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Xu Y, Li Z, Zhang Z, Zhang H, Liu P. Neuroendoscopy-Assisted Entire-Process Visualization Technique of Ventricular Puncture for External Ventricular Drainage. J Craniofac Surg 2024; 35:1201-1204. [PMID: 38829146 DOI: 10.1097/scs.0000000000010146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/15/2024] [Indexed: 06/05/2024] Open
Abstract
OBJECTIVE This study aimed to investigate the feasibility, safety, and efficacy of the neuroendoscopy-assisted entire-process visualization technique (NEAEVT) of ventricular puncture for external ventricular drainage. METHODS Eighty-eight patients with cerebral hemorrhage who underwent unilateral ventricular puncture for external ventricular drainage in our hospital from June 2021 to June 2023 were analyzed. Patients were grouped according to puncture technique: NEAEVT (30 patients), freehand (30 patients), and laser-navigation-assisted (28 patients). Operation time, drainage tube placement, and catheter-related hemorrhage incidence were compared between the groups. RESULTS Mean operation time significantly differed between the freehand, NEAEVT, and laser-assisted groups (17.07, 18.37, and 34.04 min, respectively; P <0.0001). The position of the drainage tube was optimal or adequate in all patients of the NEAEVT group; optimal/adequate positioning was achieved in 80% of the freehand group. No catheter-related hemorrhage occurred in the NEAEVT group. Three freehand group patients and 2 laser-assisted group patients experienced catheter-related hemorrhage. CONCLUSION The NEAEVT of ventricular puncture is accurate and achieves ventricular drainage without significantly increasing surgical trauma, operation time, or incidence of hemorrhage.
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Affiliation(s)
- Yongqiang Xu
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, Shandong, China
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Hieber M, Lambeck J, Halaby A, Roelz R, Demerath T, Niesen WD, Bardutzky J. Minimally-invasive bedside catheter haematoma aspiration followed by local thrombolysis in spontaneous supratentorial intracerebral haemorrhage: a retrospective single-center study. Front Neurol 2023; 14:1188717. [PMID: 37342780 PMCID: PMC10277509 DOI: 10.3389/fneur.2023.1188717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/16/2023] [Indexed: 06/23/2023] Open
Abstract
Background and purpose The role of surgery in the treatment of intracerebral haemorrhage (ICH) remains controversial. Whereas open surgery has failed to show any clinical benefit, recent studies have suggested that minimal invasive procedures can indeed be beneficial, especially when they are applied at an early time point. This retrospective study therefore evaluated the feasibility of a free-hand bedside catheter technique with subsequent local lysis for early haematoma evacuation in patients with spontaneous supratentorial ICH. Methods Patients with spontaneous supratentorial haemorrhage of a volume of >30 mL who were treated with bedside catheter haematoma evacuation were identified from our institutional database. The entry point and evacuation trajectory of the catheter were based on a 3D-reconstructed CT scan. The catheter was inserted bedside into the core of the haematoma, and urokinase (5,000 IE) was administered every 6 h for a maximum of 4 days. Evolution of haematoma volume, perihaemorrhagic edema, midline-shift, adverse events and functional outcome were analyzed. Results A total of 110 patients with a median initial haematoma volume of 60.6 mL were analyzed. Haematoma volume decreased to 46.1 mL immediately after catheter placement and initial aspiration (with a median time to treatment of 9 h after ictus), and to 21.0 mL at the end of urokinase treatment. Perihaemorrhagic edema decreased significantly from 45.0 mL to 38.9 mL and midline-shift from 6.0 mm to 2.0 mm. The median NIHSS score improved from 18 on admission to 10 at discharge, and the median mRS at discharge was 4; the latter was even lower in patients who reached a target volume ≤ 15 mL at the end of local lysis. The in-hospital mortality rate was 8.2%, and catheter/local lysis-associated complications occurred in 5.5% of patients. Conclusion Bedside catheter aspiration with subsequent urokinase irrigation is a safe and feasible procedure for treating spontaneous supratentorial ICH, and can immediately reduce the mass effects of haemorrhage. Additional controlled studies that assess the long-term outcome and generalizability of our findings are therefore warranted. Clinical trial registration [www.drks.de], identifier [DRKS00007908].
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Affiliation(s)
- Maren Hieber
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johann Lambeck
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Amjad Halaby
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Theo Demerath
- Department of Neuroradiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Bardutzky
- Department of Neurology and Neurophysiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Siddique HH, Elkambergy H, Bayrlee A, Abulhasan YB, Roser F, Dibu JR. Management of External Ventricular Drains and Related Complications: a Narrative Review. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00725-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Khalaveh F, Fazel N, Mischkulnig M, Vossen MG, Reinprecht A, Dorfer C, Roessler K, Herta J. Risk Factors Promoting External Ventricular Drain Infections in Adult Neurosurgical Patients at the Intensive Care Unit-A Retrospective Study. Front Neurol 2021; 12:734156. [PMID: 34858309 PMCID: PMC8631749 DOI: 10.3389/fneur.2021.734156] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/05/2021] [Indexed: 11/30/2022] Open
Abstract
Objectives: Multiple risk factors have been described to be related to external ventricular drain (EVD) associated infections, with results varying between studies. Former studies were limited by a non-uniform definition of EVD associated infection, thus complicating a comparison between studies. In this regard, we assessed risk factors promoting EVD associated infections and propose a modified practice-oriented definition of EVD associated infections. Methods: We performed a retrospective, single-center study on patients who were treated with an EVD, at the neurosurgical intensive care unit (ICU) at a tertiary center between 2008 and 2019. Based on microbiological findings and laboratory results, patients were assigned into an infection and a non-infection group. Patient characteristics and potential risk factors were compared between the two groups (p < 0.05). Receiver operating characteristics (ROC) for significant clinical, serum laboratory and cerebrospinal fluid (CSF) parameters were calculated. Results: In total, 396 patients treated with an EVD were included into the study with a mean age of 54.3 (range: 18–89) years. EVD associated infections were observed in 32 (8.1%) patients. EVD insertion at another hospital (OR 3.86), and an increased CSF sampling frequency of more than every third day (OR 12.91) were detected as major risk factors for an EVD associated infection. The indication for EVD insertion, surgeon's experience, the setting of EVD insertion (ICU vs. operating room) and the operating time did not show any significant differences between the two groups. Furthermore, ROC analysis showed that clinical, serum laboratory and CSF parameters did not provide specific prediction of EVD associated infections (specificity 44.4%). This explains the high overtreatment rate in our cohort with the majority of our patients who received intrathecal vancomycin (63.3%), having either negative microbiological results (n = 12) or were defined as contaminations (n = 7). Conclusions: Since clinical parameters and blood analyzes are not very predictive to detect EVD associated infections in neurosurgical patients, sequential but not too frequent microbiological and laboratory analysis of CSF are still necessary. Furthermore, we propose a uniform classification for EVD associated infections to allow comparability between studies and to sensitize the treating physician in determining the right treatment.
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Affiliation(s)
- Farjad Khalaveh
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Nadia Fazel
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Mario Mischkulnig
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Matthias Gerhard Vossen
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Andrea Reinprecht
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Christian Dorfer
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Karl Roessler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Johannes Herta
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
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Bardutzky J, Shah M, Lambeck J, Meckel S, Niesen WD. Emergency Free-Hand Bedside Catheter Evacuation of Large Intracerebral Hematomas Following Thrombolysis for Ischemic Stroke: A Case Series. Neurocrit Care 2021; 33:207-217. [PMID: 31797279 DOI: 10.1007/s12028-019-00887-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Symptomatic intracerebral hemorrhage (sICH) following systemic thrombolysis for ischemic stroke is often devastating, and open surgical evacuation is considered dangerous due to the increased risk of perioperative bleeding, and stereotactic placement of a catheter is too time-consuming. We therefore evaluated the feasibility of a free-hand bedside catheter technique for emergency hematoma evacuation. METHODS Patients who had a supratentorial sICH after thrombolysis, a hematoma volume > 30 ml, and an ensuing reduction in vigilance were consecutively treated with acute minimally invasive catheter hematoma evacuation. Catheter insertion and trajectory were planned via 3D-reconstructed computed tomography (CT) scan, and free-hand insertion of an external ventricular catheter into the core of the hematoma was performed bedside, followed by careful blood aspiration. Cranial CT was used to verify catheter position and residual hematoma volume. In cases, where the residual volume exceeded 15 ml, urokinase (5000 IE) was administered into the clot every 6 h until the volume decreased to < 15 ml. RESULTS In all six patients, catheter aspiration immediately reduced hematoma volume by 77%, from 73 ± 20 ml to 17 ± 16 ml (p = 0.028). In four patients, the hematoma was almost completely removed (< 10 ml) by singular aspiration. In the remaining two patients with a residual hematoma size > 15 ml, consecutive urokinase application resulted in a further reduction to 1 ml and 15 ml, respectively, after 30 h. The median National Institues of Health Stroke Scale/Score after sICH was 19.5 points, rapidly decreasing to 11 after catheter aspiration (p = 0.027), and further improving to 4 at discharge. No procedure-related complications were observed. CONCLUSIONS Emergency free-hand bedside catheter aspiration is a reasonable option for hematoma evacuation in large thrombolysis-associated sICH when performed by experienced neurosurgeons. Larger studies would help in determining the generalizability of our findings to other centers and assessing their impact on functional outcome.
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Affiliation(s)
- Juergen Bardutzky
- Department of Neurology, University of Freiburg Medical School, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Mukesch Shah
- Department of Neurosurgery, University of Freiburg Medical School, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Johann Lambeck
- Department of Neurology, University of Freiburg Medical School, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Stephan Meckel
- Department of Neuroradiology, University of Freiburg Medical School, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology, University of Freiburg Medical School, Breisacher Str. 64, 79106, Freiburg, Germany
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Amoo M, Henry J, Javadpour M. Common Trajectories for Freehand Frontal Ventriculostomy: A Systematic Review. World Neurosurg 2020; 146:292-297. [PMID: 33271380 DOI: 10.1016/j.wneu.2020.11.065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Freehand ventriculostomy is one of the most commonly performed neurosurgical procedures. While a variety of approaches have been described, frontal via Kocher's point is the most common. Multiple trajectories have been described, but no consensus exists as to the most efficacious. Our objective was to assess the literature regarding trajectories for frontal ventriculostomy and their associated success rates and complications. METHODS We performed a systematic review of the literature, querying the PubMed/MEDLINE database with the search term "(EVD OR extra-ventricular drain OR ventriculostomy OR external ventricular drain) AND (hand OR freehand OR bedside)" and reported the characteristics and findings of both simulation and clinical studies according to trajectory and catheter position. Final catheter tip position was graded on the Kakarla scale. RESULTS A total of 198 abstracts were screened; 40 full papers were assessed. Sixteen were included, 11 of which were clinical studies and 5 of which were simulation studies. Six studies coronally targeted the ipsilateral medial epicanthus (IMC), 4 utilized an orthogonal trajectory (P), and 1 targeted the naison (N). Ideal placement (Kakarla grade 1) was achieved in 954 of 1391 (68.58%) procedures when the IMC was targeted versus 243 of 354 (70.43%) when P was targeted. Potentially harmful (Kakarla grade 3) placement was observed in 142 of 1391 (10.21%) procedures when the IMC was targeted and 20 of 345 (5.80%) when P was targeted. All 5 simulation studies found the IMC target to be inferior. CONCLUSIONS The IMC is the most prevalent trajectory for frontal ventriculostomy but no target is demonstrably superior. More robust clinical research is required to determine the optimal trajectory.
