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Fogg DN, Mallela AN, Abou-Al-Shaar H, González-Martínez J. Robotic-assisted stereotactic drainage of cerebral abscess and placement of ventriculostomy. Br J Neurosurg 2024; 38:954-957. [PMID: 34463595 DOI: 10.1080/02688697.2021.1969006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Robotic surgery has found increasing use in multiple subfields of neurosurgery. While the initial applications of stereotactic robotic surgery were for the placement of electrodes for extra-operative seizure monitoring, this technique has become increasingly relevant in other areas of neurosurgery. To the best of our knowledge, we report the first case of successful robotic surgery utilization to drain a cerebral abscess and place an external ventricular drain. CASE REPORT The authors demonstrate a novel use for stereotactic robotic assistance to drain a cerebral abscess and place ventriculostomy in a 74-year-old female patient who presented with a left basal ganglia Streptococcus intermedius abscess and concomitant ventriculitis. Drainage of a deep-seated abscess and placement of ventriculostomy was successfully performed in this patient without intraoperative difficulties or complications. The total operative time, including registration was 64 minutes and the estimated blood loss was 25 mL. The patient recovered well and was discharged to inpatient rehabilitation on postoperative day 19. CONCLUSIONS The use of robotic surgery to drain cerebral abscesses and place ventriculostomies is technically feasible and may potentially decrease operative time and increase accuracy and safety.
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Affiliation(s)
- David N Fogg
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arka N Mallela
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Sharma N, Head JR, Mallela AN, Shanahan RM, Canton SP, Abou-Al-Shaar H, Kass NM, Steuer F, Cheng L, Raver M, Andrews EG. Single institution series describing external ventricular drain (EVD) placement and short- and long-term complications related to placement accuracy. Surg Neurol Int 2024; 15:67. [PMID: 38468651 PMCID: PMC10927197 DOI: 10.25259/sni_894_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/05/2024] [Indexed: 03/13/2024] Open
Abstract
Background The placement of an external ventricular drain (EVD) for the treatment of acute hydrocephalus is one of the most common life-saving procedures that neurosurgeons perform worldwide. There are many well-known complications associated with EVD placement, including tract hemorrhages, intra-parenchymal and subdural hemorrhages, infection, and catheter misplacement. Given the variety of complications associated with EVD placement and the inconsistent findings on the relationship of accuracy to complications, the present study reviewed short- and long-term complications related to EVD placement at our institution. Methods A retrospective review was conducted for all consecutive patients who underwent bedside EVD placement for any indication between December 2020 and December 2021. Collected variables included demographic information, etiology of disease state, pre-and post-operative head computed tomography measurements, and post-procedural metrics (immediate and delayed complications). Results A total of 124 patients qualified for inclusion in our study. EVDs that were non-functioning/exchanged were not significantly related to age, accuracy, ventriculomegaly, sex, disposition, laterality, type of EVD used, intraventricular hemorrhage (IVH), etiology, or Kakarla Grade (KG) (all P > 0.17). The need for a second EVD was similarly not related to age, accuracy, ventriculomegaly, sex, disposition, location, laterality, type of EVD used, IVH, etiology, or KG (all P > 0.130). Patients who died, however, were significantly more likely to have a second contralateral EVD placed (18.2% vs. 4.9% P = 0.029). We also found that left-sided EVDs were significantly more likely to fail within seven days of placement (29.4% vs 13.3%, P = 0.037; relative risk (RR) 1.93, 95% confidence interval: 1.09-3.43), unrelated to age, sex, etiology, type of EVD, IVH, location of the procedure, or accuracy (all P > 0.07). This remained significant when using a binary logistic regression to control for ventriculomegaly, accuracy, mortality, age, sex, and etiology (P = 0.021, B = 3.43). Conclusion In our cohort, although a clear relationship between inaccuracy and complication rates was not found, our data did demonstrate that left-sided EVDs were more likely to fail within the immediate postoperative time point, and patients who died were more likely to have a second, contralateral EVD placed.
