A US-based survey on ventriculostomy practices

Rehman, Tausif; Rehman, Atiq-ur; Rehman, Amina; Bashir, Hamid; Ali, Rushna; Bhimani, Salima; Khan, Sidra

doi:10.1016/j.clineuro.2011.12.040

Cited by 27 publications

(13 citation statements)

References 16 publications

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“…In slit ventricles failure rates of even up to 68% were described [37]. A US-based survey on ventriculostomy practice showed that in slit ventricles 51.7% of participants nowadays use image guidance, while 41.6% use freehand techniques and 6.7% use the Ghajar guide [38]. Clearly, the rate of shunt malfunction increases with suboptimally placed ventricular catheters [39].…”

Section: Discussionmentioning

confidence: 99%

Shunt Surgery in Idiopathic Intracranial Hypertension Aided by Electromagnetic Navigation

Hermann¹,

Polemikos²,

Heissler³

et al. 2017

Stereotact Funct Neurosurg

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Background: Idiopathic intracranial hypertension (IIH) is characterized by increased cerebrospinal fluid (CSF) pressure and normal or slit ventricles. Lumboperitoneal shunting had been favored by many investigators for CSF diversion in IIH for decades; however, it has been associated with various side effects. Because of the small ventricular size adequate positioning of a ventricular catheter is challenging. Objectives: Here, we investigated the usefulness of electromagnetic (EM)-guided ventricular catheter placement for ventriculoperitoneal shunting in IIH. Methods: Eighteen patients with IIH were included in this study. The age of patients ranged from 5 to 58 years at the time of surgery (mean age: 31.8 years; median: 29 years). There were 2 children (5 and 11 years old) and 16 adults. Inclusion criteria for the study were an established clinical diagnosis of IIH, lack of improvement with medication, and the presence of small ventricles. In all patients EM-navigated placement of the ventricular catheter was performed using real-time tracking of the catheter tip for exact positioning close to the foramen of Monro. Postoperative CT scans were correlated with intraoperative screen shots to validate the position of the catheter. Results: In all patients EM-navigated ventricular catheter placement was achieved with a single pass. There were no intraoperative or postoperative complications. Postoperative imaging confirmed satisfactory positioning of the ventricular catheter. No proximal shunt failure was observed during the follow-up at a mean of 41.5 months (range: 7-90 months, median: 40.5 months). Conclusions: EM-navigated ventricular catheter placement in shunting for IIH is a safe and straightforward technique. It obviates the need for sharp head fixation, the head of the patient can be moved during surgery, and it may reduce the revision rate during follow-up.

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Section: Discussionmentioning

confidence: 99%

Shunt Surgery in Idiopathic Intracranial Hypertension Aided by Electromagnetic Navigation

Hermann¹,

Polemikos²,

Heissler³

et al. 2017

Stereotact Funct Neurosurg

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“…1,2,7,14,15 In a recent US survey of the surgical techniques used for ventriculostomy placement in patients with slit ventricles, the Ghajar Guide technique was used by only 6.7% of the respondents, whereas the remaining respondents used image guidance or a freehand technique. 12 When the survey asked about improvements that would increase usage of the Ghajar Guide, 22.1% of the respondents suggested an adjustable guide for a midline shift or abnormal ventricular anatomy, and 19.0% suggested the availability of more data on the use of the Ghajar Guide technique. Thus, the results of our study may encourage greater use of a Ghajar Guide-based technique with coronal adjustment.…”

Section: Discussionmentioning

confidence: 99%

Calvarial slope affecting accuracy of Ghajar Guide technique for ventricular catheter placement