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Affiliation(s)
- Michael Amoo
- National Centre for Neurosurgery, Beaumont Hospital, Dublin, Ireland; Department of Neurosurgery, Royal College of Surgeons Ireland, Dublin, Dublin, Ireland.
| | - Jack Henry
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Mohsen Javadpour
- National Centre for Neurosurgery, Beaumont Hospital, Dublin, Ireland; Department of Neurosurgery, Royal College of Surgeons Ireland, Dublin, Dublin, Ireland
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Sun Z, Wu L, Liu Z, Zhong W, Kou Z, Liu J. Optimizing accuracy of freehand cannulation of the ipsilateral ventricle for intracranial pressure monitoring in patients with brain trauma. Quant Imaging Med Surg 2020; 10:2144-2156. [PMID: 33139994 DOI: 10.21037/qims-20-128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Intracranial pressure (ICP) monitoring in traumatic brain injury (TBI) usually requires the placement of a catheter into the ipsilateral ventricle. This surgical procedure is commonly performed via a freehand method using surface anatomical landmarks as guides. The current accuracy of the catheter placement remains relatively low and even lower among TBI patients. This study was undertaken to optimize the freehand ventricular cannulation to increase the accuracy for TBI. The authors hypothesized that an optimal surgical plan of cannulation should give an operator the greatest degrees of freedom, which could be measured as the range of operation angle, range of catheter placement depth, and size of the target area. Methods An imaging simulation was first performed using the computed tomography (CT) images of 47 adult patients with normal brain anatomy. On the reconstructed 3D head model, four different coronal planes of ventricular cannulation were identified: a 4-cm anterior, a 2-cm anterior, a standard (central), and a 2-cm posterior plane. The degrees of freedom during the cannulation procedure were determined, including the relevant angles, lengths of cannulation, cross-sectional area, and bounding rectangle of the lateral ventricle. Next, a retrospective assessment was performed on the CT scans of another 111 patients with TBI who underwent freehand ventricular cannulation for ICP monitoring. Postoperative measurements were also performed based on CT images to calculate the accuracy and safety of catheter placement between coronal planes in practice. Results Our simulation results showed that the 2-cm anterior plane had more extensive degrees of freedom for ventricular cannulation, in terms of length of catheter trajectory (7% longer, P<0.001), cross-sectional area of the lateral ventricle (14% larger, P=0.046), and length of the lateral ventricle (17% wider, P<0.001) than that of the standard plane, while both the 4-cm anterior and 2-cm posterior planes did not offer advantages over the standard plane in these ways. The mean length range of catheter trajectory in the 2-cm anterior plane was 41 to 58 mm. Retrospective assessment of TBI patients with ICP monitor placement also confirmed our simulation data. It showed that the accuracy of ipsilateral ventricle cannulation in the 2-cm anterior plane was 70.6%, which was a significant increase from 42.9% in the standard plane (P=0.007). Conclusions Our imaging simulation and retrospective study demonstrate that different coronal planes could provide different degrees of freedom for cannulation, the 2-cm anterior plane has the greatest degrees of freedom in terms of larger target area and greater length range of the trajectory. The optimized surgical plan in this manner could improve cannulation accuracy and benefit a significant number of TBI patients.
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Affiliation(s)
- Zhongyi Sun
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Lin Wu
- Department of Ophthalmology and Anatomy and Cell Biology, Wayne State University, Detroit, MI, USA
| | - Zhixiong Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Weiming Zhong
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Zhifeng Kou
- Departments of Biomedical Engineering and Radiology, Wayne State University, Detroit, MI, USA
| | - Jinfang Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
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Lee KS, Zhang JJY, Bolem N, Leong ML, Goh CP, Hassan R, Salek AAM, Sein Lwin APT, Teo K, Chou N, Nga V, Yeo TT. Freehand Insertion of External Ventricular Drainage Catheter: Evaluation of Accuracy in a Single Center. Asian J Neurosurg 2020; 15:45-50. [PMID: 32181172 PMCID: PMC7057862 DOI: 10.4103/ajns.ajns_292_19] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 01/10/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction External ventricular drain (EVD) placement is the gold standard for managing acute hydrocephalus. Freehand EVD, using surface anatomical landmarks, is performed for ventricular cannulation due to its simplicity and efficiency. This study evaluates accuracy and reason(s) for misplacements as few studies have analyzed the accuracy of freehand EVD insertion. Patients and Methods Preoperative and postoperative computed tomography scans of patients who underwent EVD insertion in 2014 were retrospectively reviewed. Diagnosis, Evans ratio, midline shift, position of burr hole, length of the catheter, and procedural complications were tabulated. The procedures were classified as satisfactory (catheter tip in the frontal horn ipsilateral lateral ventricle) and unsatisfactory. Unsatisfactory cases were further analyzed in relation to position of burr hole from midline and length of the catheter. Results Seventy-seven EVD placements in seventy patients were evaluated. The mean age of the patients was 57.5 years. About 83.1% were satisfactory placements and 11.7% were unsatisfactory in the contralateral ventricle, corpus callosum, and interhemispheric fissure. Nearly 5.2% were in extraventricular locations. Almost 2.6% EVD placements were complicated by hemorrhage and 1 catheter was reinserted. Suboptimal placements were significantly associated with longer intracranial catheter length. The mean length was 66.54 ± 10.1 mm in unsatisfactory placements compared to 58.32 ± 4.85 mm in satisfactory placements. Between the two groups, no significant difference was observed in Evans ratio, midline shift, surgeon's experience, distance of burr hole from midline, and coronal suture. Conclusion Freehand EVD insertion is safe and accurate. In small number of cases, unsatisfactory placement is related to longer catheter length.
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Affiliation(s)
- Keng Siang Lee
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - John Jiong Yang Zhang
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Nagarjun Bolem
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - May Lian Leong
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Chun Peng Goh
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Rashidul Hassan
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Al Amin Maa Salek
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | | | - Kejia Teo
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Ning Chou
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Vincent Nga
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
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Talibi SS, Silva AHD, Afshari FT, Hodson J, Roberts SAG, Oppenheim B, Flint G, Chelvarajah R. The implementation of an external ventricular drain care bundle to reduce infection rates. Br J Neurosurg 2020; 34:181-186. [DOI: 10.1080/02688697.2020.1725436] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Sayed Samed Talibi
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Adikarige HD Silva
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Fardad T. Afshari
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - James Hodson
- Institute of Translational Medicine, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom
| | - Stuart AG Roberts
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Beryl Oppenheim
- Department of Microbiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Graham Flint
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Ramesh Chelvarajah
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
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Bardutzky J, Hieber M, Roelz R, Meckel S, Lambeck J, Niesen WD. Cerebral amyloid angiopathy-related intracerebral hemorrhage: Feasibility and safety of bedside catheter hematoma evacuation with urokinase. Clin Neurol Neurosurg 2020; 190:105655. [PMID: 31901893 DOI: 10.1016/j.clineuro.2019.105655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/18/2019] [Accepted: 12/27/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Cerebral amyloid angiopathy (CAA) is an important cause of intracerebral hemorrhage (ICH). However, data on surgical intervention in CAA-related ICH is very limited. In this retrospective study we assessed safety and efficacy of free-hand catheter aspiration followed by local thrombolysis in CAA-related large ICH. PATIENTS AND METHODS Patients with CAA-related lobar ICH>30 ml that were treated with this catheter technique were identified from our prospective database. The catheter was inserted at the bedside in the core of the hematoma and urokinase (5000IE) was administered every 6 h for a maximum of 4 days. Evolution of hematoma volume, perihemorrhagic edema (PHE) and midline-shift (MLS) as well as adverse events and functional outcome were analyzed. RESULTS Twenty-one patients (median age 79 years) were treated between 2013-2018. Hematoma volume decreased from 70 ml at admission (IQR 49-98 ml) to 52 ml (IQR 35-76 ml, p < 0.001) immediately after catheter aspiration, and to 23.5 ml (IQR 17-47 ml, p < 0.001) at the end of urokinase treatment. At day 4, PHE volume (from 45 ml [IQR 33-71 ml] to 36 ml [IQR 22-50 ml]; p = 0.001) and MLS (from 5 mm [IQR 3.5-7 mm] to 1 mm [IQR 0.5-3 mm]; p < 0.001) were reduced significantly. No infection was observed, rebleeding after administration of 4 × 5000IE urokinase occurred in one patient (5 %). At discharge, modified Rankin Scale was 3 in 33 %, 4 in 24 %, and 5 in 43 % of patients, and had further improved after rehabilitation to an mRS of 2 in 10 %, 3 in 38 %, 4 in 19 %, and 5 in 33 % (median 9 weeks after ictus). There were no patient deaths during this time. CONCLUSIONS Bedside catheter hematoma evacuation in large CAA-related ICH seemed feasible and safe and could immediately decrease mass effect. Further studies assessing functional outcome are warranted.