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Affiliation(s)
- Nikhil Sharma
- School of Medicine, University of Pittsburgh, Pennsylvania, United States
| | - Jeffery R. Head
- Department of Neurosurgery, University of Pittsburgh, Medical School, Pennsylvania, United States
| | - Arka N. Mallela
- Department of Neurosurgery, University of Pittsburgh, Medical School, Pennsylvania, United States
| | - Regan M. Shanahan
- School of Medicine, University of Pittsburgh, Pennsylvania, United States
| | - Stephen P. Canton
- Department of Orthopaedic Surgery Pittsburgh, Pennsylvania, United States
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, University of Pittsburgh, Medical School, Pennsylvania, United States
| | | | - Fritz Steuer
- School of Medicine, University of Pittsburgh, Pennsylvania, United States
| | - Lucille Cheng
- School of Medicine, University of Pittsburgh, Pennsylvania, United States
| | - Michael Raver
- School of Medicine, University of Pittsburgh, Pennsylvania, United States
| | - Edward G. Andrews
- Department of Neurosurgery, University of Pittsburgh, Medical School, Pennsylvania, United States
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Nawabi NLA, Stopa BM, Lassarén P, Bain PA, Mekary RA, Gormley WB. External ventricular drains and risk of freehand placement: A systematic review and meta-analysis. Clin Neurol Neurosurg 2023; 231:107852. [PMID: 37399698 DOI: 10.1016/j.clineuro.2023.107852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/18/2023] [Accepted: 06/23/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE External ventricular drains (EVDs) are used to monitor and treat elevated intracranial pressure. EVDs are often placed blindly without the use of imaging guidance, and successful placement with respect to pass attempts and final catheter location may suffer as a result of this freehand technique. METHODS A systematic literature search was conducted in PubMed, Embase, Web of Science, and Cochrane databases to identify studies pertaining to freehand EVD placement through March 30, 2022. Studies were included if they reported percentage of EVDs placed successfully on the first pass attempt, or final catheter location as defined by the Kakarla Grading System. Pooled weighted incidence estimates and 95% confidence intervals (95%CI) were calculated using a random effects model. RESULTS Of the 2964 results returned from the literature search, 39 studies were included in this meta-analysis. These studies reported on 6313 EVDs placed via freehand technique in 6070 patients with the following respective incidence: successful EVD placement on the first attempt (78%, 95%CI: 67-86%); placement with a Kakarla Grade of 1 (optimal location) (72%, 95%CI: 66-77%); hemorrhage (7%, 95%CI: 6-10%), and infection (5%, 95%CI: 3-8%). CONCLUSIONS Only 78% of EVDs in this meta-analysis were placed successfully on the first pass, and only 72% of final placements were deemed optimal. This represents a relatively high rate of suboptimal outcomes with respect to EVD placement, which could potentially be avoided with the use of navigation-assisted placement techniques.
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Affiliation(s)
- Noah L A Nawabi
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Brittany M Stopa
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA, Fralin Biomedical Research Institute, Roanoke, VA, USA
| | - Philipp Lassarén
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Paul A Bain
- Harvard Countway Library, 10 Shattuck St, Boston, MA 02115, USA
| | - Rania A Mekary
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, MCPHS University, 179 Longwood Avenue, 02115 Boston, MA, USA
| | - William B Gormley
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, MCPHS University, 179 Longwood Avenue, 02115 Boston, MA, USA; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Mahto N, Owodunni OP, Okakpu U, Kazim SF, Varela S, Varela Y, Garcia J, Alunday R, Schmidt MH, Bowers CA. Postprocedural Complications of External Ventricular Drains: A Meta-Analysis Evaluating the Absolute Risk of Hemorrhages, Infections, and Revisions. World Neurosurg 2023; 171:41-64. [PMID: 36470560 DOI: 10.1016/j.wneu.2022.11.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 11/29/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND External ventricular drain (EVD) insertion is often a lifesaving procedure frequently used in neurosurgical emergencies. It is routinely done at the bedside in the neurocritical care unit or in the emergency room. However, there are infectious and noninfectious complications associated with this procedure. This meta-analysis sought to evaluate the absolute risk associated with EVD hemorrhages, infections, and revisions. The secondary purpose was to identify and characterize risk factors for EVD complications. METHODS We searched the MEDLINE (PubMed) database for "external ventricular drain," "external ventricular drain" + "complications" or "Hemorrhage" or "Infection" or "Revision" irrespective of publication year. Estimates from individual studies were combined using a random effects model, and 95% confidence intervals (CIs) were calculated with maximum likelihood specification. To investigate heterogeneity, the t2 and I2 tests were utilized. To evaluate for publication bias, a funnel plot was developed. RESULTS There were 260 total studies screened from our PubMed literature database search, with 176 studies selected for full-text review, and all of these 176 studies were included in the meta-analysis as they met the inclusion criteria. A total of 132,128 EVD insertions were reported, with a total of 130,609 participants having at least one EVD inserted. The pooled absolute risk (risk difference) and percentage of the total variability due to true heterogeneity (I2) for hemorrhagic complication was 1236/10,203 (risk difference: -0.63; 95% CI: -0.66 to -0.60; I2: 97.8%), infectious complication was 7278/125,909 (risk difference: -0.65; 95% CI: -0.67 to -0.64; I2: 99.7%), and EVD revision was 674/4416 (risk difference: -0.58; 95% CI: -0.65 to -0.51; I2: 98.5%). On funnel plot analysis, we had a variety of symmetrical plots, and asymmetrical plots, suggesting no bias in larger studies, and the lack of positive effects/methodological quality in smaller studies. CONCLUSIONS In conclusion, these findings provide valuable information regarding the safety of one of the most important and most common neurosurgical procedures, EVD insertion. Implementing best-practice standards is recommended in order to reduce EVD-related complications. There is a need for more in-depth research into the independent risk factors associated with these complications, as well as confirmation of these findings by well-structured prospective studies.
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Affiliation(s)
- Neil Mahto
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Oluwafemi P Owodunni
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Uchenna Okakpu
- West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Syed F Kazim
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Samantha Varela
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Yandry Varela
- Burrell College of Osteopathic Medicine, New Mexico, USA
| | - Josiel Garcia
- Burrell College of Osteopathic Medicine, New Mexico, USA
| | - Robert Alunday
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA.
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Pandit AS, Palasz J, Nachev P, Toma AK. Mechanical Complications of External Ventricular and Lumbar Drains. World Neurosurg 2022; 166:e140-e154. [PMID: 35787961 DOI: 10.1016/j.wneu.2022.06.127] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND External ventricular drain (EVD) and lumbar drain insertion are 2 of the most commonly performed neurosurgical procedures worldwide for acute hydrocephalus. Mechanical complications, such as obstruction or cerebrospinal fluid (CSF) leakage, are often seen and may contribute toward significant patient morbidity. Different CSF drainage methods are advocated to reduce the incidence of complications, but evidence regarding comparative effectiveness is limited. METHODS In this single-center prospective cohort study, the incidence of mechanical complications and associated interventional factors, including choice of drain, collecting system, and location, were studied in patients requiring CSF diversion for acute hydrocephalus. Univariate analyses were performed to explore trends within the data, followed by a repeated-measures mixed-effects regression to determine the independent influence of drain device on mechanical failure. RESULTS Sixty-one patients required CSF diversion between January 2020 and March 2021, via 3 different drain types (lumbar drain, tunneled, and bolted EVD) and 2 collection systems (LiquoGuard 7 and AccuDrain), performed in either theater or intensive care. Twenty-one patients (39%) experienced a mechanical complication, with blockage being the most common. Multivariate analyses showed that bolted EVDs (odds ratio, 0.08; confidence interval, 0.01-0.58) and LiquoGuards (OR, 0.23; CI, 0.08-0.69) were significantly associated with fewer mechanical complications compared with tunneled EVDs and gravity-based collection systems, respectively (P ≤ 0.01). DISCUSSION Drain device has an influence on the occurrence of EVD-related complications. These preliminary findings suggest that choosing bolted EVDs and motor-assisted drainage can reduce drain-associated mechanical failure. A randomized controlled trial comparing drain devices is required to confirm these findings.
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Affiliation(s)
- Anand S Pandit
- High-Dimensional Neurology Group, UCL, London, United Kingdom; Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Joanna Palasz
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | | | - Ahmed K Toma
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom.
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