Ventricular Catheter Placement Research Articles

Angulation Toward Coronal Convexity Measure and Catheter Length Indication Improves the Quality of Ventricular Catheter Placement—A Smartphone-Assisted Guidance Technique

Accurate placement of a ventricular catheter (VC) is crucial to reduce the risk of shunt failure. In the randomized, prospective, multicenter GAVCA (guided application of ventricular catheters) trial, which evaluated the quality of VC placement, the subgroup of patients with detailed length-marked VCs (dVCs) reflected a difference in the primary endpoint of optimal VC placement compared with the subgroup of patients with simplified length-marked VCs (sVCs). The objective of the present analysis was to compare the dVC and sVC groups and the smartphone-assisted guidance technique (GA) with the standard freehand technique (FH) for VC placement. We performed a further analysis of the GAVCA trial in 2 steps. First, we compared the dVCs, which provided a detailed distance from the tip to the base (3-13 cm) in 0.5-cm intervals, with the sVCs with a length indication at 5 and 10 cm from the tip to base. Second, we compared the GA technique with the FH in the dVC group. The data from 137 patients (104 dVC patients vs. 33 sVC patients) were eligible for the present analysis. Optimal VC placement was achieved in 72.1% of the dVC group and 39.4% of the sVC group (odds ratio, 3.9; 95% confidence interval, 1.7-9.3; P ≤ 0.001). In addition, we performed a subgroup analysis of the 104 dVC patients concerning the accuracy of catheter placement using 2 different techniques (GA, n= 54; and FH, n= 50). Optimal catheter placement was achieved in 81.5% of the GA group and 62.0% of the FH group (odds ratio, 2.7; 95% confidence interval, 1.1-6.8; P= 0.03). VC placement using the GA technique was successful in all patients at the primary puncture. In contrast, for 8.7% of the patients in the FH group, multiple attempts were necessary (P= 0.03). The results from the present analysis suggest that the combination of a GA technique and the use of a dVC will improve the rate of accurate VC placement. Compared with the FH technique, patient safety was increased by the reduction of unsuccessful VC placement attempts using the GA technique and dVCs.

Outcome of Initial 3 Years of Cranial Endoscopy at DG Khan Medical College and Teaching Hospital, Dera Ghazi Khan

With the evolution of surgical approaches, endoscopic skull base surgery has emerged as a suitable alternative to many other invasive methods. The aim of this study was to investigate the efficacy and outcome of cranial endoscopy in treating various neurosurgical intracranial pathologies in terms of procedural success and complications. This observational, prospective case series was conducted at the Department of Neurosurgery of DG Khan Medical College from November 2017 to October 2020. The study enrolled 74 patients with indications for cranial neuroendoscopy. Clinical examination was performed, and a detailed history of the disease was obtained. Follow-up was conducted in the outpatient department. The collected data were analyzed using statistical analysis software. Of 77 procedures performed, endoscopic third ventriculostomy, arachnoid cyst fenestration, septostomy, colloid cyst excision, endoscopic assisted ventricular catheter placement, and intraventricular tumor biopsy were performed in 53.3%, 18.2%, 10.4%, 7.8%, 6.5%, and 3.9% of patients. Aqueductal stenosis was identified as the most common cause of obstructive hydrocephalus. Seizures and cerebrospinal fluid leaks were the most commonly reported complications (12% and 8.1%, respectively). The observed mortality rate was 2.7%. Neuroendoscopic surgery has become safe and effective, as surgeon experience and learning have lowered the risk of complications, and offers a low-cost alternative intervention.

Endoscopic Placement of Fourth Ventricular Catheter Using Seldinger Technique: Description of Technique and Case Series.