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Affiliation(s)
- Jürgen Bardutzky
- Neurological Department, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany.
| | - Maren Hieber
- Neurological Department, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
| | - Roland Roelz
- Neurosurgical Department, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
| | - Stephan Meckel
- Neuroradiological Department, University of Freiburg, Breisacher Strasse 64, 79106 Freiburg, Germany
| | - Johann Lambeck
- Neurological Department, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
| | - Wolf-Dirk Niesen
- Neurological Department, University of Freiburg, Breisacher Strasse 64, 79106, Freiburg, Germany
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Katzir M, Lefkowitz JJ, Ben-Reuven D, Fuchs SJ, Hussein K, Sviri GE. Decreasing External Ventricular Drain-Related Infection Rates with Duration-Independent, Clinically Indicated Criteria for Drain Revision: A Retrospective Study. World Neurosurg 2019; 131:e474-e481. [PMID: 31382072 DOI: 10.1016/j.wneu.2019.07.205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 07/27/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To lower external ventricular drain (EVD)-related infection rates, in April 2013, our institution enacted a major protocol change, switching from routine EVD replacement every 5 days to EVD replacement only when clinically indicated. In the present study, we evaluated the effect of this change on nosocomial EVD-related infections. METHODS We performed a retrospective cohort study to compare the EVD-related infection rates between 2 groups (group A, elective EVD replacement; group B, clinically indicated EVD replacement). We analyzed the data from 142 patients (group A, n = 43; group B, n = 99), with a total of 227 EVDs for 5 years and 3 months (1721 catheter days). RESULTS The overall EVD-related infection rates were elevated in group A (0.14; 32% of patients) compared with group B (0.08; 8%; P = 0.001). The median hospital stay (33 vs. 24 days; P = 0.001) and neurosurgical intensive care unit stay (30.5 vs. 17 days; P < 0.0001) were also longer for group A. The requirement for multiple EVDs was an independent risk factor (P = 0.003), with a 4.6 times greater risk in group A (odds ratio, 4.64; 95% confidence interval, 1.7-12.6). CONCLUSIONS The findings from our study strengthen an increasing body of evidence suggesting the importance of inoculation of skin flora as a critical risk factor for EVD-related infections, underscoring the importance of drain changes only when clinically indicated and that, as soon as clinically permitted, catheters should be removed.
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Affiliation(s)
- Miki Katzir
- Department of Neurosurgery, Rambam (Maimonides) Health Care Campus, Technion Israel Institute of Technology, Haifa, Israel
| | - Jason J Lefkowitz
- Technion American Medical School, The Bruce and Ruth Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Daniel Ben-Reuven
- Technion American Medical School, The Bruce and Ruth Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Steven J Fuchs
- Technion American Medical School, The Bruce and Ruth Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Khetam Hussein
- Infectious Diseases Institute, Rambam (Maimonides) Health Care Campus, The Bruce and Ruth Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Gill E Sviri
- Department of Neurosurgery, Rambam (Maimonides) Health Care Campus, Technion Israel Institute of Technology, Haifa, Israel.
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Catapano JS, Lee M, Veljanoski D, Whiting AC, Brigeman S, Morgan CD, Labib MA, Ducruet AF, Nakaji P. Iatrogenic pseudoaneurysm rupture of the anterior cerebral artery after placement of an external ventricular drain, treated with clip-wrapping: a case report and review of the literature. Acta Neurochir (Wien) 2019; 161:1371-1376. [PMID: 31102006 DOI: 10.1007/s00701-019-03935-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
Abstract
External ventricular drains (EVDs) are often placed emergently for patients with hydrocephalus, which carries a risk of hemorrhage. Rarely, rupture of a pseudoaneurysm originating from an EVD placement precipitates such a hemorrhage. An EVD was placed in a patient with a ruptured left posterior communicating artery aneurysm who later underwent endovascular coil embolization. On post-bleed day 20, a distal right anterior cerebral artery pseudoaneurysm along the EVD tract ruptured, which was successfully treated via clip-wrapping. Although EVD-associated pseudoaneurysms are rare, they have a high propensity for rupture. Early treatment of these lesions should be considered to prevent neurologic deterioration.
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13
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Sorinola A, Buki A, Sandor J, Czeiter E. Risk Factors of External Ventricular Drain Infection: Proposing a Model for Future Studies. Front Neurol 2019; 10:226. [PMID: 30930840 PMCID: PMC6428739 DOI: 10.3389/fneur.2019.00226] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 02/22/2019] [Indexed: 11/23/2022] Open
Abstract
Background: External ventricular drain (EVD) has a major role in the management and monitoring of intracranial pressure (ICP) and its major complication is EVD infection. The risk factors for EVD infection are still a major topic of controversy, hence the need for further research. Objective: The objective of this review was to identify risk factors that affect the incidence of EVD infection and create a model, which can be used in future studies in order to contribute to elaborations on guideline for EVD. Methods: A PubMed and Google Scholar literature search was performed and data were extracted from studies published from 1966 through 2017. The search of the databases generated 604 articles and 28 articles of these were found to be relevant. A manual search of the 28 relevant papers generated 4 new articles. Of the 32 relevant articles, 20 articles that performed a multivariate analysis of the suspected risk factors of EVD infection and had a positive culture as a mandatory component in diagnosis were selected for data collection and analysis. Results: Because reviewed papers investigated only a few influencing factors, and could not determine convincingly the real risk factors of EVD infection and their real strengths. A total of 15 supposed influencing factors which includes: age, age & sex interactions, coinfection, catheter insertion outside the hospital, catheter type, CSF leakage, CSF sampling frequency, diagnosis, duration of catheterization, ICP > 20 mmHg, irrigation, multiple catheter, neurosurgical operation, reduced CSF glucose at catheter insertion and sex were identified. Conclusion: This review summarizes a set of variables which have to be covered by future clinical epidemiological investigations in order to describe the etiological background of EVD infection.
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Affiliation(s)
- Abayomi Sorinola
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
| | - Andras Buki
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Janos Sandor
- Department of Bio-statistics and Epidemiology, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Endre Czeiter
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary.,MTA PTE Clinical Neuroscience MR Research Group, University of Pécs, Pécs, Hungary
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14
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Gender and Population Variation in Craniometry and Freehand Pass Ventriculostomy. World Neurosurg 2018; 117:e194-e203. [DOI: 10.1016/j.wneu.2018.05.240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 12/25/2022]
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15
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Park J, Choi YJ, Ohk B, Chang HH. Cerebrospinal Fluid Leak at Percutaneous Exit of Ventricular Catheter as a Crucial Risk Factor for External Ventricular Drainage–Related Infection in Adult Neurosurgical Patients. World Neurosurg 2018; 109:e398-e403. [DOI: 10.1016/j.wneu.2017.09.190] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 09/26/2017] [Accepted: 09/27/2017] [Indexed: 11/26/2022]
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16
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Raabe C, Fichtner J, Beck J, Gralla J, Raabe A. Revisiting the rules for freehand ventriculostomy: a virtual reality analysis. J Neurosurg 2017; 128:1250-1257. [PMID: 28524798 DOI: 10.3171/2016.11.jns161765] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Frontal ventriculostomy is one of the most frequent and standardized procedures in neurosurgery. However, many first and subsequent punctures miss the target, and suboptimal placement or misplacement of the catheter is common. The authors therefore reexamined the landmarks and rules to determine the entry point and trajectory with the best hit rate (HtR). METHODS The authors randomly selected CT scans from their institution's DICOM pool that had been obtained in 50 patients with normal ventricular and skull anatomy and without ventricular puncture. Using a 5 × 5-cm frontal grid with 25 entry points referenced to the bregma, the authors examined trajectories 1) perpendicular to the skull, 2) toward classic facial landmarks in the coronal and sagittal planes, and 3) toward an idealized target in the middle of the ipsilateral anterior horn (ILAH). Three-dimensional virtual reality ventriculostomies were simulated for these entry points; trajectories and the HtRs were recorded, resulting in an investigation of 8000 different virtual procedures. RESULTS The best HtR for the ILAH was 86% for an ideal trajectory, 84% for a landmark trajectory, and 83% for a 90° trajectory, but only at specific entry points. The highest HtRs were found for entry points 3 or 4 cm lateral to the midline, but only in combination with a trajectory toward the contralateral canthus; and 1 or 2 cm lateral to the midline, but only paired with a trajectory toward the nasion. The same "pairing" exists for entry points and trajectories in the sagittal plane. For perpendicular (90°) trajectories, the best entry points were at 3-5 cm lateral to the midline and 3 cm anterior to the bregma, or 4 cm lateral to the midline and 2 cm anterior to the bregma. CONCLUSIONS Only a few entry points offer a chance of a greater than 80% rate of hitting the ILAH, and then only in combination with a specific trajectory. This "pairing" between entry point and trajectory was found both for landmark targeting and for perpendicular trajectories, with very limited variability. Surprisingly, the ipsilateral medial canthus, a commonly reported landmark, had low HtRs, and should not be recommended as a trajectory target.
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Affiliation(s)
- Clemens Raabe
- Departments of1Neuroradiology and.,2Neurosurgery, University of Bern, Inselspital, Bern, Switzerland
| | - Jens Fichtner
- 2Neurosurgery, University of Bern, Inselspital, Bern, Switzerland
| | - Jürgen Beck
- 2Neurosurgery, University of Bern, Inselspital, Bern, Switzerland
| | | | - Andreas Raabe
- 2Neurosurgery, University of Bern, Inselspital, Bern, Switzerland
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17
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Miller C, Tummala RP. Risk factors for hemorrhage associated with external ventricular drain placement and removal. J Neurosurg 2017; 126:289-297. [DOI: 10.3171/2015.12.jns152341] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
External ventricular drains (EVDs) have an important role in the management of neurological disease, and their placement is a frequently performed neurosurgical procedure. Hemorrhage is a common complication of EVD placement and occurs more frequently than originally believed. There is also risk of hemorrhage with removal of an EVD, which has not been well described. The authors investigated the risk factors associated with placement and removal of EVDs at their institution.
METHODS
A database was created including patients who required EVD placement from March 2008 to June 2014 at the University of Minnesota. A retrospective chart review was completed, and data were collected for each patient. All cranial imaging studies during the index hospitalization were reviewed to identify hemorrhages associated with either EVD placement or removal. The study was performed using a research protocol approved by the University of Minnesota's institutional review board.
RESULTS
Four hundred eighty-two EVDs were placed during the designated time period. Among the cases in which patients underwent imaging after the placement procedure, hemorrhage was found in 94 (21.6%). The hemorrhage volume ranged from 0.003 cm3 to 45.9 cm3 (mean [± SD] 1.96 ± 6.48 cm3). Two of these hemorrhages resulted in additional interventions: 1 surgical evacuation and 1 contralateral EVD. In 55 (22.5%) of the 244 cases in which imaging was performed after EVD removal, hemorrhage associated with removal was identified. The mean volume of these hemorrhages was 8.25 ± 20.34 cm3 (range 0.012–82.08 cm3). Two EVDs were replaced, and 1 patient died as a result of a large hemorrhage. Large hemorrhages (> 30 cm3) occurred in 2 patients on placement (0.46%) and in 5 patients on removal (2.0%). In this series, decreased platelet levels on admission and an increasing number of EVD placement attempts correlated with an increased risk of hemorrhage on placement. Only those with an EVD placed at bedside were more likely to have hemorrhage on EVD removal.
CONCLUSIONS
Multiple studies have reported varying EVD hemorrhage rates while very few studies have described hemorrhage secondary to EVD removal. This is the first reported analysis of risk factors associated with hemorrhage on EVD removal. Hemorrhages occur relatively frequently following EVD placement and removal, though clinical significance of these events seems to be low.
