Kocher's Point Research Articles

Intracranial pressure changes in traumatic brain injury patients undergoing unilateral decompressive craniectomy with dural expansion

BackgroundThe aim of this study is to assess the ICP changes induced by a unilateral fronto-temporo-parietal DC with dural expansion after moderate to severe TBI. The effect of different bone flap sizes on ICP and the neurological outcomes were also evaluated after the decompressive surgery. Methods52 TBI patients with clinical and radiological evidences of increased ICP were included in this prospective study. All patients received unilateral fronto-temporo-parietal DC with dural expansion and ventriculostomy at contralateral Kocher's point. Postoperatively, ICP values and the largest antero-posterior (AP) diameter of bone flap removed was measured, and the clinical outcomes were assessed using Extended Glasgow Outcome Scale (GOS-E) at discharge and 6 months after DC. ResultsThe median ICP significantly decreased with an average of 56.7 % reduction from the initial opening ICP. Similar ICP changes were observed in all groups. This study also found that the large bone flap group (AP diameter >15 cm) demonstrated better postoperative ICP control as compared to the small bone flap group (AP diameter 12–15 cm), although not statistically significant. The SDH and cerebral swelling groups did better in the GOS-E at 6 months after TBI compared with cerebral contusion group. ConclusionThe ICP reduction in moderate to severe TBI patients undergoing unilateral fronto-temporo-parietal DC with dural expansion occurred in accordance with decompressive steps, regardless of intracranial lesions and the surgical procedure should be performed with the bone flap size of at least 12 cm in AP diameter for adequate and sustained ICP control.

Ventriculoperitoneal shunt entry points in patients undergoing shunt placement: A single-center study

BackgroundThe ventriculoperitoneal (VP) shunt redirects cerebrospinal fluid flow, with the selection of entry points crucial for optimal outcomes. Anatomical landmarks and specific entry points, such as Kocher's, Frazier's, Keen's, and Dandy's points, have been utilized for shunt catheter placement. This study investigates the impact of various entry points on outcomes, particularly the necessity for revision procedures, in patients undergoing VP shunt placement. MethodsIn this retrospective cohort study, we analyzed data from patients in our center's database, collected from October 2017 to October 2022. Participants were classified based on ventriculoperitoneal shunt entry points. The study followed STROBE guidelines. Continuous variables were presented as means with standard deviations (SD) and categorical variables as frequencies and percentages. Linear Model ANOVA and Pearson's Chi-squared tests were used for comparisons. Data analysis was conducted using Jamovi software. ResultsOur study included 94 patients who underwent shunt procedures. The patients were categorized into four treatment groups: Dandy point (10), Frazier point (21), Keen point (43), and Kocher point (20). ConclusionOur study found no significant differences in age, FOHR, and indication for shunt placement among catheter entry point subgroups. However, gender distribution, catheter length, and catheter tip location significantly varied. The proportion of patients requiring revision surgery varied among the groups, with the highest rate in the Dandy point group and the lowest in the Keen group; however, the difference among the entry groups was insignificant.

Neuroanatomical refinement of Kocher's point for enhanced precision in ventriculostomy: A technical note and a literature review.

This study was designed to assess the effectiveness and safety of using a modified Kocher's point for ventriculostomy using endoscopic third ventriculostomy (ETV) and external ventricular drainage (EVD) in 200 patients at PAR Private Hospital in Erbil, Iraqi Kurdistan. In this retrospective analysis, a total of 200 patients who were diagnosed with obstructive hydrocephalus and underwent ETV and EVD utilizing a modified entry site were included. The revised Kocher point was located 11.5 cm posterior and superior to the nasion, 3 cm laterally, and 0-1 cm before the coronal suture. The use of this modified Kocher's point has brought much improvement in surgical precision and safety. This would minimize incidences of bleeding and misplacement of the catheters. The anatomical structure was well organized, and nothing was challenging in the process of traversing through the foramen of Monro into the third ventricle. It was easily introduced through the modified Kocher point with increasing efficacy and near zero possibility of sustaining injury to the limiting cerebral region. Using the modified point of Kocher provides added reliability and accuracy to ventriculostomy, thereby reducing complications and increasing the overall outcome of surgeries. It overcomes all the drawbacks of classical entry sites and, further, helps in increasing the productivity of ETV and EVD. More research must be done to support the benefits of this modification in other clinical settings.

