Optimizing ventriculoperitoneal shunt placement in the treatment of idiopathic intracranial hypertension: an analysis of neuroendoscopy, frameless stereotaxy, and intraoperative CT

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>Cerebrospinal fluid shunting can effectively lower intracranial pressure and improve the symptoms of idiopathic intracranial hypertension (IIH). Placement of ventriculoperitoneal (VP) shunts in this patient population can often be difficult due to the small size of the ventricular system. Intraoperative adjuvant techniques can be used to improve the accuracy and safety of VP shunts for these patients. The purpose of this study was to analyze the efficacy of some of these techniques, including the use of intraoperative CT (iCT) and frameless stereotaxy, in optimizing postoperative ventricular catheter placement.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>The authors conducted a retrospective review of 49 patients undergoing initial ventriculoperitoneal shunt placement for the treatment of IIH. The use of the NeuroPEN Neuroendoscope, intraoperative neuronavigation, and iCT was examined. To analyze ventricular catheter placement on postoperative CT imaging, the authors developed a new grading system: Grade 1, catheter tip terminates optimally in the ipsilateral frontal horn or third ventricle; Grade 2, catheter tip terminates in the contralateral frontal horn; Grade 3, catheter terminates in a nontarget CSF space; and Grade 4, catheter tip terminates in brain parenchyma. All shunts had spontaneous CSF flow upon completion of the procedure.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>The average body mass index among all patients was 37.6 ± 10.9 kg/m<jats:sup>2</jats:sup>. The NeuroPEN Neuroendoscope was used in 44 of 49 patients. Intraoperative CT scans were obtained in 24 patients, and neuronavigation was used in 32 patients. Grade 1 or 2 final postoperative shunt placement was achieved in 90% of patients (44 of 49). In terms of achieving optimal postoperative ventricular catheter placement, the use of iCT was as effective as neuronavigation. Two patients had their ventricular catheter placement modified based on an iCT study. The use of neuronavigation significantly increased time in the operating room (223.4 ± 46.5 vs 190.8 ± 31.7 minutes, p = 0.01). There were no shunt infections in this study.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>The use of iCT appears to be equivalent to the use of neuronavigation in optimizing ventricular shunt placement in IIH. Additionally, it may shorten operating room time and limit overall costs.</jats:p></jats:sec>

Intraoperative navigation system for ventriculoperitoneal shunting improves outcomes in patients with hydrocephalus compared with conventional procedures via the occipital horn

“…Such accurate catheter placement may be more easily achieved with intraoperative navigation for VPS. Previous studies [ 11,[14][15][16][17][18][19] have reported the use of ultrasound, frameless stereotaxy, neuroendoscopy and navigation to increase the accuracy of ventricular catheter placement and to improve long-term outcomes for patients with hydrocephalus. A systematic review by Flannery [ 20] showed that there was insufficient evidence to recommend the use of neuroendoscopy for routine VPS.…”

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

“…Accurate catheter placement may be more easily achieved when intraoperative navigation is used during VPS. Previous studies [11,[14][15][16][17][18][19] have reported the use of ultrasound, frameless stereotaxy, neuroendoscopy and navigation to increase the accuracy of ventricular catheter placement and improve long-term outcomes in patients with hydrocephalus. A systematic review by Flannery [20] showed that there was insufficient evidence to recommend the use of neuroendoscopy for routine VPS.…”

Ventriculoperitoneal shunt treatment in a pregnant renal transplant recipient with idiopathic intracranial hypertension: Case report and review of the literature

“…Various intraoperative adjuvant techniques have been employed in addressing the challenges of accurately cannulating the undersized ventricular system in IIH. These include the use of ultrasound guidance, neuronavigation, neuroendoscopy and intraoperative computed tomography (CT) [15]. In our case we used the It is recommended that pregnant patients with IIH should be managed in the same way as any other patient with IIH.…”