Neonatal intraventricular hemorrhage remains a significant source of morbidity in premature and low-weight patients. Approximately 15% of patients who require cerebrospinal fluid shunting develop trapped fourth ventricle (TFV). Surgical treatment presents challenges with short- and long-term complications. To describe a technique that applies the Seldinger technique with image-guided endoscopy for direct visualization of catheter placement. A guidewire is passed down the endoscope while it is positioned in the fourth ventricle. The endoscope is removed while the guidewire is held in place. The catheter is slid down the guidewire. The guidewire is removed and placement is confirmed with image guidance. Three patients, all less than 14 mo old, with history of prematurity and intraventricular hemorrhage with ventriculoperitoneal shunts, presented with loculated hydrocephalus with TFV. They each underwent image-guided endoscopic fenestration of the fourth ventricle with placement of a fourth ventricular catheter performed by our described technique. All 3 patients recovered well and were discharged on postoperative day 1. Follow-up imaging showed decompression of the fourth ventricle and good placement of the fourth ventricular catheter. None have had complications from catheter placement, and one revision of a fourth ventricular catheter was needed, which was completed with the same described technique. This technique is well suited for cases in which a fourth ventricular catheter or a difficult trajectory catheter is needed during endoscopic fenestration or when distorted anatomy is present that would make a straight trajectory with a pen endoscope more difficult or higher risk.

Accurate placement of parieto-occipital shunt ventricular catheter: use of craniometrics and technical note.

Ventriculoperitoneal shunt insertion is one of the most commonly performed procedures in neurosurgery but has arelatively high complication rate. One important source of complications is shunt malposition from erroneousplacement of the parieto-occipital burr hole or poor shunt trajectory. There are significant variations in the freehandparieto-occipital approach amongst neurosurgeons that are derived from variations in technique or experience. Thepatient's skull shape or size is also often not taken into consideration if fixed measurements are used to define theburr hole entry point. The authors suggest a variation to the technique of ventricular catheter placement by relyingon the patient's own craniometrics and skull landmarks. The technique is illustrated and supported by analysis of a case series of 25 patients undergoing shunt placement. By this method, all shunts were positioned in the lateral ventricle. Using a 3-point scale, the catheter position wasevaluated: grade 1, free floating in cerebrospinal fluid; grade 2, touching the choroid plexus or ventricular wall; andgrade 3, tip within the parenchyma. The catheter position was grade 1 in sixteen (64%) cases and grade 2 in nine(36%) cases; none was grade 3. Only one shunt malfunction occurred from proximal shunt obstruction in theseries. The use of this technique aims to reduce operator and patient variability as contributors to shunt malposition, toincrease user reproducibility and decrease the learning curve for trainees. Further prospective study could bedesigned to validate the technique.

Left Ventricular Perforation and Improper Catheter Placement in Ascending Aorta as a Complication of Emergency Pericardiocentesis

Complications associated with pericardiocentesis can be severe and life-threatening. We report a case of a 25-year-old male presented in the emergency department after a polytrauma. The initial full-body scan showed grade I aortic isthmus injury, hemopericardium at 10-mm depth, grade 3 hepatic lacerations, and grade V spleen laceration complicated by hemoperitoneum. The indication for total splenectomy was emergent. Postprocedural, the patient was hemodynamically unstable and an emergency ultrasound-guided pericardiocentesis was performed to treat the hemopericardium. After draining 500 mL of coagulated blood, rupture of the aortic isthmus with pericardial effusion was suspected. A CT angiography showed an improper catheter placement with left ventricular perforation and the presence of the catheter tip in the ascending aorta. Emergency median sternotomy was performed to remove the catheter and to repair the left ventricle. The patient’s hemodynamic condition improved hours after intervention, and he was discharged 11 days later. Pericardiocentesis should be performed guided by ultrasonography, and even so, it carries risks of complications. Cardiac injury after pericardiocentesis is a rare but serious complication that must be identified quickly and should be treated by a multidisciplinary team.

Freehand stereotactic ventricular catheter insertion for ventriculoperitoneal shunts based on individualized radio-anatomical landmarks.

The accurate placement of the ventricular catheter (VC) is critical in reducing the incidence of proximal failure of ventriculoperitoneal shunts (VPSs). The standard freehand technique is based on validated external anatomical landmarks but remains associated with a relatively high rate of VC malposition. Already proposed alternative methods have all their specific limitations. Herein, we evaluate the accuracy of our adapted freehand technique based on an individualized radio-anatomical approach. Reproducing the preoperative imaging on the patient's head using common anatomical landmarks allows to define stereotactic VC coordinates to be followed at surgery. Fifty-five consecutive patients treated with 56 VPS between 11/2005 and 02/2020 fulfilled the inclusion criteria of this retrospective study. Burr hole coordinates, VC trajectory, and length were determined in all cases on preoperative computed tomography (CT) scan and were accurately reported on patients' head. The primary endpoint was to evaluate VC placement accuracy. The secondary endpoint was to evaluate the rate and nature of postoperative VC-related complications. Our new technique was applicable in all patients and no VC-related complications were observed. Postoperative imaging showed VC optimally placed in 85.7% and sub-optimally placed in 14.3% of cases. In all procedures, all the holes on the VC tip were found in the ventricular system. This simple individualized technique improves the freehand VC placement in VPS surgery, making its accuracy comparable to that of more sophisticated and expensive techniques. Further randomized controlled studies are required to compare our results with those of the other available techniques.