Minimally invasive craniotomy for putaminal hemorrhage using a tubular retractor: A technical note.

Minimally invasive endoscopic and stereotactic surgery have been established as surgical treatments for putaminal hemorrhage. However, facilities that do not have equipment for endoscopic or stereotactic surgery will likely have to perform conventional craniotomy. Using a tubular retractor, we were able to perform minimally invasive surgery, such as endoscopic surgery. A craniotomy was performed for left putaminal hemorrhage after cerebral infarction treatment. A 3-4 cm craniotomy centered at Kocher's point was performed under general anesthesia. A 2 cm incision was made in the cortex, and a tubular retractor was inserted under a microscope. The hematoma was reached at a position 4-5 cm from the cortex. Thanks to the tubular retractor, it was relatively easy to observe the hematoma, and it was possible to remove it and confirm hemostasis without difficulty. Brain injury caused by the retractor insertion cavity was small, and no hemostasis was required. The surgery was completed by dura mater closure, bone flap fixation, and wound closure as per the standard. Most of the putaminal hemorrhage could be removed, and there was no rebleeding after the operation. The patient is still undergoing rehabilitation because of aphasia and muscle weakness. Manual Muscle Testing was at three points in the upper limb, and four points in the lower limb remained. For putaminal hemorrhage, microscopic craniotomy was performed using a tubular retractor and an approach such as endoscopic surgery. Craniotomy, hematoma removal, and hemostasis operations are also considered to be minimally invasive surgeries.

Endoscopic Excision of Third Ventricle Choroid Plexus Papilloma

Abstract Introduction Choroid plexus papilloma is a rare intraventricular tumor in children. Its management poses a challenge. Here we describe such a case of third ventricular choroid plexus papilloma and its endoscopic excision through a single burr hole. Case Description A 1-year-old child presented with headache, vomiting, and a large head with sunset sign and tense fontanel. Computed tomography (CT) and magnetic resonance imaging brain plain and contrast revealed dilated ventricles with a frondlike mass in the third ventricle with intense contrast enhancement, suggestive of choroid plexus papilloma of the third ventricle. The lesion was excised completely using an endoscope placed through a single burr hole at the right Kocher's point. Postoperative recovery was uneventful. The child was relieved of his symptoms. CT scan revealed complete removal of the lesion. Histopathology confirmed the diagnosis of choroid plexus papilloma. Results and Conclusion We document our surgical experience and present an edited video of the surgery. The key steps and nuances are described in the audio timeline. The authors acknowledge the feasibility of performing this complex surgery via a minimally invasive method, which has not been accepted routinely for this pathology.

Intraoperative ultrasound-guided ventricular cannulation in patients with normal-sized ventricles

IntroductionMany pathologies require normal-sized ventricle cannulation, which may be technically challenging even with neuronavigation guidance. This study presents a series of ventricular cannulation of normal-sized ventricles using intraoperative ultrasound (iUS) guidance and the outcomes of patients treated by this technique, for the first time. MethodsThe study included patients who underwent ultrasound-guided ventricular cannulation of normal-sized ventricles (either ventriculoperitoneal (VP) shunting or Ommaya reservoir) between January 2020 and June 2022. All patients underwent iUS-guided ventricular cannulation from the right Kocher's point. The inclusion criteria for normal-sized ventricles were as follows: (1) Evans index <30%, and (2) widest third ventricle diameter <6mm. Medical records and pre-, intra- and post-operative imaging were retrospectively analyzed. ResultsNine of the 18 included patients underwent VP shunt placement; 6 had idiopathic intracranial hypertension (IIH), 2 had resistant cerebrospinal fluid fistula following posterior fossa surgery, and 1 had iatrogenic intracranial pressure elevation following foramen magnum decompression. Nine patients underwent Ommaya reservoir implantation, 6 of whom had breast carcinoma and leptomeningeal metastases and 3 hematologic disease and leptomeningeal infiltration. All catheter tip positions were achieved in a single attempt, and none were placed suboptimally. Mean follow-up was 10 months. One IIH patient (5.5%) had early shunt infection which necessitated shunt removal. ConclusioniUS is a simple and safe method for accurate cannulation of normal-sized ventricles. It provides an effective real-time guidance option for challenging punctures.

