Abstract Placement of external ventricular drains subjects patients to risks of injury, intracerebral hematoma, and failure from improper placement. Traditional free-hand placement has been associated with a relatively frequent occurrence of these complications. We sought to assess the accuracy of ventriculostomy when performed using image-navigation technology in the intensive care unit (ICU). Thirty-five patients were consecutively enrolled in a single-arm trial evaluating the accuracy and complications from ventriculostomies performed at the ICU bedside using electromagnetic image guidance technology. The duration of any additional imaging and the length of the total procedure were also quantified. There were no unacceptably placed ventriculostomy catheters; only two catheters were not perfectly placed in the ipsilateral frontal horn. There was only one patient with tract hemorrhage. The use of image guidance technology added approximately 36minutes to the time from when the need was identified to when successful drainage was achieved (p=0.002), but added only 4minutes of operative time (p=0.12). Accuracy of placement demonstrated a statistically significant improvement in the accuracy of ventriculostomy over historical data. There were two registration failures which were converted to the traditional technique; there were no other complications arising from the use of image-guided technology. Electromagnetic image guidance is feasible and accurate. Image guidance technology eliminated unacceptably placed catheters and may reduce the risk of catheter-associated intracerebral hemorrhages.