Abstract
Ommaya reservoir placement has been an option for patients requiring cerebrospinal fluid (CSF) access since the 1960s. It is preferred to repeat lumbar punctures, both in terms of patient comfort and the consistency of intrathecal drug concentration. Technological developments have advanced the placement technique, allowing for better accuracy and reduced complications. Freehand placement was first augmented with pneumoencephalograms and intraoperative computerized tomography (CT), then with optical-based navigation, and finally by utilizing electromagnetic neuronavigation. We outline a method of placement using electromagnetic neuronavigation and intraoperative endoscopic visualization, which allows for both real-time guidance and the confirmation of placement while maintaining tract patency for the entirety of the procedure. We make our incision and burr hole near Kocher’s point. The neuronavigation stylet is placed in a peel-away sheath (Cook Medical, Bloomington, Indiana, US), which allows us to advance into the ventricle under real-time neuronavigation guidance. After the ventricle is entered, the stylet may be withdrawn and an endoscope advanced down the sheath. The intraventricular anatomy and catheter placement are confirmed. The burr hole reservoir is attached to a ventricle catheter that has been trimmed based on trajectory measurement on preoperative imaging. The reservoir-catheter construct can then be placed and the sheath removed from around it. This method provides a high level of confidence in appropriate catheter placement.
Highlights
The Ommaya reservoir was initially developed in 1963 and has since become an important neurosurgical tool for patients requiring repeated cerebrospinal fluid (CSF) sampling or intrathecal therapeutics [1]. While these devices can be used for a number of conditions, e.g., intraventricular hemorrhages, tumor cyst aspiration, meningitis, and neoplastic diseases, they are most commonly utilized for the instillation of intraventricular chemotherapy for the treatment of neoplastic meningitis and central nervous system (CNS) lymphoma
Treatment and CSF sampling can be performed via repeated lumbar punctures (LPs), the administration of chemotherapy via a reservoir has higher and more consistent drug concentrations compared to an LP as well as less discomfort for the patient [2]
While a right-sided approach is our standard operating procedure (SOP), we will perform the procedure on the left if anatomy or pathology so dictate
Summary
The Ommaya reservoir was initially developed in 1963 and has since become an important neurosurgical tool for patients requiring repeated cerebrospinal fluid (CSF) sampling or intrathecal therapeutics [1]. Two recent retrospective studies demonstrated the rates of Ommaya reservoir infection at 5.5 percent and 8 percent [5,6] Another common complication of reservoir placement is suboptimal catheter positioning. While initial methods for the placement of ventricular catheters for reservoirs or ventricular shunts relied on external landmarks, the development of imaging guidance has allowed for accurate targeting. We present a technical modification of Ommaya reservoir placement utilizing frameless, electromagnetic neuronavigation and ventricular endoscopy, providing guidance into the ventricular system and the real-time confirmation of accurate placement. While a right-sided approach is our standard operating procedure (SOP), we will perform the procedure on the left if anatomy or pathology so dictate Screens for both the neuronavigation and the endoscope system are placed at the foot of the bed for easy visualization during catheter advancement (Figure 1). The wound is cleansed and dressed with bacitracin ointment
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