External Ventricular Drain Placement Teleproctoring Using a Novel Camera-Projector Navigation System: A Proof-of-Concept Study

Teleproctoring is an emerging method of bedside clinical teaching; however, its feasibility has been limited by the available technologies. The use of novel tools that incorporate 3-dimensional environmental information and feedback might offer better bedside teaching options for neurosurgical procedures, including external ventricular drain placement. A platform with a camera-projector system was used to proctor medical students on placing external ventricular drains on an anatomic model as a proof-of-concept study. Three-dimensional depth information of the model and surrounding environment was captured by the camera system and provided to the proctor who could provide projected annotations in a geometrically compensated manner onto the head model in real time. The medical students were randomized to identify Kocher's point on the anatomic model with or without the navigation system. The time required to identify Kocher's point and the accuracy were measured as a proxy for determining the effectiveness of the navigation proctoring system. Twenty students were enrolled in the present study. Those in the experimental group identified Kocher's point an average of 130 seconds faster than did the control group (P < 0.001). The mean diagonal distance from Kocher's point was 8.0 ± 4.29 mm for the experimental group compared with 23.6 ± 21.98 mm for the control group (P= 0.053). Of the 10 students randomized to the camera-projector system arm, 70% were accurate to within 1 cm of Kocher's point compared with 40% of the control arm (P > 0.05). Camera-projector systems for bedside procedure proctoring and navigation are a viable and valuable technology. We demonstrated its viability for external ventricular drain placement as a proof-of-concept. However, the versatility of this technology indicates that that it could be useful for a variety of even more complex neurosurgical procedures.

Skin landmarks as ideal entry points for ventricular drainage, a radiological study.

Ventricular drainage remains a usual but challenging procedure for neurosurgical trainees. The objective of the study was to describe reliable skin landmarks for ideal entry points (IEPs) to catheterize brain ventricles via frontal and parieto-occipital approaches. We included 30 subjects who underwent brain MRI and simulated the ideal catheterization trajectories of lateral ventricles using anterior and posterior approaches and localized skin surface IEPs. The optimal frontal target was the interventricular foramen and that for the parieto-occipital approach was the atrium. We measured the distances between these IEPs and easily identifiable skin landmarks. The frontal IEP was localized to 116.8 ± 9.3mm behind the nasion on the sagittal plane and to 39.7 ± 4.9mm lateral to the midline on the coronal plane. The ideal catheter length was estimated to be 68.4 ± 6.4mm from the skin surface to the interventricular foramen. The parieto-occipital point was localized to 62.9 ± 7.4mm above the ipsilateral tragus on the coronal plane and to 53.1 ± 9.1mm behind the tragus on the axial plane. The ideal catheter length was estimated to be 48.3 ± 9.6mm. The IEP for the frontal approach was localized to 11cm above the nasion and 4cm lateral to the midline. The IEP for the parieto-occipital approach was 5.5cm behind and 6cm above the tragus. These measurements lightly differ from the classical descriptions of Kocher's point and Keen's point and seem relevant to neurosurgical practice while using an orthogonal insertion.

