Background: Placement of an external ventricular drain is considered a simple yet fundamental procedure. Despite its wide practice, an inaccuracy rate of around 50% has been reported. In the trauma setting, targeting the ventricles with a blind freehand technique is challenging due to distorted anatomy. Failure to cannulate lead to multiple passes with a higher risk of complications. Methods: A retrospective study from a single institution was conducted using a trauma registry between March-2014 and March-2019 were included. Accuracy of EVD placement was determined using the Kakarla grading system Results: 224 TBI patients with total of 241 EVDs were performed, 211 met our criteria. Among them, Grade-1 (optimal placement) was achieved in 39.3%, Grade-2 (suboptimal in non-eloquent tissue) in 21.8% and Grade-3 (suboptimal in eloquent tissue) in 38.9%. A total of 74 EVDs were inserted in the intensive care unit, while 137 EVDs were inserted in the operating room. Our accuracy for ICU insertions was 50%, 25.7%, 24.3% for Grades1,2 and3 respectively, while our OR insertion accuracy was 33.6%,19.7%,and46.7% Conclusions: EVD is commonly performed, yet a substantial rate of inaccuracy is reported. This highly suggests the need to improve accuracy, possibly with the adjunct of image-guided techniques, to further optimize catheter placement