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Woo PYM, Wong DKK, Yuan Y, Guo X, See MKW, Tam M, Wong AKS, Chan KY. A Morphometric Analysis of Commonly Used Craniometric Approaches for Freehand Ventriculoperitoneal Shunting. Oper Neurosurg (Hagerstown) 2022; 22:51-60. [PMID: 35007256 DOI: 10.1227/ons.0000000000000047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 09/06/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Ventricular catheter tip position is a predictor for ventriculoperitoneal shunt survival. Cannulation is often performed freehand, but there is limited consensus on the best craniometric approach. OBJECTIVE To determine the accuracy of localizing craniometric entry sites and to identify which is associated with optimal catheter placement. METHODS This is a retrospective analysis of adult patients who underwent ventriculoperitoneal shunting. The approaches were categorized as Kocher's, Keen's, Frazier's and Dandy's points as well as the parieto-occipital point. An accurately sited burr hole was within 10 mm from standard descriptions. Optimal catheter tip position was defined as within the ipsilateral frontal horn. RESULTS A total of 110 patients were reviewed, and 58% (65/110) of burr holes were accurately sited. Keen's point was the most correctly identified (65%, 11/17), followed by Kocher's point (65%, 37/57) and Frazier's point (60%, 3/5). Predictors for accurate localization were Keen's point (odds ratio 0.3; 95% CI: 01-0.9) and right-sided access (odds ratio 0.4; 95% CI: 0.1-0.9). Sixty-three percent (69/110) of catheters were optimally placed with Keen's point (adjusted odds ratio 0.04; 95% CI: 0.01-0.67), being the only independent factor. Thirteen patients (12%) required shunt revision at a mean duration of 10 ± 25 mo. Suboptimal catheter tip position was the only independent determinant for revision (adjusted odds ratio 0.11; 95% CI: 0.01-0.98). CONCLUSION This is the first study to compare the accuracy of freehand ventricular cannulation of standard craniometric entry sites for adult patients. Keen's point was the most accurately sited and was a predictor for optimal catheter position. Catheter tip location, not the entry site, predicted shunt survival.
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Affiliation(s)
- Peter Y M Woo
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Desiree K K Wong
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Yixuan Yuan
- Department of Electrical Engineering, City University of Hong Kong, Hong Kong, China
| | - Xiaoqing Guo
- Department of Electrical Engineering, City University of Hong Kong, Hong Kong, China
| | - Michael K W See
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Matthew Tam
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Alain K S Wong
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
| | - Kwong-Yau Chan
- Department of Neurosurgery, Kwong Wah Hospital, Hong Kong, China
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2
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Umana GE, Scalia G, Yagmurlu K, Mineo R, Di Bella S, Giunta M, Spitaleri A, Maugeri R, Graziano F, Fricia M, Nicoletti GF, Tomasi SO, Raudino G, Chaurasia B, Bellocchi G, Salvati M, Iacopino DG, Cicero S, Visocchi M, Strigari L. Multimodal Simulation of a Novel Device for a Safe and Effective External Ventricular Drain Placement. Front Neurosci 2021; 15:690705. [PMID: 34194297 PMCID: PMC8236630 DOI: 10.3389/fnins.2021.690705] [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: 04/03/2021] [Accepted: 05/04/2021] [Indexed: 11/13/2022] Open
Abstract
Background External ventricular drain (EVD) placement is mandatory for several pathologies. The misplacement rate of the EVD varies widely in literature, ranging from 12.3 to 60%. The purpose of this simulation study is to provide preliminary data about the possibility of increasing the safety of one of the most common life-saving procedures in neurosurgery by testing a new device for EVD placement. Methods We used a novel guide for positioning the ventricular catheter (patent RM2014A000376). The trajectory was assessed using 25 anonymized head CT scans. The data sets were used to conduct three-dimensional computer-based and combined navigation and augmented reality-based simulations using plaster models. The data set inclusion criteria were volumetric head CT scan, without midline shift, of patients older than 18. Evans' index was used to quantify the ventricle's size. We excluded patients with slit ventricles, midline shift, skull fractures, or complex skull malformations. The proximal end of the device was tested on the cadaver. Results The cadaveric tests proved that a surgeon could use the device without any external help. The multimodal simulation showed Kakarla grade 1 in all cases but one (grade 2) on both sides, after right and left EVD placement. The mean Evans' index was 0.28. The geometric principles that explain the device's efficacy can be summarized by studying the properties of circumference and chord. The contact occurs, for each section considered, at the extreme points of the chord. Its axis, perpendicular to the plane tangent to the spherical surface at the entry point, corresponds to the direction of entry of the catheter guided by the instrument. Conclusion According to our multimodal simulation on cadavers, 3D computer-based simulation, 3D plaster modeling, 3D neuronavigation, and augmented reality, the device promises to offer safer and effective EVD placement. Further validation in future clinical studies is recommended.
