Placement accuracy of external ventricular drain when comparing freehand insertion to neuronavigation guidance in severe traumatic brain injury

Abstract

AndTo the memory of my mother, Rahma.ii ACKNOWLEDGMENTSThanks go first to my advisor, Dr. Judith Marcoux, who supported me in this endeavor. I have always appreciated the trust she has shown in me. Thanks also to the program director of the neurosurgery residency at McGill University, Dr. Jeffrey Atkinson, who has given me the opportunity to have the time for the master study. I also thank the head of the neurosurgery department, Dr. Kevin Petrecca, who supported me to have the funding of this project, and to Mr. Kelvin Mok, the biomedical engineer at the neuronavigation unit, who was the key point for correspondence for the equipment supply, and who spared his time to help with the training of using the AxiEM navigation system. This project has been made possible by the funding provided by the Medtronic Surgical Technology Neurosurgery, which has provided the navigation system and the disposable kits plus the cost paid to the Research Institute of the Montreal University Hospital Centre. The authors report no conflict of interest concerning the methods used in this study or the findings specified in this paper, and have no personal financial or institutional interest in any of the materials, or devices described in this thesis. iv ABSTRACTExternal ventricular drain (EVD) placement is one of the most frequently performed neurosurgical procedures. Inaccuracies in the drain positioning and the need for multiple passes using the classic freehand insertion technique are increasingly reported in the literature. The problem is seen most frequently in the severe traumatic brain injury (TBI) population. Many proposed methods were discussed to improve the placement accuracy and none gained enough support to be implemented in EVD placement. The purpose of this study is to evaluate the use of electromagnetic neuronavigation guidance to aid EVD insertion to improve the accuracy and minimize the number of passes in severe TBI patients. The navigation was applied prospectively for all new severe TBI patients who required ventricular catheter placement over a year period, and this was compared to a retrospective cohort of severe TBI patients who had EVD inserted freehand in the preceding year. Fifty-four cases were recruited, 35 (64.8%) had their EVD placed using the freehand technique and 19 (35.2%) using navigation guidance. In the navigation group, the placement accuracy was as follows: 94.7% (18/19) achieved a grade 1 and 5.3% (1/19) a grade 2, while none were in

A wearable mixed-reality holographic computer for guiding external ventricular drain insertion at the bedside

“…2 The situation becomes even more challenging in patients with aberrant anatomy due to trauma or underlying pathology. 6 The need for multiple passes during EVD insertion performed with the blind freehand technique has also been criticized, 1 because each pass leads to greater injury to the already compromised brain. In addition, an increased number of catheter passes is associated with a higher risk of complications, including hemorrhage and infection.…”

“…In addition, an increased number of catheter passes is associated with a higher risk of complications, including hemorrhage and infection. 1 To address the above-mentioned problems, a precise patient-tailored navigational approach would be very beneficial. 2 The use of image guidance during EVD insertion has been demonstrated to greatly minimize the number of passes required for successful insertion and improve targeting accuracy.…”

“…2 The use of image guidance during EVD insertion has been demonstrated to greatly minimize the number of passes required for successful insertion and improve targeting accuracy. 1,9 However, because currently available navigational devices are expensive and large enough to take up valuable space, 1,6 image-guided methods are not routinely applied to assist in bedside EVD placement. To achieve a low-cost, portable approach, researchers have ingeniously adopted the concept of "augmented reality," in which computer-generated images are superimposed on the user's view, resulting in a composite view.…”

Complications of invasive intracranial pressure monitoring devices in neurocritical care

“…16 With regard to ICPMs, Guyot et al reported no infections in 229 patients who underwent placement of Camino (Integra LifeSciences) intraparenchymal ICP monitors; 27 in addition, rates of infection with concurrent placement of EVDs and ICPMs seem to be similar to those of EVD placement alone. 2,5 To date, the majority of studies reporting VAI rates have been in TBI-predominant patient populations; however, in a large retrospective analysis of 116,813 patients with aneurysmal SAH, 32.9% were managed with EVDs, with a mean annual rate of infection of 7.3%. 48 In a similar retrospective analysis of the Nationwide Inpatient Sample of 34,238 patients with spontaneous intracranial hemorrhage, a subset of patients with VAIs had an overall significant increase in the rate of inpatient mortality, length of stay, and cost of care.…”

“…A prospective study that compared EVDs placed with a frameless computer-based neuronavigation guidance system with a retrospective cohort of patients with TBI with EVDs placed freehand found that neuronavigation nearly doubled the likelihood of achieving placement in the ipsilateral lateral ventricle (94.7% vs 57.1%; p = 0.009) and required statistically significantly fewer passes (1.16 ± 0.38 vs 1.63 ± 0.86 passes; p = 0.018). 2 Likewise, Mahan et al found that stereotactic imageguided placement of EVDs in the ICU setting allowed for near perfect catheter placement; ironically, this occurred at the cost of 40 additional minutes to achieve successful ventricular cannulation compared with historical cohorts. 40 The increased time that is required to use image guidance may not be the best management option for patients with impending cerebral herniation issues; however, if time allows, an imaging guidance system may improve the likelihood of optimal placement.…”