Emergent Right Frontal Camino Bolt Placement for Intracranial Pressure Monitoring for a GCS Under 8

Intracranial hypertension is a critical concern in traumatic brain injury (TBI), with elevated intracranial pressure (ICP) significantly impacting patient outcomes.¹ ICP monitoring is an essential component in managing patients with various brain pathologies that can lead to dangerously elevated intracranial pressure. In neurosurgical practice, accurate monitoring and timely intervention are critical when dealing with the challenges of intracranial hypertension, and its timely resolution is crucial for preventing severe neurological sequelae and fatal outcomes.

The risk of Infections or hemorrhage of significance associated with ICP devices, which can lead to patient morbidity, usually do not outweigh the benefit of continuous ICP monitoring in TBI. Therefore, these should not deter the decision to monitor ICP.

This video provides step-by-step visual guidance for placing a right frontal Camino bolt to guide optimal patient care. In this clinical case a patient presents without prior opportunity for clinical exam and with reported signs of a cranial hemorrhage, coupled with a right occipital fracture, thereby requiring ICP monitoring to proceed with further neurosurgical care.

The patient is administered general anesthesia to ensure comfort and immobility during the procedure. The surgeon marks the midline, measures 1 cm anteriorly from the coronal suture and 3 cm laterally from the midline. It is called Kocher’s point and should be in line with the mid-pupillary line. Afterwards, the designated area of the head is carefully sterilized to prevent the risk of infection. Then the surgeon administers local anesthesia to numb the scalp and the underlying tissues, thereby facilitating postoperative pain management, and makes a small incision in the scalp at the predetermined location. Next, a surgical drill is used to create a burr hole in the skull, followed by careful opening of the meninges, allowing access to the intracranial space. A surgical probe or the drill itself can be used to assess the depth of the hole.

Then, the Camino 1104B bolt catheter, equipped with a pressure sensor, is threaded through the burr hole and securely tightened to the skull, thus inserting the sensor slightly into the brain parenchyma. After securing the bolt, the surrounding incision is closed with interrupted sutures, and a sterile dressing is applied to minimize the risk of infection.

A head CT was then obtained to confirm ICP monitor placement, ensure the absence of placement-associated bleeding, and to assess for any interval change of the initial hemorrhage.  

In this particular case, a resident performed the procedure, which is why it took longer than usual. The ICP monitoring lasted for 4 days, and no complications related to the procedure were noted. On the 6th day, the patient, with a Modified Rankin Scale of 1, was discharged from our department.

The Brain Trauma Foundation’s 4th edition guidelines for the management of severe TBI discussed the necessity and indications for ICP monitoring, but there is no specific recommendation regarding the type of monitoring device. The guidelines acknowledge that the choice of monitoring device should be based on the clinician’s experience and judgment.⁴

Among other invasive ICP monitoring methods, the Intraparenchimal (IPM) and Intraventricular (IVM) methods are most prevalent. Each of these has its advantages and disadvantages.

IVM is a cost-effective method that allows for real-time measurement of global CSF pressure and therapeutic CSF drainage. However, it carries risks such as infection and bleeding, with infection rates as high as 27% and significant bleeding impacting morbidity and mortality at a rate of 0.9% to 1.2%. Other challenges include potential misplacement, obstruction due to clots or protein, and difficulties in accurate measurement in pediatric patients or cases of Subarachnoid Hemorrhage, especially when severe brain edema leads to ventricular collapse.

The Camino Micro Ventricular Bolt ICP Monitoring Catheter and Drainage Kit allows continuous ICP monitoring and provides real-time data, enabling clinicians to assess the severity of intracranial swelling or bleeding.² In the event of dangerous ICP elevation, certain interventions, including mannitol administration or therapeutic cerebrospinal fluid (CSF) drainage via the inserted ICP catheter, can be employed to reduce ICP, potentially averting the need for immediate surgical intervention.³

IPM devices, such as Camino, Codman, Spiegelberg, and Neurovent-P, are used globally for local ICP measurement but can over or underestimate overall CSF pressure. While they offer benefits like lower risk of infection and hemorrhage, they face challenges with accuracy, potential zero drift, and possible malfunction or failure of components.

IVM has a higher procedural difficulty, relatively higher risk of infection, and uncertainty in measurements caused by ventricle shape or compliance compared to IPM. One of the significant advantages of IVM is the ability to perform CSF drainage. IVM shows lower mortality, favorable 6-month Glasgow Coma Scale (CGS), and lower refractory intracranial hypertension compared to IPM, suggesting it has a role of CSF drainage. Therefore, IVM is more commonly used in conditions of subarachnoid hemorrhage or ICH which are highly required for therapeutic CSF drainage compared to TBI. IPM is more commonly used for TBI (73%), while IVM is frequently for subarachnoid hemorrhage and intracerebral hemorrhage cases (54%).⁴