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Affiliation(s)
- Giuseppe Emmanuele Umana
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Gianluca Scalia
- Department of Neurosurgery, Highly Specialized Hospital and of National Importance "Garibaldi," Catania, Italy
| | - Kaan Yagmurlu
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, United States
| | - Rosalia Mineo
- MT Ortho Srl, Aci Sant'Antonio, Catania, Italy.,DICAR, University of Catania, Catania, Italy
| | - Simone Di Bella
- MT Ortho Srl, Aci Sant'Antonio, Catania, Italy.,DICAR, University of Catania, Catania, Italy
| | | | - Angelo Spitaleri
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Rosario Maugeri
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, AOUP "Paolo Giaccone," Palermo, Italy
| | - Francesca Graziano
- Department of Neurosurgery, Highly Specialized Hospital and of National Importance "Garibaldi," Catania, Italy.,Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, AOUP "Paolo Giaccone," Palermo, Italy
| | - Marco Fricia
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Giovanni Federico Nicoletti
- Department of Neurosurgery, Highly Specialized Hospital and of National Importance "Garibaldi," Catania, Italy
| | - Santino Ottavio Tomasi
- Department of Neurosurgery, Christian-Doppler-Klinik, Paracelsus Private Medical University, Salzburg, Austria
| | - Giuseppe Raudino
- Department of Neurosurgery, Humanitas University, Catania, Italy
| | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal
| | - Gianluca Bellocchi
- Department of Otorhinolaryngology, San Camillo Forlanini Hospital, Rome, Italy
| | - Maurizio Salvati
- Department of Neurosurgery, Policlinico Tor Vergata, Rome, Italy
| | - Domenico Gerardo Iacopino
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, AOUP "Paolo Giaccone," Palermo, Italy
| | - Salvatore Cicero
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Massimiliano Visocchi
- Craniovertebral Junction Operative Unit, Master CVJ Surgical Approach Research Center, Institute of Neurosurgery, Policlinic "A. Gemelli", Catholic University, Rome, Italy
| | - Lidia Strigari
- Department of Medical Physics, IRCCS University Hospital of Bologna, Bologna, Italy
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3
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Modern Brain Retractors and Surgical Brain Injury: A Review. World Neurosurg 2020; 142:93-103. [DOI: 10.1016/j.wneu.2020.06.153] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 12/22/2022]
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Deora H, Pruthi N, Rao KVLN, Saini J, Dikshit P. Predicting the Ideal Ventricular Freehand Pass Trajectory Using Osirix Software and the Role of Occipital Shape Variations. World Neurosurg 2020; 141:e341-e357. [PMID: 32454198 DOI: 10.1016/j.wneu.2020.05.146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cannulation of lateral ventricles via a posterior approach is a common neurosurgical procedure. It is often believed that a single entry and fiducial point applies to all. No importance is given to skull shape variations, which can lead to wrong shunt positions and revisions. OBJECTIVE A virtual-reality study was conducted to find the ideal entry point, ideal forehead fiducial point, and ideal angulation of the ventricular catheter and variations in these with changes in skull shapes. METHODS Fifty human cadaveric skulls were used to measure anteroposterior (AP) diameter and width and to classify shape of skulls into 4 types. Hydrocephalus (100 cases) and normal magnetic resonance images (50 cases) were studied from a PACS (Picture Archiving and Communication System) database. An Osirix DICOM Viewer (3.9.4) was used to reconstruct the images and estimate the ideal, 90°, and midline shunt trajectory and correlate the same with AP/width ratios and skull shapes. RESULTS Contrary to popular practice, the vertical distance from the inion for ideal trajectory placement was <6 cm and >4 cm in all shapes and ratio groups for hydrocephalus and nonhydrocephalus cases, respectively. As the AP/width ratio increases, the fiducial needs to be placed at a higher distance from the nasion and the distance of the entry point also increased from the inion. A rounder or more dolichocephalic skull dictates a 90° approach to be better, especially as the first pass. CONCLUSIONS No magical external entry point uniformly applicable for all cases exists. Hence, there is a need to classify skulls according to shapes/ratios and to use a tailored approach for a freehand pass to cannulate the ventricles.