Clinical Study on a Modified Hematoma Puncture Drainage Treatment in Patients with Hypertensive Basal Ganglia Hemorrhage

We aim to investigate the clinical efficacy and safety of a modified hematoma puncture drainage treatment through the burr hole lateral to Kocher's point from the frontal lobe in patients with hypertensive basal ganglia hemorrhage. Twenty-six patients were enrolled in the retrospective study. The volume of hematoma in those patients was between 25 and 35mL, and the Glasgow Coma Scale scores were between 9 and 11; they were divided into a hematoma puncture drainage treatment group and a traditional conservative treatment group. The volume of remaining hematoma, neurological function defect scores, and life quality after treatment, duration of hospitalization, and cost of hospitalization were analyzed in these 2 groups. The volume of remaining hematoma was significantly less in the drainage group than that in the traditional group on the first day and the third day after treatment (P < 0.05). Posttreatment neurological function defect scores in the drainage group were statistically lower than those in the traditional group (P < 0.05). The duration of hospitalization was significantly shorter and the cost of hospitalization was also significantly less in the drainage group than that in the traditional group (P < 0.05). The Extended Glasgow Outcome Scale and Barthel Index scores were significantly higher in the drainage group than those in the traditional group (P < 0.05). There were no significant differences between the 2 groups in the complication rates (P > 0.05). The modified hematoma puncture drainage treatment represents an effective and safe way to treat hypertensive basal ganglia hemorrhage.

A Morphometric Analysis of Commonly Used Craniometric Approaches for Freehand Ventriculoperitoneal Shunting.

Ventricular catheter tip position is a predictor for ventriculoperitoneal shunt survival. Cannulation is often performed freehand, but there is limited consensus on the best craniometric approach. To determine the accuracy of localizing craniometric entry sites and to identify which is associated with optimal catheter placement. This is a retrospective analysis of adult patients who underwent ventriculoperitoneal shunting. The approaches were categorized as Kocher's, Keen's, Frazier's and Dandy's points as well as the parieto-occipital point. An accurately sited burr hole was within 10 mm from standard descriptions. Optimal catheter tip position was defined as within the ipsilateral frontal horn. A total of 110 patients were reviewed, and 58% (65/110) of burr holes were accurately sited. Keen's point was the most correctly identified (65%, 11/17), followed by Kocher's point (65%, 37/57) and Frazier's point (60%, 3/5). Predictors for accurate localization were Keen's point (odds ratio 0.3; 95% CI: 01-0.9) and right-sided access (odds ratio 0.4; 95% CI: 0.1-0.9). Sixty-three percent (69/110) of catheters were optimally placed with Keen's point (adjusted odds ratio 0.04; 95% CI: 0.01-0.67), being the only independent factor. Thirteen patients (12%) required shunt revision at a mean duration of 10 ± 25 mo. Suboptimal catheter tip position was the only independent determinant for revision (adjusted odds ratio 0.11; 95% CI: 0.01-0.98). This is the first study to compare the accuracy of freehand ventricular cannulation of standard craniometric entry sites for adult patients. Keen's point was the most accurately sited and was a predictor for optimal catheter position. Catheter tip location, not the entry site, predicted shunt survival.

Effect of Intraoperative Computed Tomography on Ventriculoperitoneal Shunt Survival

In patients with hydrocephalus who undergo ventriculoperitoneal shunt placement, the ventricular catheter tip position is one of the most important prognostic factors influencing shunt survival. The aim of this study was to present our findings of ventriculoperitoneal shunt placement performed with intraoperative computed tomography (CT) and to evaluate the effect of intraoperative CT-based image guidance on optimal catheter positioning and overall shunt survival. Of the study enrolled 345 patients with hydrocephalus who underwent ventriculoperitoneal shunt placement for the first time between 2008 and 2018. Ventricular catheters were inserted freehand via the Kocher point into the lateral ventricle in all patients. In 163 patients, intraoperative CT was performed to confirm the tip position. In this group of patients, if the tip position was nonoptimal, the catheter was ejected and reinserted during the surgery. In the remaining 182 patients, the tip position was assessed with routine postoperative CT. The effect of performing intraoperative CT on catheter tip positioning and shunt failure was investigated. Nonoptimal tip position was significantly correlated with shunt dysfunction even when excluding nonobstructive causes (P < 0.001). In the intraoperative CT group, 11 ventricular catheters (6.7%) were intraoperatively repositioned. The repositioning significantly improved the optimal tip position rate from 54% to 58.3% (P= 0.007). Intraoperative CT usage also showed direct correlation with shunt survival (P= 0.006). Intraoperative CT is an effective tool for increasing the rate of optimal tip positioning and thereby overall shunt survival.

