Background: The use of Image-guidance to improve the accuracy during ventricular drain insertion has been attempted. We aim to assess the effect of use of Image-guidance on accuracy, drain failure rate and number of ventricular cannulation attempts. Methods: MEDLINE, EMBASE and Cochrane Library databases were searched from inception to February 2021 looking for studies comparing image-guided versus freehand ventricular drain insertion. Two reviewers independently screened studies, extracted data and assessed risk of bias and quality of evidence. Metanalysis was conducted in compliance with PRISMA guidelines using a random-effects model and GRADE tool was used to assess quality of evidence. Results: 17 studies with 3404 patients were included, all of which were of non-randomized design. Pooled data on drain accuracy and drain failure rates showed favourable effect of image-guidance with risk ratio of 1.31 (95% CI of 1.13 – 1.51, low quality evidence) and 0.63 (95% CI 0.48 – 0.83, moderate quality evidence), respectively. Pooled data were equivocal for number of attempts with mean difference score of -0.11 times (95% CI -0.31 – 0.09, very low-quality evidence). Conclusions: Image-guidance likely enhances drain accuracy and reduces drain failure rate. No clear recommendation can be drawn on the benefit of intervention on number of drain insertion attempts.