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Affiliation(s)
- Harsh Deora
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Nupur Pruthi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India.
| | - Kannepalli V L N Rao
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Jitender Saini
- Department of Neuroradiology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Priyadarshi Dikshit
- Department of Neurosurgery, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, India
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Tayebi Meybodi K, Hoseinzadeh E, Ahmadi M, Taghvaei M, Saberi H. Reevaluation of Classic Posterior Ventricular Puncture Sites Using a 3-Dimensional Brain Simulation Model. World Neurosurg 2017; 107:22-27. [PMID: 28765021 DOI: 10.1016/j.wneu.2017.07.134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/20/2017] [Accepted: 07/22/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To revalidate the craniometric dimensions of classic posterior burr holes for ventricular catheter insertion in hydrocephalic patients, based on ideal catheter position on a 3-dimensional simulated computed tomography (CT) reconstruction model of the ventricles. METHODS Fifteen patients with hydrocephaly underwent multislice, thin-cut CT to geometrically determine the Cartesian coordinates of a new point for optimal posterior ventricular catheterization. The success rate for ventricular puncture and the thickness of brain traversed by the catheter with 3 approaches (Frazier, Keen, and the suggested point) were compared. RESULTS The suggested burr hole point for posterior ventricular catheterization is 51 and 57 mm posterior and 58 and 60 mm above the external auditory meatus parallel to the orbitomeatal plane on the right and left sides, respectively, significantly different from the classical Frazier and Keen points. The success rate was 100% for approaches using the suggested point and the Frazier point, compared with 83% using the Keen point. This 17% difference was marginally significant (P = 0.052). The parenchymal mantle for the Frazier point was thicker than that of the suggested point on both sides, although the difference was statistically significant only on the right side (P = 0.006). The parenchymal mantle was thinner in the Keen approach compared with the suggested approach, but the difference was not statistically significant. CONCLUSIONS The use of a suggested burr hole point for posterior ventricular catheterization may decrease the amount of parenchymal mantle of the brain transgressed by the catheter, and may marginally improve the chance of successful posterior ventricular catheterization.
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Affiliation(s)
- Keyvan Tayebi Meybodi
- Department of Neurological Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Hoseinzadeh
- Department of Neurological Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Ahmadi
- Department of Neurological Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Taghvaei
- Department of Neurological Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hooshang Saberi
- Department of Neurological Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Sánchez JJG, Rincon-Torroella J, Prats-Galino A, Notaris MD, Berenguer J, Rodríguez EF, Benet A. New endoscopic route to the temporal horn of the lateral ventricle: surgical simulation and morphometric assessment. J Neurosurg 2014; 121:751-9. [DOI: 10.3171/2014.5.jns132309] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The temporal horn of the lateral ventricle is a complex structure affected by specific pathological conditions. Current approaches to the temporal horn involve a certain amount of corticotomy and white matter disruption. Surgeons therefore set aside anterior temporal lobectomy as a last resource and avoid it in the dominant hemisphere. The authors propose a minimally invasive endoscopic intraventricular approach to the temporal horn and describe a standardized analysis and technical assessment of the feasibility of this approach.
Methods
To determine the best trajectory, angulation, and entry point to the temporal horn of the lateral ventricle, the authors evaluated 50 cranial MRI studies (100 temporal lobes) from healthy patients. They studied and systematized the neurosurgical endoscopic anatomy. They also simulated the proposed approach in 9 cadaveric specimens (18 approaches).
Results
Mean scalp entry point coordinates (± SD) were 2.7 ± 0.28 cm lateral to the inion and 5.6 ± 0.41 cm superior to the inion. The mean total distance from the uncal recess to the scalp (± SD) was 10.64 ± 0.6 cm. The mean total intraparenchymal distance crossed by the endoscope was 3.76 ± 0.36 cm. The approach was successfully completed in all studied specimens.
Conclusions
In this study, the endoscopic intraventricular approach to the temporal horn is standardized. The morphometric analysis makes this approach anatomically feasible and replicable. This approach provides minimally invasive endoscopic access to the uncal recess, amygdala, hippocampus, fornix, and paraventricular temporal lobe structures. The following essential strategies enabled access to and maneuverability inside the temporal horn: tailored preoperative planning of the trajectory and use of anatomical and radiological references, constant irrigation, and an angled endoscopic lens. Safety assessment and novel instruments and techniques may be proposed to advance this very promising route to pathological changes in the temporal lobe.