Park

Son

Park

et al. 2016

JNS

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OBJECT The Ghajar Guide technique is used to direct a ventricular catheter at a 90° angle to the skull surface at Kocher’s point. However, the human calvaria is not completely spherical. Lateral to the sagittal midline, the calvaria slopes downward with individual variation and thereby affects the accuracy of ventricular catheter placement. Accordingly, the authors investigated the accuracy of the orthogonal catheter trajectory using radiographic simulation and examined the effect of the calvarial slope on this accuracy. METHODS A catheter trajectory orthogonal to the skull surface at Kocher’s point and the ideal catheter trajectory to the foramen of Monro were drawn bilaterally on coronal head images of 52 patients with hydrocephalus. The correction angle, the difference between the 2 catheter trajectories, was then measured. Meanwhile, the calvarial slope was measured around Kocher’s point by using a coronal head image. The correlation between the correction angle and factors such as the calvarial slope and bicaudate index was then assessed using a Pearson correlation analysis. RESULTS The ventricular catheter trajectory orthogonal to the skull at Kocher’s point in the patients with hydrocephalus led to a catheter trajectory into the ipsilateral (70.2%) or contralateral (29.8%) lateral ventricles. The correction angles ranged from −3.3° to 16.4° (mean ± SD 5.7° ± 3.7°). In 87 (83.7%) head sides, lateral deviation from the orthogonal trajectory was required to approximate the ideal trajectory, and the correction angle ranged from 2.0° to 16.4° (mean 6.7° ± 2.9°). The calvarial slope in the 104 head sides ranged from 15.6° to 32.5° (mean 24.2° ± 3.1°). Pearson correlation analysis revealed a strong positive correlation (r = 0.733) between the calvarial slope and the correction angle. CONCLUSIONS The accuracy of ventricular catheter placement using the Ghajar Guide technique is affected primarily by the calvarial slope around Kocher’s point. A radiographic analysis of a preoperative coronal head image can be used to estimate the accuracy of ventricular catheter placement and enable adjustment to approximate the ideal catheter trajectory.

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“…15 Since then, endoscopy, ultrasonography, and neuronavigation are being increasingly used in selected cases. A recent nationwide survey revealed that more than half of neurosurgeons and neurosurgical residents in the US prefer to use image-guided techniques, 18 and recent trials are aiming to use smartphone technology in conjunction with MRI and CT images. 19,20 The development of an easy-to-use, portable, image-guided system could reduce the need for multiple passes and improve the rate of accurate catheter placement in a more efficient, safe, and cost-effective manner.…”

Section: Discussionmentioning

confidence: 99%

Ventriculostomy-associated hemorrhage: a risk assessment by radiographic simulation

Robertson

Abd-El-Barr

Mukundan

et al. 2017

Journal of Neurosurgery

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OBJECTIVEVentriculostomy entry sites are commonly selected by freehand estimation of Kocher's point or approximations from skull landmarks and a trajectory toward the ipsilateral frontal horn of the lateral ventricles. A recognized ventriculostomy complication is intracranial hemorrhage from cortical vessel damage; reported rates range from 1% to 41%. In this report, the authors assess hemorrhagic risk by simulating traditional ventriculostomy trajectories and using CT angiography (CTA) with venography (CTV) data to identify potential complications, specifically from cortical draining veins.METHODSRadiographic analysis was completed on 50 consecutive dynamic CTA/CTV studies obtained at a tertiary-care academic neurosurgery department. Image sections were 0.5 mm thick, and analysis was performed on a venous phase that demonstrated high-quality opacification of the cortical veins and sagittal sinus. Virtual ventriculostomy trajectories were determined for right and left sides using medical diagnostic imaging software. Entry points were measured along the skull surface, 10 cm posteriorly from the nasion, and 3 cm laterally for both left and right sides. Cannulation was simulated perpendicular to the skull surface. Distances between the software-traced cortical vessels and the virtual catheter were measured. To approximate vessel injury by twist drill and ventricular catheter placement, veins within a 3-mm radius were considered a hemorrhage risk.RESULTSIn 100 virtual lines through Kocher's point toward the ipsilateral ventricle, 19% were predicted to cause cortical vein injury and suspected hemorrhage (radius ≤ 3 mm). Little difference existed between cerebral hemispheres (right 18%, left 20%). The average (± SD) distance from the trajectory line and a cortical vein was 7.23 ± 4.52 mm. In all 19 images that predicted vessel injury, a site of entry for an avascular zone near Kocher's point could be achieved by moving the trajectory less than 1.0 cm laterally and less than 1.0 cm along the anterior/posterior axis, suggesting that empirical measures are suboptimal, and that patient-specific coordinates based on preprocedural CTA/CVA imaging may optimize ventriculostomy in the future.CONCLUSIONSIn this institutional radiographic imaging analysis, traditional methods of ventriculostomy site selection predicted significant rates of cortical vein injury, matching described rates in the literature. CTA/CTV imaging potentiates identification of patient-specific cannulation sites and custom trajectories that avoid cortical vessels, which may lessen the risk of intracranial hemorrhage during ventriculostomy placement. Further development of this software is underway to facilitate stereotactic ventriculostomy and improve outcomes.

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A US-based survey on ventriculostomy practices

Cited by 27 publications

References 16 publications

Shunt Surgery in Idiopathic Intracranial Hypertension Aided by Electromagnetic Navigation

Shunt Surgery in Idiopathic Intracranial Hypertension Aided by Electromagnetic Navigation

Calvarial slope affecting accuracy of Ghajar Guide technique for ventricular catheter placement

Ventriculostomy-associated hemorrhage: a risk assessment by radiographic simulation

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