Paediatric bacterial meningitis in the USA: outcomes and healthcare resource utilization of nosocomial versus community-acquired infection.

Introduction. Paediatric bacterial meningitis remains a costly disease, both financially and clinically.Hypothesis/Gap Statement. Previous epidemiological and cost studies of bacterial meningitis (BM) have largely focused on adult populations or single pathogens. There have been few recent, large-scale studies of pediatric BM in the USA.Aim. We examined healthcare resource utilization (HCRU) and associated morbidity and mortality of community-acquired versus nosocomial bacterial infections in children across the USA.Methodology. The IBM MarketScan Research databases were used to identify patients <18 years old admitted to USA hospitals from 2008 to 2015 with a primary diagnosis of BM. Cases were categorized as either community-acquired or nosocomial. HCRU, post-diagnosis neurosurgical procedures, 30-day in-hospital mortality, and complications were compared between groups. Multivariable regression adjusted for sex, age and Gram staining was used to compare costs of nosocomial versus community-acquired infections over time.Results. We identified 1928 cases of paediatric BM without prior head trauma or neurological/systemic complications. Of these, 15.4 % were nosocomial and 84.6 % were community-acquired infections. After diagnostic lumbar puncture (37.1 %), the most common neurosurgical procedure was placement of ventricular catheter (12.6 %). The 30-day complication rates for nosocomial and community-acquired infections were 40.5 and 45.9 %, respectively. The most common complications were hydrocephalus (20.8 %), intracranial abscess (8.8 %) and cerebral oedema (8.1 %). The 30-day in-hospital mortality rates for nosocomial and community-acquired infections were 2.7 and 2.8 %, respectively.Median length of admission was 14.0 days (Q1: 7 days, Q3: 26 days). Median 90-day cost was $40 861 (Q1: $11 988, Q3: $114,499) for the nosocomial group and $56 569 (Q1: $26 127, Q3: $142 780) for the community-acquired group. In multivariable regression, the 90-day post-diagnosis total costs were comparable between groups (cost ratio: 0.89; 95 % CI: 0.70 to 1.13), but at 2 years post-diagnosis, the nosocomial group was associated with 137 % higher costs (CR: 2.37, 95 % CI: 1.51 to 3.70).Conclusion. In multivariable analysis, nosocomial infections were associated with significantly higher long-term costs up to 2 years post-infection. Hydrocephalus, intracranial epidural abscess and cerebral oedema were the most common complications, and lumbar punctures and ventricular catheter placement were the most common neurosurgical procedures. This study represents the first nation-wide, longitudinal comparison of the outcomes and considerable HCRU of nosocomial versus community-acquired paediatric BM, including characterization of complications and procedures contributing to the high costs of these infections.

Free-hand stereotactic ventricular catheter insertion technique based on radio-anatomical landmarks. How I do it

Accurate ventricular catheter (VC) placement plays an important role in reducing the risk of ventriculoperitoneal shunt failure. Free-hand VC insertion is associated with a significant misplacement rate. Consequently, several expensive alternative methods that are unfortunately not available worldwide have been used. To overcome these limitations, we developed a simple surgical technique based on radio-anatomical landmarks aimed at reducing VC's misplacements. We reproduce the preoperative imaging on the patient's head using common anatomical landmarks. This allows defining stereotactic VC coordinates to be followed during the surgical procedure. This simple and cost-effective method improves VC insertion accuracy.

Role of intraoperative computed tomography scanner in modern neurosurgery - An early experience.