Acute Fulminant Cerebellitis in Children with COVID-19 Infection: A Rare But Treatable Complication

Acute Fulminant Cerebellitis in Children with COVID-19 Infection: A Rare But Treatable Complication

Tips and Tricks in Difficult ETV

The neuroendoscopy is supported by three pivotal pillars: training, planning, and prudence. The training consists of attending practical courses with synthetic head models for immersion in the intricate ventricular anatomy and practice in handling the neuroendoscope. The planning begins with the choice of the entry point, usually performed at the Kocher's point, and measurement of this to the ventricle. Neuroendoscopy in intraventricular hemorrhage or ventriculitis is always challenging due to low visibility, thus, copious irrigation with a heated solution at 37°C, like plasma type, is mandatory, often reaching 6L of solution. Narrow spaces between the clivus and basilar artery can be very dangerous, therefore we prefer a "Sputnik" fórceps rather than blunt instruments to open the floor of the III ventricle and subsequently widen it with Fogarty n°3. Sometimes it is necessary to mechanically remove the larger clots that do not come off the ventricle walls only with irrigation; in these cases, we aspirate them through the neuroendoscope until we see the structures that allow us to perform ETV and guarantee its patency. Navigating inside the ventricle when the complex anatomy is distorted, such as cases of myelomeningoceles with large interthalamic masses, can be very difficult; for these cases, we use the optics inversion technique to access different locations with the same field of view. The innovation in neuroendoscope models allowed us to associate techniques, such as the concomitant use of an ultrasonic aspirator to remove intraventricular lesions. Another field of great development was fetal surgery for hydrocephalus; initially with cephalocenteses passing through the ventriculo-aminiotic shunt until the fetal ETV. For complex cases of the second look of ETV, we can still associate techniques such as aqueductoplasty and implantation of stents in the third ventricular floor and cerebral aqueduct to keep them patent. Last but not least, we have the pillar of prudence. Any neuroendoscopy, regardless of the surgeon's experience or the apparent simplicity of the case, must be done with the utmost caution, avoiding minimal bleeding, avoiding touching structures that are not vital to the procedure, and be objective.

Endoscopic Anatomy of Lateral and Third Ventricles: A must Know for Performing Endoscopic Third Ventriculostomy.

Endoscopic third ventriculostomy is a safe alternative to ventriculo-peritoneal shunt for certain cases of obstructive hydrocephalus. It has the advantage of not leaving a permanent foreign body in-situ, besides preventing over-drainage and reducing chances of infection. A thorough knowledge of endoscopic anatomy of ventricles is a must for performing various endoscopic procedures. The aim of this study was to demonstrate the endoscopic anatomy of ventricles for educational purpose. ETV is done using a zero-degree LOTTA endoscope. Right Kocher's point is usually chosen as entry site into ventricle. The scope is negotiated into third ventricle through foramen of Monro. The premammillary membrane is perforated and dilated, thereby communicating the third ventricle to the chiasmatic, interpeduncular and prepontine cisterns. The video was recorded on Karl Storz recording system. It was edited using Imovie software. Photographs labeling was done using Windows PowerPoint 2018. Endoscopic anatomy knowledge allows a neurosurgeon to perform ETV safely.

Frame-Based Stereotactic Endoscopic Third Ventriculostomy—Toward Improved Precision and Minimizing Morbidities

Endoscopic third ventriculostomy (ETV) is a widely accepted treatment for obstructive hydrocephalus. For most practitioners, this procedure will be performed without navigation guidance. Without such guidance, the complications associated with the procedure have ranged from 1% to 8%. We hypothesized that the discrepancy between the surface bony anatomy and internal cranial anatomy contributes to the morbidities associated with ETV. We tested this hypothesis by comparing the position of the entry point defined by the classic Kocher's point relative to the ideal entry point that would result in no manipulation of the endoscope defined by frame-based stereotaxis. The cranial computed tomography scan of 58patients who had undergone frame-based stereotactic ETV was reformatted into 3-dimensional renderings. The location of this entry point was compared with the Kocher point, as determined by the external bony anatomy. Overall, >70% of the burr holes that provided an ideal trajectory to the third ventricle were ≥0.5 cm from the Kocher point in both the sagittal and the coronal planes. Median deviations of 0.74 and 0.81 cm in the coronal (P < 0.01) and sagittal (P < 0.0001) planes were observed. The use of stereotactic endoscopic techniques increase the safety of third ventriculostomy by adding precision and reducing otherwise unnecessary surgical maneuvering.