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18
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Lovasik BP, McCracken DJ, McCracken CE, McDougal ME, Frerich JM, Samuels OB, Pradilla G. The Effect of External Ventricular Drain Use in Intracerebral Hemorrhage. World Neurosurg 2016; 94:309-318. [DOI: 10.1016/j.wneu.2016.07.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 07/06/2016] [Accepted: 07/07/2016] [Indexed: 10/21/2022]
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19
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Behmanesh B, Setzer M, Noack A, Bartels M, Quick-Weller J, Seifert V, Freiman TM. Noninvasive epicutaneous transfontanelle intracranial pressure monitoring in children under the age of 1 year: a novel technique. J Neurosurg Pediatr 2016; 18:372-6. [PMID: 27231824 DOI: 10.3171/2016.3.peds15701] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Monitoring of intracranial pressure (ICP) may be indicated in children with traumatic brain injury, premature intraventricular hemorrhage, or hydrocephalus. The standard technique is either a direct measurement with invasive intracranial insertion of ICP probes or indirect noninvasive assessment using transfontanelle ultrasonography to measure blood flow. The authors have developed a new technique that allows noninvasive epicutaneous transfontanelle ICP measurement with standard ICP probes. They compared the ICP measurements obtained using the same type of standard probe used in 2 different ways in 5 infants (age < 1 year) undergoing surgery for craniosynostosis. The first ICP probe was implanted epidurally (providing control measurements) and the second probe was fixed epicutaneously on the skin over the reopened frontal fontanelle. ICP values were measured hourly for the first 24 hours after surgery and the values obtained with the 2 methods were compared using Bland-Altman 2-methods analysis. A total of 110 pairs of measurements were assessed. There was no significant difference between the ICPs measured using the epicutaneous transfontanelle method (mean 13.10 mm Hg, SEM 6.68 mm Hg) and the epidural measurements (mean 12.46 mm Hg, SEM 6.45 mm Hg; p = 0.4643). The results of this analysis indicate that epicutaneous transfontanelle measurement of ICP is a reliable method that allows noninvasive ICP monitoring in children under the age of 1 year. Such noninvasive ICP monitoring could be implemented in the therapy of children with traumatic brain injury or intraventricular hemorrhage or for screening children with elevated ICP without invasive intracranial implantation of ICP probes.
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Affiliation(s)
| | | | | | - Marco Bartels
- Neuropaediatrics, Goethe University, Frankfurt am Main, Germany
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20
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Antes S, Tschan CA, Heckelmann M, Breuskin D, Oertel J. Telemetric Intracranial Pressure Monitoring with the Raumedic Neurovent P-tel. World Neurosurg 2016; 91:133-48. [DOI: 10.1016/j.wneu.2016.03.096] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 03/28/2016] [Accepted: 03/29/2016] [Indexed: 01/19/2023]
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21
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Talibi S, Tarnaris A, Shaw SA. Has the introduction of antibiotic-impregnated external ventricular drain catheters changed the nature of the microorganisms cultured in patients with drain-related infection? A single neurosurgical centre’s experience. Br J Neurosurg 2016; 30:560-6. [DOI: 10.1080/02688697.2016.1181150] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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22
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Dimitriou J, Levivier M, Gugliotta M. Comparison of Complications in Patients Receiving Different Types of Intracranial Pressure Monitoring: A Retrospective Study in a Single Center in Switzerland. World Neurosurg 2016; 89:641-6. [DOI: 10.1016/j.wneu.2015.11.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 11/25/2015] [Accepted: 11/26/2015] [Indexed: 10/22/2022]
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23
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Kirkman MA, Muirhead W, Sevdalis N. The relative efficacy of 3 different freehand frontal ventriculostomy trajectories: a prospective neuronavigation-assisted simulation study. J Neurosurg 2016; 126:304-311. [PMID: 27081908 DOI: 10.3171/2016.1.jns152263] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Ventriculostomy is a relatively common neurosurgical procedure, often performed in the setting of acute hydrocephalus. Accurate positioning of the catheter is vital to minimize morbidity and mortality, and several anatomical landmarks are currently used. The aim of this study was to prospectively evaluate the relative performance of 3 recognized trajectories for frontal ventriculostomy using imaging-derived metrics: perpendicular to skull (PTS), contralateral medial canthus/external auditory meatus (CMC/EAM), and ipsilateral medial canthus/external auditory meatus (IMC/EAM). METHODS Participants completed 9 simulated ventriculostomy attempts (3 of each trajectory) on a model head with Medtronic StealthStation coregistered imaging. Performance measures were distance of the ventricular catheter tip to the foramen of Monro (FoM) and presence of the catheter tip in a lateral ventricle. RESULTS Thirty-one individuals of varying seniority and prior ventriculostomy experience performed a total of 279 simulated freehand frontal ventriculostomies. The PTS and CMC/EAM trajectories were found to be significantly more likely to result in both the catheter tip being closer to the FoM and in a lateral ventricle compared with the IMC/EAM trajectory. These findings were not influenced by the prior ventriculostomy experience of the participant, corroborating the significance of these results. CONCLUSIONS The PTS and CMC/EAM trajectories were superior to the IMC/EAM trajectories during freehand frontal ventriculostomy in this study, and further data from studies incorporating varying ventricular sizes and bur hole locations are required to facilitate a change in clinical practice. In addition, neuronavigation and other guidance techniques for ventriculostomy are becoming increasingly popular and may be superior to freehand techniques, necessitating further prospective data evaluating their safety, efficacy, and feasibility for routine clinical use.
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Affiliation(s)
- Matthew A Kirkman
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London.,Department of Surgery and Cancer, Imperial College London, St Mary's Campus, London; and
| | - William Muirhead
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London
| | - Nick Sevdalis
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
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24
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Tahir MZ, Sobani ZA, Murtaza M, Enam SA. Long-tunneled versus short-tunneled external ventricular drainage: Prospective experience from a developing country. Asian J Neurosurg 2016; 11:114-7. [PMID: 27057216 PMCID: PMC4802931 DOI: 10.4103/1793-5482.145052] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND External ventricular drains (EVD) are commonly utilized for temporary diversion of cerebrospinal fluid (CSF). Many neurosurgeons prefer long-tunneled EVDs in their routine practice. However, it is still unclear whether this extended tunneling helps in reducing CSF infection. Keeping this in mind, we decided to compare infection rates in long-tunneled versus short-tunneled EVDs in the setting of a developing country. MATERIALS AND METHODS A prospective study of 60 patients was conducted. Consenting patients who underwent short-tunneled (Group A) or long-tunneled (Group B) EVDs between January 2008 and June 2009 were followed during the course of their inpatient care. All operational protocol was standardized during the trial. Serial samples of CSF were analyzed to detect infection. RESULTS Mean age of patients was 33.6 years with 32 males (53.3%). Mean duration of long-tunneled EVD was 13.4 ± 7.2 days, whereas that of short-tunneled EVD was 5.3 ± 2.7 days (P < 0.001). Three patients with long-tunneled EVD (10.0%), whereas one patient with short-tunneled EVD (3.3%) developed drain-related infections; however, this was non-significant (P = 0.301). However, patients with short-tunneled EVD got infected earlier on day 3when compared with the long-tunneled EVDs, which got infected after a mean duration of 7.3 days. The overall risk of infection for long-tunneled EVDs was 7.46 per 1,000 ventricular drainage days which was comparable to the risk of 6.33 per 1,000 ventricular drainage days seen for short-tunneled EVDs. CONCLUSION Long-tunneled EVDs appear to only delay potential infections without having any effect on the actual risk of infection. Long-tunneled EVD in a resource-limited setting is technically challenging and may not yield additional benefits to the patient. However, larger and prospective studies are needed to establish the rate of infections and other complications.
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Affiliation(s)
| | - Zain A Sobani
- Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Muhammed Murtaza
- Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Syed Ather Enam
- Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
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25
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Fried HI, Nathan BR, Rowe AS, Zabramski JM, Andaluz N, Bhimraj A, Guanci MM, Seder DB, Singh JM. The Insertion and Management of External Ventricular Drains: An Evidence-Based Consensus Statement. Neurocrit Care 2016; 24:61-81. [DOI: 10.1007/s12028-015-0224-8] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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26
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Kirmani AR, Sarmast AH, Bhat AR. Role of external ventricular drainage in the management of intraventricular hemorrhage; its complications and management. Surg Neurol Int 2015; 6:188. [PMID: 26759733 PMCID: PMC4697206 DOI: 10.4103/2152-7806.172533] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 09/30/2015] [Indexed: 11/23/2022] Open
Abstract
Background: External ventricular drainage (EVD) is the procedure of choice for the treatment of acute hydrocephalus and increased intracranial pressure in patients of subarachnoid hemorrhage (SAH) and intracerebral hemorrhage with hydrocephalus and its sequelae. We evaluated the use of EVD in patients of SAHs (spontaneous/posttraumatic with/without hydrocephalus), hypertensive intracerebral bleeds with interventricular extensions, along with evaluation of the frequency of occurrence of complications of the procedure, infectious and noninfectious, and their management. Methods: During the period of 2½ years, between September 2012 and February 2015, 130 patients were subjected to external drainage procedure and were prospectively enrolled in this study. Information was collected on each patient regarding age, sex, diagnosis, underlying illness, secondary complications, other coexisting infections, use of systemic steroids, antibiotic treatment (systemic and intraventricular), and whether any other neurosurgical procedures were performed within 2 weeks of EVD insertion or any time the duration of ventriculostomy. Results: The study population of 130 patients underwent a total of 193 ventriculostomies. Thirty-six patients had ventriculostomy infection (27.6%). Evaluation of the use of EVD was done by comparing preoperative and postoperative grading scores. Forty-nine patients survived and improved their score from Grade 3–5 to Grade 2–4. Twenty-nine patients were moderately disable, 16 were severely disable, and 5 were left in the vegetative state. Evaluation of outcome of patients revealed that there was an overall mortality of 61 (46.9%) patients both in the acute phase and later. 33 of the 39 patients having Glasgow Coma Score (GCS) 3–5 at the time of EVD insertion expired, as against 20 of the 51 patients in GCS 6–8. Patients in GCS 9–12 had an even better outcome, with 8 of the 35 patients in this group expiring. Conclusions: The use of EVD should be undertaken only in situation where it is absolutely necessary and ventriculostomy should be kept only for the duration required, and this should be monitored on a daily basis, given the exponential increase in infection after 5 days.