Background: Intraoperative imaging addresses the limitations of frameless neuronavigation systems by providing real-time image updates. With the advent of new multidetector intraoperative computed tomography (CT), soft tissue can be visualized far better than before. We report the early departmental experience of our intraoperative CT scanner’s use in a wide range of technically challenging neurosurgical cases.Methods: We retrospectively analyzed the data of all patients in whom intraoperative CT scanner was utilized. Out of 31 patients, 24 (77.4%) were cranial and 8 (22.6%) spinal cases. There were 13 male (41.9%) and 18 (58.1%) female patients, age ranged from 1 to 83 years with a mean age of 34.29 years ±17.54 years. Seven patients underwent spinal surgery, 2 cases were of orbital tumors, and 16 intra-axial brain tumors, including 5 low- grade gliomas, 10 high-grade gliomas, and 1 colloid cyst. There were four sellar lesions and two multiloculated hydrocephalus.Results: The intraoperative CT scan guided us to correct screw placement and was crucial in managing four complex spinal instabilities. In intracranial lesions, 59% of cases were benefitted due to intraoperative CT scan. It helped in the precise placement of ventricular catheter in multiloculated hydrocephalus and external ventricular drain for a third ventricular colloid cyst.Conclusion: Intraoperative CT scan is safe and logistically and financially advantageous. It provides versatile benefits allowing for safe and maximal surgery, requiring minimum changes to an existing neurosurgical setup. Intraoperative CT scan provides clinical benefit in technically difficult cases and has a smooth workflow.

Compared with conventional procedures, an intraoperative navigation system for ventriculoperitoneal shunting via the occipital horn improves outcomes in patients with hydrocephalus

Background Ventriculoperitoneal shunting (VPS) is a common neurosurgical procedure used to treat hydrocephalus. Although the use of a navigation system in VPS achieves superior results compared with conventional surgery, the relationships among clinical symptoms, ventricular catheter placement, catheter obstruction, and the postoperative Evans index have not been clearly reported. Methods We performed a retrospective study of 40 patients with VPS (the navigation surgery group) and 31 patients with VPS (the conventional surgery group). Clinical data, follow-up times, catheterization accuracy, postoperative outcomes, cumulative survival times, and correlations between catheter placement and obstruction, symptom grade and the postoperative Evans index were analyzed. Results Thirty-seven patients experienced optimal ventricular catheter placement (grade 1), three experienced suboptimal placements (grade 2), and none experienced poor ventricular catheter placement (grade 3) in the navigation surgery group. Greater improvement in postoperative symptoms (p < 0.001), including less catheter readjustment (p < 0.001), was observed in the navigation surgery group. A Kaplan–Meier analysis showed that the cumulative catheter obstruction-free survival time was longer in the navigation surgery group (p = 0.016). Moreover, catheter placement was significantly correlated with catheter obstruction (p < 0.001). Additionally, catheter obstruction was significantly correlated with the symptom grade (p < 0.001) and postoperative Evans index (p = 0.002). Conclusion VPS for hydrocephalus via the occipital horn with a navigation system is superior to the conventional surgical procedure in terms of clinical outcomes, the precision of ventricular catheterization, and the occurrence of complications. Catheter obstruction-free survival times were longer in the navigation surgery group and catheter placement was significantly correlated with catheter obstruction.

A simple and cost-effective model for ventricular catheter placement training: technical note.

External ventricular drain (EVD) placement is one of first cranial procedures neurosurgery residents are expected to perform independently. While proper training improves patient outcomes, there are few options for practicing EVD placement prior to placing the EVD in patients in a clinical setting. Proposed solutions to this include using cadaveric models and virtual simulations, but barriers exist with these as well in regard to authenticity. EVD simulators using virtual reality technologies are a promising new technique for training, but the cost of these devices poses a barrier to general/widespread accessibility among smaller programs or underserved hospitals. The authors desribe a novel, yet simple, and cost-effective technique (less than $5 per mold) for developing a brain model constructed of homemade ballistics gelatin that can be used for teaching and practicing the placement of EVD. A brain model is made with ballistics gelatin using an anatomically correct skull model as a mold. A 3D-printed ventricular system model is used to create a mold of an anatomically correct ventricular system in the brain model. A group of medical students (n = 10) were given a basic presentation about EVD placement, including standard landmarks and placement techniques, and were also shown a demonstration of EVD placement on the brain model. They were then allowed to perform an EVD placement using the brain model. The students were surveyed on their experience with using the brain model, including usability and practicality of the model. Accuracy of EVD placement by each student was also assessed, with adequate position of catheter tip being in the ipsilateral frontal horn. The final product is fairly inexpensive and easy to make. It is soft enough to pass a catheter through, but it is also firm enough to maintain its shape, including a cavity representing the lateral ventricles. The dense gelatin holds the catheter in its final resting position, while the two halves are separated and inspected. All participants in the test group of medical students reported that the brain model was easy to use, helped them understand the steps and technique of EVD placement, and provided good feedback on the ideal position of ventricular catheters. All of the participants in the group had adequate positioning of their ventricular catheters after one attempt. The presented brain model is easy to replicate, inexpensive, anatomically accurate, and provides a medium for neurosurgeons to teach and practice ventricular catheter placement in a risk-free environment.

