
pressure if CSF diversion is halted for even brief periods of time. Troubleshooting these drains often
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involves directly accessing and manual flushing of the EVD and possibly replacing the catheter entirely.
In the case of small frontal horns, entering the ventricle remains a challenge often requiring multiple
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catheter passes. Few authors have described alternatives to the standard Kocher’s point EVD in such
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scenarios, but notably some investigators have proposed that a more medial (paramedian) entry point may
be a potential solution.7 In our series we found that utilizing a Keen’s point EVD allowed us to maintain
continuous CSF drainage over an extended period of time, and allowed us to avoid further surgical
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procedures.

Cases 1 and 3 represent patients in whom we were able to avoid surgical decompression through
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the utilization of a Keen’s point EVD for CSF diversion. In these cases, although frontal EVD catheters
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were initially placed, cerebral swelling and shift led to frequent catheter failures and difficult replacement.
Targeting the catheters in the relatively open trigone allowed us to continuously and reliably divert CSF,
maintain normal ICP, and avoid surgical decompression. Case 2 represented a case of severe neurotrauma
with multifocal injuries. Although, she had an extensive initial hemicraniectomy, she continued to have
malignant ICP elevation. Again in this situation, placement of a Keene’s point EVD allowed us to
maintain continuous CSF diversion without further EVD manipulation.

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In cases of severe traumatic brain injury, malignant intracranial hypertension has a profound
effect on morbidity and mortality.8-12 Minimizing secondary injury during this period is crucial.1312 The
peak period of cerebral edema occurs in the first 24-96 hours after the initial trauma and can last on the
order of weeks.9, 14, 15 Medical management to reduce ICP while maintaining adequate cerebral perfusion
pressure includes head of bed elevation, hyperosmolar therapy, management of the partial pressure of

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carbon dioxide, cooling, sedation, paralysis and on occasion even the induction of medical coma.8, 9 The
surgical placement of an EVD to assist management of ICP with continuous CSF drainage, has also
become an early intervention in this patient population. When patients’ ICP becomes refractory to

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medical management, a decompressive craniectomy with or without a lobectomy may be utilized.16

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Early decompression for treatment of refractory ICP elevation remains controversial, as multiple
studies have questioned whether the improvement in ICP control actually leads to improvements in
functional outcomes.17, 18 However, it has been extensively demonstrated that CSF diversion is vital in

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managing elevated ICP, and leads to improved functional outcomes.19-22 Furthermore, when comparing
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intermittent versus continuous CSF drainage, continuous CSF drainage has been demonstrated to provide
superior ICP control.23 Together, these sets of studies support the use of alternative ventricular access
points when frontal access is not readily available or drainage is not reliable.
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There exists some evidence that CSF diversion via lumbar drainage should also be considered as
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a potential avenue. This method has not been widely employed in the United States, as there is concern
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that in the setting of multifocal TBI and asymmetric cerebral edema, that lumbar drainage could induce
cerebellar tonsillar herniation. Although limited data have shown that lumbar drainage can be employed,
the authors of the study warn that lumbar drainage should only be performed so long as the basilar
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cisterns remain patent.24 More studies will be needed to further evaluate the efficacy and safety of this
modality of treatment in TBI patients.
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This report describes an intervention aimed at the treatment of a very rare subset of neurotrauma
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patients with extremely recalcitrant elevations in intracranial pressure and continued malfunctioning of
frontal EVD catheters. As such, our recommendations are based upon a limited population of three patient
cases. This creates an obvious limitation to our findings and their wider applicability. This
communication, however, is intended to serve as a technical note that could increase our management
interventions in this complex group of patients.

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We believe that the Keen’s point EVD is a viable option to maintain continuous CSF drainage in
patients with diffuse intracranial injury and should be considered in patients for whom frontal EVD
placement is challenging due to anatomical shifts in the setting of trauma, as well as those in whom there
is frequent frontal catheter failure. In our series, anatomic landmarks were utilized to perform the
ventriculostomy at the bedside, however, image guided placement in the operating room may also be

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considered.

Acknowledgements

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This research did not receive any specific grant from funding agencies in the public, commercial, or not-
for-profit sectors.

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Uncategorized References
1. O'Neill, B.R., et al., A survey of ventriculostomy and intracranial pressure monitor placement
practices. (2008). Surg Neurol 70(3): 268-73; discussion 273
2. Keen, W.W., Exploratory Trephining and Puncture of the Brain Almost to the Lateral Ventricle:
For Intracranial Pressure Supposed to be Due to an Abscess in the Temporo-sphenoidal Lobe:
Temporary Improvement, Death on the Fifth Day: Autopsy, Meningitis with Effusion Into the

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Ventricles: with a Description of a Proposed Operation to Tap and Drain the Ventricles as a
Definite Surgical Procedure. 1888: publisher not identified
3. Keen, W., Surgery of the lateral ventricles of the brain. (1890). The Lancet 136(3498): 553-555
4. Ghajar, J.B., A guide for ventricular catheter placement. Technical note. (1985). J Neurosurg