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Affiliation(s)
- Jose Juan González Sánchez
- 1Departments of Neurosurgery and
- 3Department of Neurosurgery, Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
| | | | - Alberto Prats-Galino
- 5Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Matteo de Notaris
- 5Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Joan Berenguer
- 2Radiology, Hospital Clinic i Provincial de Barcelona, Barcelona, Spain
| | | | - Arnau Benet
- 3Department of Neurosurgery, Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
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Schichor C, Witte J, Schöller K, Tanner P, Uhl E, Goldbrunner R, Tonn JC. Magnetically Guided Neuronavigation of Flexible Instruments in Shunt Placement, Transsphenoidal Procedures, and Craniotomies. Oper Neurosurg (Hagerstown) 2008. [DOI: 10.1227/01.neu.0000297082.28670.b1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Objective:
Magnetically guided neuronavigation of flexible instruments is a new tool that can be used in the frameless navigation of deep-seated lesions or shunt placements. Disadvantages of optical systems such as the line-of-sight problem, the necessity of rigid pin fixation of the head, and missing tracking of the tip of flexible instruments should be solved by the new tracking system. Until now, the accuracy of magnetically guided systems was mostly estimated in laboratory setups.
Methods:
In this study, intraoperative accuracy of the system was tested in 60 patients with either hydrocephalus or cranial base tumors. In daily routine use, different operative setups with a variety of metallic instruments were examined. Accuracy of the neuronavigation system was estimated, comparing microscopically or endoscopically identified anatomic landmarks with neuronavigated data and postoperative computed tomographic scans.
Results:
The main advantage of the new system is the tracking of a magnetic coil at the tip of a flexible instrument. After an initial learning curve during the developmental phase of the system, the latter showed reliable accuracy values with no operative setups leading to mismatch of more than 2 mm.
Conclusion:
Tracking of flexible instruments was easily accomplished as the tip of the instrument was followed within the patient's head. There were no major interferences with other metallic instruments within the surgical field.
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Affiliation(s)
- Christian Schichor
- Neurosurgical Clinic Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | | | - Karsten Schöller
- Neurosurgical Clinic Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - Philipp Tanner
- Neurosurgical Clinic Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - Eberhard Uhl
- Neurosurgical Clinic Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - Roland Goldbrunner
- Neurosurgical Clinic Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - Jörg-Christian Tonn
- Neurosurgical Clinic Grosshadern, Ludwig-Maximilians-University, Munich, Germany
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Lind CRP, Tsai AMC, Law AJJ, Lau H, Muthiah K. Ventricular catheter trajectories from traditional shunt approaches: a morphometric study in adults with hydrocephalus. J Neurosurg 2008; 108:930-3. [PMID: 18447709 DOI: 10.3171/jns/2008/108/5/0930] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this study was to compare the margins of error of different shunt catheter approaches to the lateral ventricle and assess surface anatomical aiming landmarks for free-hand ventricular catheter insertion in adult patients with hydrocephalus. METHODS Four adults who had undergone stereotactic brain magnetic resonance (MR) imaging and had normal ventricles, and 7 prospectively recruited adult patients with acute hydrocephalus were selected for inclusion in this study. Reconstructed MR images obtained prior to surgical intervention were geometrically analyzed with regard to frontal, parietal, and parietooccipital (occipital) approaches in both hemispheres. RESULTS The ventricular target zones were as follows: the frontal horn for frontal and occipital approaches, and the atrium/posterior horn for parietal approaches. The range of possible angles for successful catheter insertion was smallest for the occipital approach (8 degrees in the sagittal plane and 11 degrees in the coronal plane), greater for parietal catheters (23 and 36 degrees ), and greatest for the frontal approach in models of hydrocephalic brains (42 and 30 degrees; p < 0.001 for all comparisons except frontal vs parietal, which did not reach statistical significance). There was no single landmark for aiming occipital or parietal catheters that achieved ventricular target cannulation in every case. Success was achieved in only 86% of procedures using occipital trajectories and in 66% of those using parietal trajectories. CONCLUSIONS The occipital approach to ventricular catheter insertion provides the narrowest margin of error with regard to trajectory but has less aiming point variability than the parietal approach. The use of patient-specific stereotaxy rather than generic guides is required for totally reliable, first-pass ventricular catheterization via a posterior approach to shunt placement surgery in adults.
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Affiliation(s)
- Christopher R P Lind
- Department of Neurosurgery, Auckland City Hospital, University of Auckland, Auckland City, New Zealand.
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