Endoscopic Versus Free Hand Insertion of the Ventricular Catheter in Ventriculo-Peritoneal Shunt

Hydrocephalus is a disturbance of cerebrospinal fluid [CSF] formation, flow, or absorption, leading to an increase in volume occupied by this fluid in the central nervous system. It is either communicating or non-communicating. On assess ventricular catheter placement Possibly for anatomic landmark–guided free hand placement or endoscopic helped placement in regards to intraoperative parameters What's more postoperative Conclusion. This examine might have been a explanatory investigation led ahead [60] patients for hydrocephalus undergoing VP shunt were haphazardly ordered under 2 groups, [30] for free hand insertion and the other [30] with endoscopic guided insertion. Concerning illustration respect our study there might have been critical statistically Contrast [P esteem = 0. 010 ] in regards to Subgalial collection, spoiling What's more glitch the middle of two groups, there is no huge statistically Contrast viewing Vomiting, Fits, sd Hygroma , Fever, SDH What's more Pneumocephalous the middle of two aggregations. In spite of expositive expression proposes that new innovative developments including navigation, ultrasonography What's more endoscope enhance ventricular catheter position especially clinched alongside challenging cases, free-handed system customized as stated by those head and ventricular setup In view of pre-operative ct mind could provide for acceptable ventricular catheter position, particularly in the control about an encountered specialist.

Image-Guided Stereotactic Ventricular Catheter Placement for Refractory Idiopathic Intracranial Hypertension: Accuracy and Effectiveness

AbstractBackground: Although lumboperitoneal shunt (LPS) is a common procedure for surgical management of idiopathic intracranial hypertension (IIH). However, many studies doc-umented a high failure and complications rate. Ventricular shunts were not commonly used for surgical management IIH due to the difficulty of inserting a shunt into normal or slit ventricles. Also, stereotactic surgery not available in every hospital.Aim of the Study: This article retrospectively evaluate the accuracy, efficacy, and safety of using stereotactic image-guided insertion of ventricular catheter in patients with IIH.Patients and Methods: The authors reviewed the clinical records of all patients in whom stereotaxy was used to guide the placement of a ventricular catheter for IIH. Stereotactic guided ventricular catheter placements were performed on sixteen patients presenting with clinical manifestation of IHH to target the frontal horn of the lateral ventricle after failure of traditional medical or previous surgical treatment. Results: We had fourteen females and two males. Their age ranged from 20 to 45 years (average 29.7). The mean follow-up period was 43.9 months (ranged from 10 to 84 months). Eleven patients had previous LPS insertion with at least one trial of revision. Five patients subjected to stereotactic VPS as a first procedure. Accurate ventricular catheter place-ment was done from the first trial in all patients which was confirmed on postoperative CT scan. Four patients underwent stereotactic ventriculo-atrial shunts due to decrease CSF absorptive capacity of peritoneal cavity due to multiple lumboperitoneal shunt revision. All patients showed improve-ment or stabilization of their visual manifestation after ven-tricular shunt insertion. Headache improved in fourteen patients whereas two patients still had headache that respond to medical treatment. We had no mortality and two patients required shunt revision.Conclusions: Image-guided stereotactic ventricular cath-eter placement is an effective, safe and durable management option that can help in management of IIH when the ordinary medical and surgical methods fail. Also it may be the first choice in certain selected cases.