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63(6): 985-6
5. Saunders, R.L. and T.A. Lyons, External ventricular drainage. A technical note. (1979). Crit Care
Med 7(12): 556-8

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6. Friedman, W.A. and J.K. Vries, Percutaneous tunnel ventriculostomy. Summary of 100
procedures. (1980). J Neurosurg 53(5): 662-5
7. Joseph, M., Intracranial pressure monitoring in a resource-constrained environment: A technical
note. (2003). Neurology India 51(3): 333

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8. Gerber, L.M., et al., Marked reduction in mortality in patients with severe traumatic brain injury.
(2013). J Neurosurg 119(6): 1583-90
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9. Suarez, J.I., Critical care neurology and neurosurgery. 2004: Springer Science & Business Media
10. Rutland-Brown, W., et al., Incidence of traumatic brain injury in the United States, 2003. (2006).
J Head Trauma Rehabil 21(6): 544-8
11. Narayan, R.K., et al., Improved confidence of outcome prediction in severe head injury. A
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comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning,

and intracranial pressure. (1981). J Neurosurg 54(6): 751-62
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severe traumatic brain injury and elevated intracranial pressure. (2008). J Neurosurg Pediatr
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13. Bouzat, P., et al., Beyond intracranial pressure: optimization of cerebral blood flow, oxygen, and
substrate delivery after traumatic brain injury. (2013). Ann Intensive Care 3(1): 23
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developments. (2010). Curr Opin Neurol 23(3): 293-9
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15. Unterberg, A., et al., Long-term observations of intracranial pressure after severe head injury.
The phenomenon of secondary rise of intracranial pressure. (1993). Neurosurgery 32(1): 17-23;
discussion 23-4
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16. Li, L.M., et al., Review article: the surgical approach to the management of increased intracranial
pressure after traumatic brain injury. (2010). Anesth Analg 111(3): 736-48
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17. Nirula, R., et al., Decompressive craniectomy or medical management for refractory intracranial
hypertension: an AAST-MIT propensity score analysis. (2014). J Trauma Acute Care Surg 76(4):
944-52; discussion 952-5
18. Cooper, D.J., et al., Decompressive craniectomy in diffuse traumatic brain injury. (2011). N Engl J
Med 364(16): 1493-502
19. Lescot, T., et al., Effect of continuous cerebrospinal fluid drainage on therapeutic intensity in
severe traumatic brain injury. (2012). Neurochirurgie 58(4): 235-40
20. Farahvar, A., et al., Increased mortality in patients with severe traumatic brain injury treated
without intracranial pressure monitoring. (2012). J Neurosurg 117(4): 729-34

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21. Kerr, M.E., et al., Dose response to cerebrospinal fluid drainage on cerebral perfusion in
traumatic brain-injured adults. (2001). Neurosurg Focus 11(4): E1
22. Timofeev, I., et al., Ventriculostomy for control of raised ICP in acute traumatic brain injury.
(2008). Acta Neurochir Suppl 102: 99-104
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24. Tuettenberg, J., et al., Clinical evaluation of the safety and efficacy of lumbar cerebrospinal fluid
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Figure 1

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(Left) original CT scan on presentation demonstrating agenesis of the corpus callosum and colpocephaly.
(Middle) first attempt right frontal catheter placement with suboptimal ventricular access.
(Right) right temporal catheter placement with secure catheter placement deep in the body of the right

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Figure 2

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(Top left) Multiple hemorrhagic contusions in the bilateral frontal lobes, leading to compression and
obfuscation of most of the lateral ventricular system except for the trigone of the left lateral ventricle (top
right and bottom left). (Bottom right) successful left temporal catheter placement placed on the edge of
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the craniectomy site.

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Figure 3

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(Top left): Head CT on presentation revealing a large, right-sided intraparenchymal hemorrhage centered
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on the external capsule. (Top right): Within 48 hours, a second, smaller hemorrhage began to develop on
the left, leading to effacement of the bilateral frontal horns. (Bottom left): Initial attempts at percutaneous
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ventriculostomy proved unsuccessful, seen here is the left frontal approach the tip of the catheter not
ideally placed within the ventricular system. (Bottom right): A right temporal approach allowed for more
easy access of the more-dilated portions of the lateral ventricular system.

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Figure 4

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(A): Demonstration of the location of Keen’s point, 3cm above and 3cm posterior to the superior aspect of
the pinna. (B): Anterior-posterior and lateral schematics demonstrating three-dimensional models of the
lateral ventricles, as well as an example trajectory of a Keen’s point passage into the atrium of the lateral
ventricle.

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Highlights
• External ventricular drainage remains indispensable in the treatment of severe TBI.
• The frontal approach via Kocher’s point may be contraindicated in certain cases.
• A transtemporal approach can prove a safe alternative for bedside EVD placement.

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Abbreviations:
CSF = cerebrospinal fluid
CT = computed tomography
EVD = external ventricular drain
ICP = intracranial pressure
TBI = traumatic brain injury

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