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Affiliation(s)
- Altaf Rehman Kirmani
- Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Arif Hussain Sarmast
- Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Abdul Rashid Bhat
- Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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Mounier R, Lobo D, Cook F, Fratani A, Attias A, Martin M, Chedevergne K, Bardon J, Tazi S, Nebbad B, Bloc S, Plaud B, Dhonneur G. Clinical, biological, and microbiological pattern associated with ventriculostomy-related infection: a retrospective longitudinal study. Acta Neurochir (Wien) 2015; 157:2209-17; discussion 2217. [PMID: 26363898 DOI: 10.1007/s00701-015-2574-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 08/28/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Our aim was to describe the pattern of ventriculostomy-related infection (VRI) development using a dynamic approach. STUDY DESIGN Retrospective longitudinal study. METHODS We analyzed the files of 449 neurosurgical patients who underwent placement of external ventricular drain (EVD). During the study period, CSF sampling was performed on a daily base setting. VRI was defined as a positive CSF culture resulting in antibiotic treatment. For VRI patients, we arbitrary defined day 0 (D0) as the day antibiotic treatment was started. In these patients, we compared dynamic changes in clinical and biological parameters at four pre-determined time points: (D-4, D-3, D-2, D-1) with those of D0. For all CSF-positive cultures, we compared CSF biochemical markers' evolution pattern between VRI patients and the others, considered as a control cohort. RESULTS Thirty-two suffered from VRI. Peripheral white blood cell count did not differ between D-4-D0. Median body temperature, CSF cell count, median Glasgow Coma Scale, CSF protein, and glucose concentrations were significantly different between D-4, D-3, D-2, and D0. At D0, 100 % of CSF samples yielded organisms in culture. The physician caring for the patient decided to treat VRI based upon positive CSF culture in only 28 % (9/32) of cases. In the control cohort, CSF markers' profile trends to normalize, while it worsens in the VRI patients. CONCLUSIONS We showed that clinical symptoms and biological abnormalities of VRI evolved over time. Our data suggest that VRI decision to treat relies upon a bundle of evidence, including dynamic changes in CSF laboratory exams combined with microbiological analysis.
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28
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Mounier R, Lobo D, Cook F, Martin M, Attias A, Aït-Mamar B, Gabriel I, Bekaert O, Bardon J, Nebbad B, Plaud B, Dhonneur G. From the Skin to the Brain: Pathophysiology of Colonization and Infection of External Ventricular Drain, a Prospective Observational Study. PLoS One 2015; 10:e0142320. [PMID: 26555597 PMCID: PMC4640851 DOI: 10.1371/journal.pone.0142320] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 10/19/2015] [Indexed: 11/18/2022] Open
Abstract
Ventriculostomy-related infection (VRI) is a serious complication of external ventricular drain (EVD) but its natural history is poorly studied. We prospectively tracked the bacteria pathways from skin towards ventricles to identify the infectious process resulting in ventriculostomy-related colonization (VRC), and VRI. We systematically sampled cerebrospinal fluid (CSF) on a daily basis and collected swabs from both the skin and stopcock every 3.0 days for microbiological analysis including in 101 neurosurgical patient. Risk factors for positive event defined as either VRC or VRI were recorded and related to our microbiological findings. A total of 1261 CSF samples, 473 skin swabs, and 450 stopcock swabs were collected. Skin site was more frequently colonized than stopcock (70 (60%) vs 34 (29%), p = 0.023), and earlier (14 ±1.4 vs 24 ±1.5 days, p<0.0001). Sixty-one (52%) and 32 (27%) skin and stopcock sites were colonized with commensal bacteria, 1 (1%) and 1 (1%) with pathogens, 8 (7%) and 1 (1%) with combined pathogens and commensal bacteria, respectively. Sixteen positive events were diagnosed; a cutaneous origin was identified in 69% of cases. The presence of a pathogen at skin site (6/16 vs 4/85, OR: 11.8, [2.5–56.8], p = 0.002) and CSF leakage (7/16 vs 6/85, OR 10 [2.4–41.2], p = 0.001)) were the two independent significant risk factors statistically linked to positive events occurrence. Our results suggest that VRC and VRI mainly results from an extra-luminal progression of pathogens initially colonizing the skin site where CSF leaks.
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Affiliation(s)
- Roman Mounier
- Department of Anesthesia and Surgical Intensive Care, Henri Mondor University Hospital of Paris, Paris XII school of medicine, Créteil, France
- * E-mail:
| | - David Lobo
- Department of Anesthesia and Surgical Intensive Care, Henri Mondor University Hospital of Paris, Paris XII school of medicine, Créteil, France
| | - Fabrice Cook
- Department of Anesthesia and Surgical Intensive Care, Henri Mondor University Hospital of Paris, Paris XII school of medicine, Créteil, France
| | - Mathieu Martin
- Department of Anesthesia and Surgical Intensive Care, Henri Mondor University Hospital of Paris, Paris XII school of medicine, Créteil, France
| | - Arie Attias
- Department of Anesthesia and Surgical Intensive Care, Henri Mondor University Hospital of Paris, Paris XII school of medicine, Créteil, France
| | - Bouziane Aït-Mamar
- Department of Anesthesia and Surgical Intensive Care, Henri Mondor University Hospital of Paris, Paris XII school of medicine, Créteil, France
| | - Inanna Gabriel
- Department of Anesthesia and Surgical Intensive Care, Henri Mondor University Hospital of Paris, Paris XII school of medicine, Créteil, France
| | - Olivier Bekaert
- Department of Neurosurgery, Henri Mondor University Hospital of Paris, Paris XII school of medicine, Créteil, France
| | - Jean Bardon
- Department of Anesthesia and Surgical Intensive Care, Henri Mondor University Hospital of Paris, Paris XII school of medicine, Créteil, France
| | - Biba Nebbad
- Department of Microbiology, Henri Mondor University Hospital of Paris, Paris XII school of medicine, Créteil, France
| | - Benoît Plaud
- Department of Anesthesiology and Surgical Intensive Care, Saint-Louis University Hospital of Paris, Paris VII school of medicine, Paris, France
| | - Gilles Dhonneur
- Department of Anesthesia and Surgical Intensive Care, Henri Mondor University Hospital of Paris, Paris XII school of medicine, Créteil, France
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Abstract
BACKGROUND We know that the brain damage resulting from traumatic and other insults is not due solely to the direct consequences of the primary injury. A significant and potentially preventable contribution to the overall morbidity arises from secondary hypoxic-ischaemic damage. Brain swelling accompanied by raised intracranial pressure (ICP) prevents adequate cerebral perfusion with well-oxygenated blood.Detection of raised ICP could be useful in alerting clinicians to the need to improve cerebral perfusion, with consequent reductions in brain injury. OBJECTIVES To determine whether routine ICP monitoring in severe coma of any cause reduces the risk of all-cause mortality or severe disability at final follow-up. SEARCH METHODS We searched the Cochrane Injuries Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL Plus, ISI Web of Science (SCI-EXPANDED & CPCI-S), clinical trials registries and reference lists. We ran the most recent search on 22 May 2015. SELECTION CRITERIA All randomised controlled studies of real-time ICP monitoring by invasive or semi-invasive means in acute coma (traumatic or non-traumatic aetiology) versus clinical care without ICP monitoring (that is, guided only by clinical or radiological inference of the presence of raised ICP). DATA COLLECTION AND ANALYSIS Two authors (ET and RF) worked independently to identify the one study that met inclusion criteria. JR and RF independently extracted data and assessed risk of bias. We contacted study authors for additional information, including details of methods and outcome data. MAIN RESULTS One randomized controlled trial (RCT) meeting the selection criteria has been identified to date.The included study had 324 participants. We judged risk of bias to be low for all categories except blinding of participants and personnel, which is not feasible for this intervention. There were few missing data, and we analysed all on an intention-to-treat basis.Participants could be 13 years of age or older (mean age of sample 29; range 22 to 44), and all had severe traumatic brain injury, mostly due to traffic incidents. All were receiving care within intensive care units (ICUs) at one of six hospitals in either Bolivia or Ecuador. Investigators followed up 92% of participants for six months or until death. The trial excluded patients with a Glasgow Coma Score (GCS) less than three and fixed dilated pupils on admission on the basis that they had sustained brain injury of an unsalvageable severity.The study compared people managed using either an intracranial monitor or non-invasive monitoring (imaging and clinical examination) to identify potentially harmful raised intracranial pressure. Both study groups used imaging and clinical examination measures.Mortality at six months was 56/144 (39%) in the ICP-monitored group and 67/153 (44%) in the non-invasive group.Unfavourable outcome (defined as death or moderate to severe disability at six months) as assessed by the extended Glasgow Outcome Scale (GOS-E) was 80/144 (56%) in the ICP-monitored group and 93/153 (61%) in the non-invasive group.Six percent of participants in the ICP monitoring group had complications related to the monitoring, none of which met criteria for being a serious adverse event. There were no complications relating to the non-invasive group.Other complications and adverse events were comparable between treatment groups, 70/157 (45%) in the ICP-monitored group and 76/167 (46%) in the non-invasive group.Late mortality in both the monitored and non-invasive groups was high, with 35% of deaths occurring > 14 days after injury. The authors comment that this high late mortality may reflect inadequacies in post-ICU services for disabled survivors requiring specialist rehabilitation care. AUTHORS' CONCLUSIONS The data from the single RCT studying the role of routine ICP monitoring in acute traumatic coma fails to provide evidence to support the intervention.Research in this area is complicated by the fact that RCTs necessarily assess the combined impact of measurement of ICP with the clinical management decisions made in light of this data. Future studies will need to assess the added value of ICP data alongside other information from the multimodal monitoring typically performed in intensive care unit settings. Additionally, even within traumatically acquired brain injury (TBI), there is great heterogeneity in mechanisms, distribution, location and magnitude of injury, and studies within more homogeneous subgroups are likely to be more informative.