Relationship of the Location of the Ventricular Catheter Tip and Function of the Ventriculoperitoneal Shunt

Object: The objective of this study was to determine the relationship of the location of the ventricular catheter tip and function of the ventriculoperitoneal shunt.&#x0D; Methods: This prospective observational study included 140 patients from a single institution who underwent a ventriculoperitoneal shunt procedure in which a new ventricular catheter was placed between September, 2013 and September 2016. Data abstracted for each patient included age, sex, diagnosis, site and side of ventricular catheter placement. Postoperative CT scan images were reviewed for accuracy of ventricular catheter placement. Patients were followed up over 2 ½ to 4 ½ years.63 patients were available for follow up. We lost communication with rest of the patients. The relationship of the location of the ventricular catheter tip and function of the ventriculoperitoneal shunt was analyzed in 63 patients.&#x0D; Results: There were 140 patients included in the study; accuracy ventricular catheter tip placement were 55 (39.28%) using freehand technique. VP shunt functioned well in 43 (68.25%) of 63 patients. Among the 43 patients with well functioning shunt ,19 were in accurate group ,7 were in suboptimal group and 17 were in inaccurate group.26 patients (41.27%) had good outcome with normal development and normal IQ&#x0D; Conclusions: Mechanical malfunction and infection are the most significant problems associated with shunts for the treatment of hydrocephalus. Above all, a significant proportion of shunt failure was due to obstruction of the ventricular catheter, and accurate placement of the shunt catheter is highly important to reduce the incidence of shunt malfunction.&#x0D; Bang. J Neurosurgery 2019; 9(1): 16-21

Accuracy of Ventricular Catheter Tip Placement Using Freehand Placement

Background: Inaccurate placement of VP shunt catheter is related to shunt failure.&#x0D; Objective: The objective of this study was to determine the accuracy of ventricular catheter placement during ventriculoperitoneal shunt operations using the freehand technique.&#x0D; Methodology: This prospective observational study included all patients from a single institution who underwent a ventriculoperitoneal shunt procedure in which a new ventricular catheter was placed between September 2013 and August 2016 for a period of three (03) years. Data abstracted for each patient included age, sex, diagnosis, site and side of ventricular catheter placement. Postoperative CT scan images were reviewed for accuracy of ventricular catheter placement.&#x0D; Results: There were 140 patients included in the study; accuracy ventricular catheter tip placement were 55 (39.28%) using freehand technique.&#x0D; Conclusion: Mechanical malfunction and infection are the most significant problems associated with shunts for the treatment of hydrocephalus.&#x0D; Journal of National Institute of Neurosciences Bangladesh, 2019;5(1): 59-63

Utility of Preoperative Simulation for Ventricular Catheter Placement via a Parieto-Occipital Approach in Normal-Pressure Hydrocephalus.

Freehand ventricular catheter placement has been reported to have poor accuracy. To investigate whether preoperative computational simulation using diagnostic images improves the accuracy of ventricular catheter placement. This study included 113 consecutive patients with normal-pressure hydrocephalus (NPH), who underwent ventriculoperitoneal shunting via a parieto-occipital approach. The locations of the ventricular catheter placement in the last 48 patients with preoperative virtual simulation on the 3-dimensional workstation were compared with those in the initial 65 patients without simulation. Catheter locations were classified into 3 categories: optimal, suboptimal, and poor placements. Additionally, slip angles were measured between the ventricular catheter and optimal direction. All patients with preoperative simulations had optimally placed ventricular catheters; the mean slip angle for this group was 2.8°. Among the 65 patients without simulations, 46 (70.8%) had optimal placement, whereas 10 (15.4%) and 9 (13.8%) had suboptimal and poor placements, respectively; the mean slip angle for the nonsimulation group was 8.6°. The slip angles for all patients in the preoperative simulation group were within 7°, whereas those for 31 (47.7%) and 10 (15.4%) patients in the nonsimulation group were within 7° and over 14°, respectively. All patients with preoperative simulations experienced improved symptoms and did not require shunt revision during the follow-up period, whereas 5 patients (7.7%) without preoperative simulations required shunt revisions for different reasons. Preoperative simulation facilitates accurate placement of ventricular catheters via a parieto-occipital approach. Minimally invasive and precise shunt catheter placement is particularly desirable for elderly patients with NPH.

Commentary: Utility of Preoperative Simulation for Ventricular Catheter Placement via a Parieto-Occipital Approach in Normal-Pressure Hydrocephalus.

Commentary: Utility of Preoperative Simulation for Ventricular Catheter Placement via a Parieto-Occipital Approach in Normal-Pressure Hydrocephalus.