The Assessment of Geometric Reliability of Conventional Trajectory of Ventriculostomy in a Three Dimensional Virtual Model and Proposal of a New Trajectory.

Ventriculostomy is a common neurosurgery procedure performed for many purposes. Kocher’s point is most often used as the ventriculostomy entry point. But the accuracy of a cannula’s trajectory into the ventricles from entry at Kocher’s point is controversial. In this paper we attempt to evaluate the accuracy of the conventional sagittal trajectory, which uses Kocher’s point, and evaluate a new trajectory by creating virtual ventriculostomy simulations from computed tomography images of the brain. About 66 patients without brain and skull pathology in radiography were included. Three dimensional images were constructed using thin sliced brain computed tomography images, and a virtual ventriculostomy was performed toward the previous used surface landmark. And the path of ideal ventricular catheter was simulated. The anterior surface landmarks included the ipsilateral medial canthus, the contralateral medial canthus, and the midpoint between bilateral medial canthi. The lateral surface landmark was the external auditory canal. The sagittal trajectory of the three surface landmarks located in the frontal horn of ipsilateral ventricle was 0% for the ipsilateral medial canthus, 87.88% for the midpoint between bilateral medial canthi and 26.52% for the contralateral medial canthus. The anterior surface target of ideal sagittal trajectory, which connects the Kocher’s point with the central axis of ipsilateral ventricle, is contralaterally 6.7 mm away from midline. It was found that the conventional sagittal trajectory is inaccurate. The anterior target of surface landmark for the ideal sagittal trajectory is medial one third of the distance between the midline and the contralateral medial canthus.

Trajectories for Freehand-Guided Aspiration of Deep-Seated Spontaneous Intracerebral Hemorrhage

Although external landmarks and trajectories for external ventricular drainage have been described for the freehand-guided method, no standard trajectory has been reported for deep-seated intracerebral hemorrhage (ICH). This article presents a freehand-guided catheter insertion technique for deep-seated spontaneous ICH using external landmarks. Freehand-guided hematoma aspiration using Kocher's point and the external auditory canal as landmarks was performed in 32 patients with a diagnosis of spontaneous ICH in basal ganglia treated between May 2015 and July 2018 at the author's institute. In computed tomographic images, the mean actual to planned catheter tip distance was 16.1 ± 7.7 mm, the mean right-left deviation was 4.6 ± 5.2 mm, the mean anterior-posterior deviation was 11.1 ± 9.5 mm, and the mean superior-inferior deviation was 8.7 ± 4.4 mm. On largest hematoma slice, the mean distance from hematoma centers to inserted catheter was 9.8 ± 4.9 mm, and the mean horizontal and vertical distances were 4.0 ± 4.7 mm and 7.7 ± 4.8 mm, respectively. In 29 of the 32 patients, all the catheter holes contacted hematomas, whereas in the other 3 patients, 1 or more holes were in contact with brain parenchymal tissue. For patients with basal ganglia hemorrhage, freehand-guided catheter insertion and hematoma aspiration with subsequent fibrinolysis is a feasible procedure that shortens procedural times. The described technique could be used as an alternative method because it can be performed when the patient is in a critical state without additional equipment.

Smartphone-assisted endoscopic surgery via Kocher's point for intraventricular hemorrhage caused by thalamic hemorrhage: A comparison with external ventricular drainage.