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Affiliation(s)
- Rob J Forsyth
- Newcastle UniversityInstitute of NeuroscienceRoyal Victoria InfirmaryNewcastle upon TyneTyne & WearUKNE1 4LP
| | - Joseph Raper
- The Newcastle Hospitals NHS Foundation TrustDepartment of PaediatricsQueen Victoria RoadNewcastleUKNE1 4LP
| | - Emma Todhunter
- Great North Children's Hospital, RVIQueen Victoria RoadNewcastleUKNE1 4LP
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Chohan MO, Akbik OS, Ramos-Canseco J, Ramirez PM, Murray-Krezan C, Berlin T, Olin K, Taylor CL, Yonas H. A novel single twist-drill access device for multimodal intracranial monitoring: a 5-year single-institution experience. Neurosurgery 2015; 10 Suppl 3:400-11; discussion 411. [PMID: 24887290 DOI: 10.1227/neu.0000000000000451] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Multimodal intracranial monitoring in the neurosurgical patient requires insertion of probes through multiple craniostomies. OBJECTIVE To report our 5-year experience with a novel device allowing multimodal monitoring though a single twist-drill hole. METHODS All devices (Hummingbird Synergy, Innerspace) were placed at the Kocher point between 2008 and 2013 at our institution. An independent clinical research nurse prospectively collected data on all bedside placements. Placement accuracy was graded on computed tomography scan as grade 1 (ipsilateral frontal horn or third ventricle), grade 2 (contralateral lateral ventricle), and grade 3 (anywhere else). Infection was monitored with serial cerebrospinal fluid samples. RESULTS Two hundred seventy-five devices (198 at bedside, 77 in operating room) were placed in patients with spontaneous subarachnoid hemorrhage (49%), traumatic brain injury (47%), and others (4%) for a median duration of 6 days. A junior (postgraduate year 1-2), midlevel (postgraduate year 3-4), or senior resident (postgraduate year 5-6) placed 39%, 32%, and 29% of the devices, respectively. Ninety-two percent of all devices placed were draining cerebrospinal fluid, ie, were grade 1 (75%) or 2 (17%). Placement accuracy did not vary with level of training. Complications included hemorrhage (10%) and infection (4%), with 1 patient requiring intraparenchymal hematoma evacuation and a second requiring abscess drainage. These rates were lower than reported in the literature for standard external ventricular drains. CONCLUSION Hummingbird Synergy is a novel single-port access device for multimodal intracranial monitoring that can be placed safely at the bedside or in the operating room with placement accuracy and has a complication profile similar to or better than that for standard external ventricular drains.
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Affiliation(s)
- Muhammad Omar Chohan
- *Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico; ‡Division of Epidemiology, Biostatistics, and Preventive Medicine, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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Yang I, Ung N, Nagasawa DT, Pelargos P, Choy W, Chung LK, Thill K, Martin NA, Afsar-Manesh N, Voth B. Recent Advances in the Patient Safety and Quality Initiatives Movement. Neurosurg Clin N Am 2015; 26:301-15, xi. [DOI: 10.1016/j.nec.2014.11.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Dey M, Stadnik A, Riad F, Zhang L, McBee N, Kase C, Carhuapoma JR, Ram M, Lane K, Ostapkovich N, Aldrich F, Aldrich C, Jallo J, Butcher K, Snider R, Hanley D, Ziai W, Awad IA. Bleeding and infection with external ventricular drainage: a systematic review in comparison with adjudicated adverse events in the ongoing Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR-III IHV) trial. Neurosurgery 2015; 76:291-300; discussion 301. [PMID: 25635887 PMCID: PMC4333009 DOI: 10.1227/neu.0000000000000624] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Retrospective series report varied rates of bleeding and infection with external ventricular drainage (EVD). There have been no prospective studies of these risks with systematic surveillance, threshold definitions, or independent adjudication. OBJECTIVE To analyze the rate of complications in the ongoing Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR III) trial, providing a comparison with a systematic review of complications of EVD in the literature. METHODS Patients were prospectively enrolled in the CLEAR III trial after placement of an EVD for obstructive intraventricular hemorrhage and randomized to receive recombinant tissue-type plasminogen activator or placebo. We counted any detected new hemorrhage (catheter tract hemorrhage or any other distant hemorrhage) on computed tomography scan within 30 days from the randomization. Meta-analysis of published series of EVD placement was compiled with STATA software. RESULTS Growing or unstable hemorrhage was reported as a cause of exclusion from the trial in 74 of 5707 cases (1.3%) screened for CLEAR III. The first 250 patients enrolled have completed adjudication of adverse events. Forty-two subjects (16.8%) experienced ≥1 new bleeds or expansions, and 6 of 250 subjects (2.4%) suffered symptomatic hemorrhages. Eleven cases (4.4%) had culture-proven bacterial meningitis or ventriculitis. CONCLUSION Risks of bleeding and infection in the ongoing CLEAR III trial are comparable to those previously reported in EVD case series. In the present study, rates of new bleeds and bacterial meningitis/ventriculitis are very low despite multiple daily injections, blood in the ventricles, the use of thrombolysis in half the cases, and generalization to >60 trial sites.
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Affiliation(s)
- Mahua Dey
- ‡Section of Neurosurgery and Neurovascular Surgery Program, Division of Biological Sciences and the Pritzker School of Medicine, University of Chicago, Chicago, Illinois; §Pritzker School of Medicine, University of Chicago, Chicago, Illinois; ¶Johns Hopkins Medicine, Baltimore, Maryland; ‖Boston Medical Center, Boston, Massachusetts; #Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; **University of Maryland, Baltimore, Maryland; ‡‡Thomas Jefferson University, Philadelphia, Pennsylvania; §§University of Alberta, Edmonton, Alberta, Canada; ¶¶Stanford University, Stanford, California
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Ramanan M, Lipman J, Shorr A, Shankar A. A meta-analysis of ventriculostomy-associated cerebrospinal fluid infections. BMC Infect Dis 2015; 15:3. [PMID: 25567583 PMCID: PMC4300210 DOI: 10.1186/s12879-014-0712-z] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Accepted: 12/11/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ventriculostomy insertion is a common neurosurgical intervention and can be complicated by ventriculostomy-associated cerebrospinal fluid infection (VAI) which is associated with increased morbidity and mortality. This meta-analysis was aimed at determining the pooled incidence rate (number per 1000 catheter-days) of VAI. METHODS Relevant studies were identified from MEDLINE and EMBASE and from reference searching of included studies and recent review articles on relevant topics. The Newcastle-Ottawa Scale was used to assess quality and risk of bias. A random effects model was used to pool individual study estimates and 95% confidence intervals (CI) were calculated using the exact Poisson method. Heterogeneity was assessed using the heterogeneity χ2 and I-squared tests. Subgroup analyses were performed and a funnel plot constructed to assess publication bias. RESULTS There were a total of 35 studies which yielded 752 infections from 66,706 catheter-days of observation. The overall pooled incidence rate of VAI was 11.4 per 1000 catheter days (95% CI 9.3 to 13.5), for high quality studies the rate was 10.6 (95% CI 8.3 to 13) and 13.5 (95% CI 8.9 to 18.1) for low quality studies. Studies which had mean duration of EVD treatment of less than 7 days had a pooled VAI rate of 19.6 per 1000 catheter-days, those with mean duration of 7-10 days had VAI rate of 12.8 per 1000 catheter-days and those with mean duration greater than 10 days had VAI rate of 8 per 1000 catheter-days. There was significant heterogeneity for the primary outcome (p = 0.004, I-squared = 44%) and most subgroups. The funnel plot did not show evidence for publication bias. CONCLUSIONS The incidence rate of VAI is 11.4 per 1000 catheter-days. Further research should focus on analysis of risk factors for VAI and techniques for reducing the rate of VAI.
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Affiliation(s)
- Mahesh Ramanan
- Burns Trauma Critical Care Research Centre, School of Medicine, University of Queensland, Brisbane, Queensland, Australia.
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, 4029, Australia.
| | - Jeffrey Lipman
- Burns Trauma Critical Care Research Centre, School of Medicine, University of Queensland, Brisbane, Queensland, Australia.
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, 4029, Australia.
| | - Andrew Shorr
- Medical Intensive Care Unit, Washington Hospital Center, Washington, DC, USA.
| | - Aparna Shankar
- Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India.
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Kaufmann AM, Lye T, Redekop G, Brevner A, Hamilton M, Kozey M, Easton D. Infection Rates in Standard vs. Hydrogel Coated Ventricular Catheters. Can J Neurol Sci 2014; 31:506-10. [PMID: 15595257 DOI: 10.1017/s0317167100003723] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background:Infection related to external ventricular drain (EVD) use is a common neurosurgical complication. Modified catheters with a hydrophilic surface may impede bacterial adherence and thereby reduce catheter related cerebrospinal fluid (CSF) infection.Methods:A prospective randomized clinical trial compared the occurrence of CSF infection related to use of either standard silastic or hydrogel coated EVD catheters (Bioglide®, Medtronic). Enrolment was available to all adult neurosurgery patients undergoing placement of a first EVD, at three university centers. The catheters were presoaked in a low concentration of bacitracin solution for 5-10 minutes prior to insertion. Bacterial infection was defined by heavy growth in a single CSF sample or light / medium growth in two consecutive samples. A secondary analysis was also conducted for “probable” CSF infection, including patients started on antibiotics after light / medium growth in a single CSF sample. Statistical analyses included Kaplan-Meier survival curve estimates accompanied by Log Rank and Breslow tests.Results:There were 158 randomized patients available to assess for EVD related infection of CSF. The two study groups had similar clinical characteristics including average duration of EVD use (8±4 days). Definite CSF infection occurred in seven and probable infection in another six (8% total). Infection incidence rose steadily from day 2 (1%) to day 11 (11%). There was no difference of daily occurrence of EVD infection between the two catheter types.Conclusion:Infection remains a common hazard in the use of EVD, and we found no reduction of infection using the hydrogel-coated catheters when presoaked in low concentration bacitracin solution.
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Dapul G, Patel P, Pannu T, Meythaler J. Treatment of severe tetanus with intrathecal baclofen via implantable infusion device: a case report. Neuromodulation 2014; 17:791-3. [PMID: 24934627 DOI: 10.1111/ner.12191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 02/11/2014] [Accepted: 02/13/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Severe tetanus remains a serious issue in less developed countries, leading to prolonged hospitalization due to prolonged neuromuscular contraction of muscles. We present a case of severe tetanus in the United States that was successfully managed with intrathecal baclofen. CASE REPORT A 42-year-old male without tetanus vaccination history presented to the emergency department with intractable jaw pain and worsening diffuse muscle contractures due to severe generalized tetanus requiring prolonged paralysis and ventilator support. After 14 days of continuous neuromuscular treatment with benzodiazepines, vecuronium, propofol, and magnesium sulfate, a baclofen pump trial was performed 14 days post-admission as an alternative to prolonged neuromuscular blockade. After demonstrable improvement in spasms and paroxysmal contractures due to intrathecal baclofen (ITB), a baclofen pump was implanted on hospital day 17. The catheter was threaded to T4 for maximal effect of intrathecal baclofen on the upper and lower extremities at an initial rate of 100 μg/day. ITB was titrated upward, the vecuronium was slowly weaned, and the patient was weaned off a ventilator by day 14 of ITB treatment. At an ITB dose of 450 μg/day, propofol was discontinued. ITB was continued over the next four weeks and eventually weaned over the next two weeks. The ITB pump was removed eight weeks after placement, and the patient was successfully discharged to home. CONCLUSION Due to prolonged muscle weakness associated with long-term use of paralytic agents and sedation, early ITB trial and pump placement should be considered as an alternative in the treatment of severe tetanus to shorten length of stay and improve the functional outcome of the patient.