Methods and Devices for Posterior Ventriculoperitoneal Shunt Placement Surgery: 25 Years of Iterative Refinement

The posterior ventriculoperitoneal shunt (VPS) placement procedure is technically efficient and cosmetically appealing. The main limitations of the posterior approach relate to the technical challenges associated with accurately placing the ventricular catheter. In this report, we describe methods and simple devices used for posterior VPS surgery that have evolved over a >25-year period to enhance catheter placement accuracy and reduce complication rates. We describe the combination of methods and customized devices used at a single institution to perform posterior VPS surgery. Results are presented for the most recent 11-year epoch, along with a description of sources of technical errors and plans for further methodologic refinements. The medical records and imaging studies of 468 patients undergoing posterior VPS, from 2007 to 2018 were reviewed. Ventricular catheter placement accuracy data were collected and complications were identified and recorded. Optimal ventricular catheter placement was achieved in 98.29%. Of the remaining 1.71%, one half (0.85%) required acute revision surgery. Four patients (0.85%) developed new neurologic deficits following surgery; 2 were related to intraparenchymal hemorrhages and 2 (0.43%) as a result of a misplaced catheter. The deficits resulting from poor catheter placement were transient. The complication rates due to causes other than catheter placement accuracy compared favorably with those reported previously in the literature. Using the methods and devices described in this series, posterior VPS operations can be performed safely with a high degree of ventricular catheter placement accuracy.

The Wishbone: A Cranial Midline Localizing Device

The Wishbone device is designed to enable surgeons to quickly and accurately localize the cranial midline. It is intended to be of particular use when localizing the burr hole site during posterior ventriculoperitoneal shunt (VPS) surgery. The Wishbone is a simple mechanical device with 2 adjustable caliper arms that reversibly attach to a patient's left and right external auditory canals. The Wishbone's laser localizer illuminates the midline scalp. The Wishbone was used to localize the posterior midline in a pilot series of patients undergoing VPS surgery. Midline localization and ventricular catheter placement accuracy were determined using findings from postoperative computed tomography scans. The Wishbone is a mechanically robust device and proved easy for surgeons to use. Forty patients underwent VPS surgery using the Wishbone to localize the posterior midline. The localization procedure took less than 3 minutes. The average distance separating the Wishbone-localized midline scalp location and the computed tomography-defined anatomical midline was 2.9 mm (95% confidence interval 1.6-4.1 mm). In all cases, the ventricular catheter entered the ipsilateral lateral ventricle. The catheter tips were placed in the ipsilateral (n= 34) or contralateral (n= 5) frontal horn in all but 1 patient. In 1 patient, the catheter tip entered the parenchyma due to a burr hole localization error in the rostrocaudal dimension, unrelated to the Wishbone. We describe a simple, efficient, and cost-effective system for accurately localizing the posterior cranial midline. A larger patient series is required to definitively compare its clinical utility relative to frameless stereotaxis-based midline localization methods.

The risk of ventricular catheter misplacement and intracerebral hemorrhage in shunt surgery for hydrocephalus

Abstract Ventricular shunt insertion is a commonly performed neurosurgical procedure but few studies evaluate the rates of ventricular catheter (VC) misplacement and postoperative intracerebral hemorrhage (ICH) after shunt surgery. In this study, we evaluated the rate of VC misplacement and ICH after shunt insertion in hydrocephalus patients. A consecutive series of adult patients (n = 240) that received a ventricular shunt for hydrocephalus were included in the study. Misplacement was defined as tip of the VC located in the contralateral ventricle or intraparenchymal. The event of ICH was based on verification of intraparenchymal blood on an early ( Misplacement of the VC tip was found in 76 patients (33%); 70 patients with the VC tip in the contralateral ventricle and six patients (3%) with the VC tip intraparenchymal. ICH occurred in 8% of the patients. The shunt revision rate for accurately placed VCs was 17% compared to 21% for misplaced VC (p = 0.37). Proximal shunt failure occurred in 11% of the patients with VC misplacement compared to 5% of the patients with accurate VC placement (p = 0.07). VC misplacement occurred in one third and ICH was evident in 8% of the patients. However, VC misplacement did not significantly increase the shunt revision rate. Still, measures to optimize VC placement may be important to reduce risks following ventricular shunt placement.