The aim of the present study was to investigate the efficacy of endoscopic surgery via a Kocher point approach for intraventricular hemorrhage (IVH) caused by thalamic hemorrhage (TH), in comparison with external ventricular drainage (EVD). Between January 2016 and August 2017, a total of 40 patients with IVH caused by TH were enrolled. The patients were assigned to an EVD group and an endoscopic surgery group in a non-randomized manner. The pre-operative characteristics recorded included age, pre-operative Glasgow Coma Scale (GCS) score, hemorrhage volume, length of neuro-intensive care unit stay and Graeb score of IVH. Outcomes included the GCS score at 2 weeks after surgery, 30-day and 90-day mortality rates, modified Rankin scale at 6 months after ictus and ventriculo-peritoneal (VP) shunt rate. The baseline characteristics were not significantly different between the two groups. The VP shunt rate in the EVD group was significantly higher compared with that in the endoscopic surgery group (50.0 vs. 15.0%; P=0.02; odds ratio, 5.7). In conclusion, smartphone-assisted endoscopic surgery via Kocher's point is feasible and safe, and significantly reduces permanent shunt dependency for IVH caused by TH.

Ultrasound-guided percutaneous ventriculo-atrial shunt placement: Technical nuances with video demonstration

Abstract Hydrocephalic patients with abdominal pathologies often need a ventriculo-atrial (VA) shunt placement. Cut-down on the internal jugular vein has historically been used to insert a VA shunt. This technique is more time consuming and has greater complications. Less invasive methods, such as ultrasound-guided percutaneous VA shunt placement provides greater comfort for surgeon, is more rapid, and has fewer complications. However, this technique has not been demonstrated on video. Here we demonstrate ultrasound-guided and ECG-aided VA shunt catheter placement in a 70-year-old patient with normal pressure hydrocephalus. The internal jugular vein is punctured under ultrasound guidance with an 18-gauge needle. A guidewire is introduced through the needle, the needle is removed, and a small skin incision is placed at the entry point of the guidewire. A skin dilator with a sheath introducer is advanced to the vein using the guidewire and the guidewire is thereafter removed. An atrial shunt catheter (e.g. Codman® Medos® Atrial catheter) filled with sterile water is inserted through the sheath. The sheath is removed and a syringe filled with sterile aqua is connected to the catheter with a metal tip. The ECG connection of the right upper limb is connected to the tip of syringe to adjust for the optimal depth of the catheter under ECG guidance (point of highest p-wave amplitude). The catheter is clamped and tunneled to reach the site for the valve on the scalp. The ventricle catheter is placed at the Kocher point and connected to the valve (Video 1). Conclusion Ultrasound-guided VA shunt placement is safe, comfortable, rapid, and has a reduced rate of complications.

Autonomous Trajectory Planning for External Ventricular Drain Placement.

External ventricular drain (EVD) placement is the most frequently performed neurosurgical procedure for management of various conditions including hydrocephalus, traumatic brain injury, and stroke. State-of-the-art computational pattern recognition techniques could improve the safety and accuracy of EVD placement. Placement of the Kocher's point EVD is the most common neurosurgical procedure which is often performed in urgent conditions. To present the development of a novel computer algorithm identifying appropriate anatomy and autonomously plan EVD placement on clinical computed tomography (CT) scans. The algorithm was tested on 2 data sets containing 5-mm slice noncontrast CT scans. The first contained images of 300 patients without significant intracranial pathology (normal), the second of 43 patients with significant acute intracranial hemorrhage. Automated planning was performed by custom 2-tiered heuristic with run-time template selection in combination with refinement using nonlinear image registration. Automated EVD planning was accurate in 297 of 300 normal and 41 of 43 patient cases. In the normal data set, mean distance between Kocher's point and the ipsilateral foramen of Monro was 63±3.1 mm in women and 65±6.5 mm in men (P=.0008). Trajectory angle with respect to the sagittal plane was 91±6° in women and 90±6° in men (obtuse posterior) (P=.15); to the coronal plane, 85±6° and 86±5° in women and men (P=.12), respectively (acute lateral). A combination of linear and nonlinear image registration techniques accurately planned EVD trajectory in 99% of normal scans and 95% of scans with significant intracranial hemorrhage.