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Affiliation(s)
- Geraldine Dapul
- Department of Physical Medicine and Rehabilitation Oakwood, School of Medicine, Wayne State University, Dearborn, MI, USA
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Sussman ES, Kellner CP, Nelson E, McDowell MM, Bruce SS, Bruce RA, Zhuang Z, Connolly ES. Hemorrhagic complications of ventriculostomy: incidence and predictors in patients with intracerebral hemorrhage. J Neurosurg 2014; 120:931-6. [DOI: 10.3171/2013.12.jns131685] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Ventriculostomy—the placement of an external ventricular drain (EVD)—is a common procedure performed in patients with acute neurological injury. Although generally considered a low-risk intervention, recent studies have cited higher rates of hemorrhagic complications than those previously reported. The authors sought to determine the rate of postventriculostomy hemorrhage in a cohort of patients with intracerebral hemorrhage (ICH) and to identify predictors of hemorrhagic complications of EVD placement.
Methods
Patients with ICH who underwent EVD placement and had both pre- and postprocedural imaging available for analysis were included in this study. Relevant data were prospectively collected for each patient who satisfied inclusion criteria. Variables with a p < 0.20 on univariate analyses were included in a stepwise logistic regression model to identify predictors of postventriculostomy hemorrhage.
Results
Sixty-nine patients were eligible for this analysis. Postventriculostomy hemorrhage occurred in 31.9% of patients. Among all patients with intraparenchymal hemorrhage, the mean hemorrhage volume was 0.66 ± 1.06 cm3. Stratified according to ventricular catheter diameter, patients treated with smaller-diameter catheters had a significantly greater mean hemorrhage volume than patients treated with larger-diameter catheters (0.84 ± 1.2 cm3 vs 0.14 ± 0.12 cm3, p = 0.049). Postventriculostomy hemorrhage was clinically significant in only 1 patient (1.4%). Overall, postventriculostomy hemorrhage was not associated with functional outcome or mortality at either discharge or 90 days. In the multivariate model, an age > 75 years was the only independent predictor of EVD-associated hemorrhage.
Conclusions
Advanced age is predictive of EVD-related hemorrhage in patients with ICH. While postventriculostomy hemorrhage is common, it appears to be of minor clinical significance in the majority of patients.
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Collins CDE, Hartley JC, Chakraborty A, Thompson DNP. Long subcutaneous tunnelling reduces infection rates in paediatric external ventricular drains. Childs Nerv Syst 2014; 30:1671-8. [PMID: 25160496 PMCID: PMC4167071 DOI: 10.1007/s00381-014-2523-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 08/04/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study is to report the efficacy of long subcutaneous tunnelling of external ventricular drains in reducing rates of infection and catheter displacement in a paediatric population. METHODS In children requiring external ventricular drainage, a long-tunnelled drain was placed and managed according to a locally agreed guideline. End points were novel CSF infection incurred during the time of drainage and re-operation to re-site displaced catheters. Data were compared to other published series. RESULTS One hundred eighty-one long-tunnelled external ventricular drains (LTEVDs) were inserted. The mean age was 6.6 years (range 0-15.5 years). Reasons for insertion included intraventricular haemorrhage (47 %), infection (27 %), tumour-related hydrocephalus (7.2 %), as a temporising measure (17 %) and trauma (2.2 %). The overall new infection rate for LTEVD was 2.76 %. If the 48 cases where LTEVDs were inserted to treat an existing infection are excluded, the infection rate was 3.8 % (5/133). The mean duration of insertion was 10 days (range 0-42 days). Four LTEVDs (2.2 %) were inadvertently dislodged, requiring reinsertion. Thirteen patients required removal of EVD alone. There was a significant difference (p < 0.05) when comparing our infection rate to 14 publications of infection rates in short-tunnelled EVDs; however, there was no difference when comparing our data to three publications using LTEVDs. CONCLUSION The use of an antibiotic-impregnated LTEVD, managed according to a predefined guideline, is associated with significantly reduced infection and displacement rates when compared with contemporary series. It is suggested that this reduction is of both clinical and economic benefits.
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Mahan M, Spetzler RF, Nakaji P. Electromagnetic stereotactic navigation for external ventricular drain placement in the intensive care unit. J Clin Neurosci 2013; 20:1718-22. [DOI: 10.1016/j.jocn.2013.03.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 03/09/2013] [Indexed: 11/17/2022]
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Fabiano AJ, Gruber TJ, Baxter MS. Increased ventriculostomy infection rate with use of intraventricular tissue plasminogen activator: A single-center observation. Clin Neurol Neurosurg 2013; 115:2362-4. [DOI: 10.1016/j.clineuro.2013.08.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 06/16/2013] [Accepted: 08/18/2013] [Indexed: 11/30/2022]
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Patil V, Lacson R, Vosburgh KG, Wong JM, Prevedello L, Andriole K, Mukundan S, Popp AJ, Khorasani R. Factors associated with external ventricular drain placement accuracy: data from an electronic health record repository. Acta Neurochir (Wien) 2013; 155:1773-9. [PMID: 23700258 DOI: 10.1007/s00701-013-1769-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 05/08/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND We evaluated external ventricular drain placement for factors associated with placement accuracy. Data were acquired using an electronic health record data requisition tool. METHOD Medical records of all patients who underwent ventriculostomy from 2003 to 2010 were identified and evaluated. Patient demographics, diagnosis, type of guidance and number of catheter passes were searched for and recorded. Post-procedural hemorrhage and/or infection were identified. A grading scale was used to classify accuracy of catheter placements. A multiple logistic regression model was developed to assess features associated with accurate catheter placement. RESULTS One hundred nine patients who underwent 111 ventriculostomies from 2003 to 2010 were identified. Patient diagnoses were classified into vascular (63 %), tumor (21 %), trauma (14 %), and cyst (2 %). Procedures were performed freehand in 90 (81 %), with the Ghajar guide in 17 (15 %), and with image guidance in 4 (4 %) patients. Eighty-eight (79 %) catheters were placed in the correct location. Trauma patients were more likely to have catheters misplaced (p = 0.007) whereas patients in other diagnostic categories were not significantly associated with misplaced catheters. Post-procedural hemorrhage was noted in 2 (1.8 %) patients on post-procedural imaging studies. Five (4.5 %) definite and 6 (5.4 %) suspected infections were identified. CONCLUSIONS External ventricular drain placement can be performed accurately in most patients. Patients with trauma are more likely to have catheters misplaced. Further development is required to identify and evaluate procedure outcomes using an electronic health record repository.
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Affiliation(s)
- Vaibhav Patil
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Dubourg J, Messerer M, Karakitsos D, Rajajee V, Antonsen E, Javouhey E, Cammarata A, Cotton M, Daniel RT, Denaro C, Douzinas E, Dubost C, Berhouma M, Kassai B, Rabilloud M, Gullo A, Hamlat A, Kouraklis G, Mannanici G, Marill K, Merceron S, Poularas J, Ristagno G, Noble V, Shah S, Kimberly H, Cammarata G, Moretti R, Geeraerts T. Individual patient data systematic review and meta-analysis of optic nerve sheath diameter ultrasonography for detecting raised intracranial pressure: protocol of the ONSD research group. Syst Rev 2013; 2:62. [PMID: 23919384 PMCID: PMC3751128 DOI: 10.1186/2046-4053-2-62] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Accepted: 06/20/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The purpose of the optic nerve sheath diameter (ONSD) research group project is to establish an individual patient-level database from high quality studies of ONSD ultrasonography for the detection of raised intracranial pressure (ICP), and to perform a systematic review and an individual patient data meta-analysis (IPDMA), which will provide a cutoff value to help physicians making decisions and encourage further research. Previous meta-analyses were able to assess the diagnostic accuracy of ONSD ultrasonography in detecting raised ICP but failed to determine a precise cutoff value. Thus, the ONSD research group was founded to synthesize data from several recent studies on the subject and to provide evidence on the diagnostic accuracy of ONSD ultrasonography in detecting raised ICP. METHODS This IPDMA will be conducted in different phases. First, we will systematically search for eligible studies. To be eligible, studies must have compared ONSD ultrasonography to invasive intracranial devices, the current reference standard for diagnosing raised ICP. Subsequently, we will assess the quality of studies included based on the QUADAS-2 tool, and then collect and validate individual patient data. The objectives of the primary analyses will be to assess the diagnostic accuracy of ONSD ultrasonography and to determine a precise cutoff value for detecting raised ICP. Secondly, we will construct a logistic regression model to assess whether patient and study characteristics influence diagnostic accuracy. DISCUSSION We believe that this IPD MA will provide the most reliable basis for the assessment of diagnostic accuracy of ONSD ultrasonography for detecting raised ICP and to provide a cutoff value. We also hope that the creation of the ONSD research group will encourage further study. TRIAL REGISTRATION PROSPERO registration number: CRD42012003072.
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Affiliation(s)
- Julie Dubourg
- Université Claude Bernard Lyon 1, 69003 Lyon, France.
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Alaraj A, Charbel FT, Birk D, Tobin M, Tobin M, Luciano C, Banerjee PP, Rizzi S, Sorenson J, Foley K, Slavin K, Roitberg B. Role of cranial and spinal virtual and augmented reality simulation using immersive touch modules in neurosurgical training. Neurosurgery 2013; 72 Suppl 1:115-23. [PMID: 23254799 DOI: 10.1227/neu.0b013e3182753093] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Recent studies have shown that mental script-based rehearsal and simulation-based training improve the transfer of surgical skills in various medical disciplines. Despite significant advances in technology and intraoperative techniques over the last several decades, surgical skills training on neurosurgical operations still carries significant risk of serious morbidity or mortality. Potentially avoidable technical errors are well recognized as contributing to poor surgical outcome. Surgical education is undergoing overwhelming change, as a result of the reduction of work hours and current trends focusing on patient safety and linking reimbursement with clinical outcomes. Thus, there is a need for adjunctive means for neurosurgical training, which is a recent advancement in simulation technology. ImmersiveTouch is an augmented reality system that integrates a haptic device and a high-resolution stereoscopic display. This simulation platform uses multiple sensory modalities, re-creating many of the environmental cues experienced during an actual procedure. Modules available include ventriculostomy, bone drilling, percutaneous trigeminal rhizotomy, and simulated spinal modules such as pedicle screw placement, vertebroplasty, and lumbar puncture. We present our experience with the development of such augmented reality neurosurgical modules and the feedback from neurosurgical residents.
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Affiliation(s)
- Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA.
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Kosty J, Pukenas B, Smith M, Storm PB, Zager E, Stiefel M, LeRoux P, Hurst R. Iatrogenic Vascular Complications Associated With External Ventricular Drain Placement: A Report of 8 Cases and Review of the Literature. Oper Neurosurg (Hagerstown) 2012; 72:ons208-13; discussion ons213. [DOI: 10.1227/neu.0b013e318279e783] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
BACKGROUND:
Placement of an external ventricular drain (EVD) is a commonly performed and often lifesaving procedure. Although hemorrhage is one of the commonest complications associated with the procedure, ventricular catheter–induced vascular injury is rarely reported.
OBJECTIVE:
To describe 9 cases of EVD-related vascular trauma: 7 arteriovenous fistulas and 2 traumatic aneurysms.
METHODS:
During a 3-year period, 299 patients had EVDs placed. Eight patients (2.75%), 3 male and 5 female (mean age, 48 ± 20 years), developed vascular lesions associated with EVDs. Six patients developed arteriovenous fistulas and 2 patients developed a traumatic aneurysm. The arterial feeders of 5 superficial draining fistulas arose from the middle meningeal artery, and the arterial feeder of a deep-draining fistula originated from a lenticulostriate artery. One traumatic aneurysm arose from a distal branch of the anterior cerebral artery, and the second from a branch of the superficial temporal artery. Four of the superficial fistulas were treated with transarterial embolization.
RESULTS:
Two superficial fistulas and the deep-draining fistula resolved spontaneously after EVD removal. The intracranial aneurysm was embolized with Onyx18, and the superficial temporal artery aneurysm was managed conservatively. There were no hemorrhages associated with any of these vascular lesions and no complications after treatment.
CONCLUSION:
Our data suggest that iatrogenic vascular trauma associated with EVD insertions (2.75%) may be more common than is currently appreciated. Endovascular treatment is effective and may be necessary when these lesions do not resolve spontaneously.
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Affiliation(s)
- Jennifer Kosty
- Departments of Radiology, West Chester Medical Center, Valhalla, New York
- Departments of Neurosurgery, West Chester Medical Center, Valhalla, New York
| | - Bryan Pukenas
- Departments of Radiology, West Chester Medical Center, Valhalla, New York
- Departments of Neurosurgery, West Chester Medical Center, Valhalla, New York
| | - Michelle Smith
- Departments of Radiology, West Chester Medical Center, Valhalla, New York
- Departments of Neurosurgery, West Chester Medical Center, Valhalla, New York
| | - Phillip B. Storm
- Departments of Radiology, West Chester Medical Center, Valhalla, New York
- Departments of Neurosurgery, West Chester Medical Center, Valhalla, New York
| | - Eric Zager
- Departments of Radiology, West Chester Medical Center, Valhalla, New York
- Departments of Neurosurgery, West Chester Medical Center, Valhalla, New York
| | - Michael Stiefel
- Department of Neurosurgery, West Chester Medical Center, Valhalla, New York
| | - Peter LeRoux
- Departments of Radiology, West Chester Medical Center, Valhalla, New York
- Departments of Neurosurgery, West Chester Medical Center, Valhalla, New York
| | - Robert Hurst
- Departments of Neurosurgery, West Chester Medical Center, Valhalla, New York
- Departments of Radiology, West Chester Medical Center, Valhalla, New York
- Departments of Neurosurgery, West Chester Medical Center, Valhalla, New York
- Departments of Neurology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
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Rehman T, Rehman AU, Rehman A, Bashir HH, Ali R, Bhimani SA, Khan S. A US-based survey on ventriculostomy practices. Clin Neurol Neurosurg 2012; 114:651-4. [DOI: 10.1016/j.clineuro.2011.12.040] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 11/24/2011] [Accepted: 12/24/2011] [Indexed: 11/29/2022]
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Saini NS, Dewan Y, Grewal SS. Efficacy of periprocedural vs extended use of antibiotics in patients with external ventricular drains – A randomized trial. INDIAN JOURNAL OF NEUROTRAUMA 2012. [DOI: 10.1016/j.ijnt.2012.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kasotakis G, Michailidou M, Bramos A, Chang Y, Velmahos G, Alam H, King D, de Moya MA. Intraparenchymal vs extracranial ventricular drain intracranial pressure monitors in traumatic brain injury: less is more? J Am Coll Surg 2012; 214:950-7. [PMID: 22541986 DOI: 10.1016/j.jamcollsurg.2012.03.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 03/08/2012] [Accepted: 03/12/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Management of severe traumatic brain injury has centered on continuous intracranial pressure (ICP) monitoring with intraparenchymal ICP monitors (IPM) or extracranial ventricular drains (EVD). Our hypothesis was that neurologic outcomes are unaffected by the type of ICP monitoring device. STUDY DESIGN We reviewed 377 adult patients with traumatic brain injury requiring ICP monitoring. Primary outcome was Glasgow Outcome Score (GOS) 1 month after injury. Secondary outcomes included mortality, monitoring-related complications, and length of ICU and hospital stay. RESULTS There were 253 patients managed with an IPM and 124 with an EVD. There was no difference in Glasgow Outcome Score (2.7 ± 1.3 vs 2.5 ± 1.3, p = 0.45), mortality (30.9% vs 32.2%, p = 0.82), and hospital length of stay (LOS) (15.6 ± 12.4 days vs 16.4 ± 10.7 days, p = 0.57). Device-related complications (11.9% vs 31.1%, p < 0.001), duration of ICP monitoring (3.8 ± 2.6 days vs 7.3 ± 5.6 days, p < 0.001), and ICU LOS (7.6 ± 5.6 days vs 9.5 ± 6.2 days, p = 0.004) were longer in the EVD group. Age, opening ICP, and size of midline shift were independent predictors for neurologic outcomes and mortality, when type and severity of brain injury, as well as overall injury severity were controlled for. Duration of ICP monitoring and opening ICP were independent predictors for hospital LOS and the former predicted prolonged ICU stay. Device-related complications were affected by type of device. CONCLUSIONS Use of EVDs in adult traumatic brain injury patients is associated with prolonged ICP monitoring, ICU LOS, and more frequent device-related complications.
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Affiliation(s)
- George Kasotakis
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Impact of antibiotic-impregnated catheters on the timing of cerebrospinal fluid infections in non-traumatic subarachnoid hemorrhage. Acta Neurochir (Wien) 2012; 154:761-6; discussion 767. [PMID: 22310970 DOI: 10.1007/s00701-012-1276-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 01/10/2012] [Indexed: 10/14/2022]
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) has been recognized as a risk factor for ventriculostomy-related infections (VRI). In addition to the hemorrhagic cerebrospinal fluid (CSF), the potential need for prolonged catheterization may contribute to the increased CSF infection rate in this population. The use of antibiotic-impregnated catheters (AIC) has effectively reduced the risk of VRI. Herein, we examined specifically the impact of systematic insertion of AIC on the timing of CSF infections in SAH patients. METHODS Retrospective review of patients admitted between April 2006 to March 2009 with a non-traumatic SAH who required an external ventriculostomy. Only patients with AIC were included. A meningitis or ventriculitis was diagnosed according to the published criteria of the Center for Disease Control and Prevention. RESULTS This study includes 75 patients in which 97 drains were inserted. Seven infections (7/75 = 9.3%) occurred over 1,024 drainage days (DD), resulting in a rate of 6.8 infections/1,000 DD. The mean drainage time was 15.4 days in the infected AIC group compared with 10.2 days in the non-infected AIC group. No infection occurred before day 9 of drainage and 71% (5/7) occurred after more than 2 weeks of drainage. The observed timing of infections is delayed in comparison with that reported in series using non-AIC, which typically occur prior to the 10th day of drainage. CONCLUSIONS In the high-risk population of non-traumatic SAH, the use of AIC delays the occurrence of infection compared with that reported with non-antibiotic-impregnated catheters. This may orient management strategies in SAH patients requiring a ventriculostomy.
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An outcome analysis of two different procedures of burr-hole trephine and external ventricular drainage in acute hydrocephalus. J Clin Neurosci 2012; 19:267-70. [DOI: 10.1016/j.jocn.2011.04.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 03/31/2011] [Accepted: 04/02/2011] [Indexed: 11/17/2022]
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49
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The Impact of Silver Nanoparticle-Coated and Antibiotic-Impregnated External Ventricular Drainage Catheters on the Risk of Infections: A Clinical Comparison of 95 Patients. ACTA NEUROCHIRURGICA SUPPLEMENTUM 2012; 114:347-50. [DOI: 10.1007/978-3-7091-0956-4_67] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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50
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Schödel P, Proescholdt M, Brawanski A, Bele S, Schebesch KM. Ventriculostomy for acute hydrocephalus in critically ill patients on the ICU--outcome analysis of two different procedures. Br J Neurosurg 2011; 26:227-30. [PMID: 21970781 DOI: 10.3109/02688697.2011.603853] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Burr-hole trephine and insertion of an external ventricular drainage (EVD) is a common procedure in neurosurgical practice. In critically ill patients, the transport to the operating room, OR represents a major risk. Thus, the burr-hole trephine and implantation of an EVD is frequently performed on the Intensive Care Unit (ICU). Since 2004, we have applied two different procedures: the conventional method with a mechanical compressed air or an electric drill, and an alternative method with a manual twist drill, including fixation of the EVD in a skull screw (Bolt Kit, Raumedic AG, Germany). This study was designed to evaluate the outcome of both surgical procedures. PATIENTS AND METHOD In this retrospective analysis we included 166 consecutive patients with acute hydrocephalus due to intracranial hemorrhage that had been operated at our neurosurgical ICU in a six years interval. We reviewed the charts for gender and age, kind of surgical procedure, cerebrospinal fluid (CSF)-infections, duration of drainage, attempts of insertions, wound infections, misplacement rate, post-surgical hemorrhages, revisions, comorbidities and shunt-dependency. RESULTS In 122 patients we applied the Bolt Kit System, in 44 patients the conventional method was performed. We found a significantly lower rate of CSF-infections and significantly fewer attempts of insertions in the Bolt Kit group (p = 0.002 and p = 0.001, respectively). The rate of wound infections, misplacement, revisions, shunt-dependency and the post-surgical hemorrhages did not differ significantly. DISCUSSION Our data indicate that the manual drill and the skull screw are safe and feasible tools in the treatment of acute hydrocephalus. Presumably, the direct skin contact is causative for the higher rate of CSF-infections when the conventional method is performed. The skull screw guides the EVD into the ventricle without skin contact. The lower number of insertions needed may be due to the fact that the skull screw allows just one trajectory for the insertion of the EVD.
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Affiliation(s)
- Petra Schödel
- Department of Neurosurgery, Medical Center University of Regensburg, Germany
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