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Atallah O, Krauss JK, Hermann EJ. External ventricular drainage in pediatric patients: indications, management, and shunt conversion rates. Childs Nerv Syst 2024; 40:2071-2079. [PMID: 38557894 PMCID: PMC11180004 DOI: 10.1007/s00381-024-06367-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 03/14/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE Placement of an external ventricular drainage (EVD) is one of the most frequent procedures in neurosurgery, but it has specific challenges and risks in the pediatric population. We here investigate the indications, management, and shunt conversion rates of an EVD. METHODS We retrospectively analyzed the data of a consecutive series of pediatric patients who had an EVD placement in the Department of Neurosurgery at Hannover Medical School over a 12-year period. A bundle approach was introduced to reduce infections. Patients were categorized according to the underlying pathology in three groups: tumor, hemorrhage, and infection. RESULTS A total of 126 patients were included in this study. Seventy-two were male, and 54 were female. The mean age at the time of EVD placement was 5.2 ± 5.0 years (range 0-17 years). The largest subgroup was the tumor group (n = 54, 42.9%), followed by the infection group (n = 47, 37.3%), including shunt infection (n = 36), infected Rickham reservoir (n = 4), and bacterial or viral cerebral infection (n = 7), and the hemorrhage group (n = 25, 19.8%). The overall complication rate was 19.8% (n = 25/126), and the total number of complications was 30. Complications during EVD placement were noted in 5/126 (4%) instances. Complications during drainage time were infection in 9.5% (12 patients), dysfunction in 7.1% (9 patients), and EVD dislocation in 3.2% (4 patients). The highest rate of complications was seen in the hemorrhage group. There were no long-term complications. Conversion rates into a permanent shunt system were 100% in previously shunt-dependent patients. Conversion rates were comparable in the tumor group (27.7%) and in the hemorrhage group (32.0%). CONCLUSION EVD placement in children is an overall safe and effective option in children. In order to make further progress, carefully planned prospective and if possible randomized studies are needed controlling for multivariable aspects.
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Affiliation(s)
- Oday Atallah
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Elvis J Hermann
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany.
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Vanstrum EB, Borzage MT, Ha J, Chu J, Upreti M, Moats RA, Lai LM, Chiarelli PA. Development of an ultrafast brain MR neuronavigation protocol for ventricular shunt placement. J Neurosurg 2023; 138:367-373. [PMID: 35901769 PMCID: PMC10338062 DOI: 10.3171/2022.5.jns22767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/06/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Advancements in MRI technology have provided improved ways to acquire imaging data and to more seamlessly incorporate MRI into modern pediatric surgical practice. One such situation is image-guided navigation for pediatric neurosurgical procedures, including intracranial catheter placement. Image-guided surgery (IGS) requires acquisition of CT or MR images, but the former carries the risk of ionizing radiation and the latter is associated with long scan times and often requires pediatric patients to be sedated. The objective of this project was to circumvent the use of CT and standard-sequence MRI in ventricular neuronavigation by investigating the use of fast MR sequences on the basis of 3 criteria: scan duration comparable to that of CT acquisition, visualization of ventricular morphology, and image registration with surface renderings comparable to standard of care. The aim of this work was to report image development, implementation, and results of registration accuracy testing in healthy subjects. METHODS The authors formulated 11 candidate MR sequences on the basis of the standard IGS protocol, and various scan parameters were modified, such as k-space readout direction, partial k-space acquisition, sparse sampling of k-space (i.e., compressed sensing), in-plane spatial resolution, and slice thickness. To evaluate registration accuracy, the authors calculated target registration error (TRE). A candidate sequence was selected for further evaluation in 10 healthy subjects. RESULTS The authors identified a candidate imaging protocol, termed presurgical imaging with compressed sensing for time optimization (PICO). Acquisition of the PICO protocol takes 25 seconds. The authors demonstrated noninferior TRE for PICO (3.00 ± 0.19 mm) in comparison with the default MRI neuronavigation protocol (3.35 ± 0.20 mm, p = 0.20). CONCLUSIONS The developed and tested sequence of this work allowed accurate intraoperative image registration and provided sufficient parenchymal contrast for visualization of ventricular anatomy. Further investigations will evaluate use of the PICO protocol as a substitute for CT and conventional MRI protocols in ventricular neuronavigation.
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Affiliation(s)
| | - Matthew T. Borzage
- Fetal and Neonatal Institute, Division of Neonatology, Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California
| | - Joseph Ha
- Division of Neurosurgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Jason Chu
- Division of Neurosurgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Meenakshi Upreti
- The Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, California
| | - Rex A. Moats
- The Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, California
| | - Lillian M. Lai
- Department of Radiology, Children’s Hospital Los Angeles, Los Angeles, California
| | - Peter A. Chiarelli
- Keck School of Medicine of USC, Los Angeles, California
- Division of Neurosurgery, Children’s Hospital Los Angeles, Los Angeles, California
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The effect of image-guided ventricular catheter placement on shunt failure: a systematic review and meta-analysis. Childs Nerv Syst 2022; 38:1069-1076. [PMID: 35501511 DOI: 10.1007/s00381-022-05547-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/26/2022] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Cerebrospinal fluid (CSF) diversion for the treatment of hydrocephalus is one of the most common neurosurgical procedures. Over the years, the development of the neuronavigation system has allowed the surgeon to be guided in real time during the procedures. Nevertheless, to date, the revision rate remains as high as 30-40%. The aim of this study was to investigate the role of intraoperative image guidance in the prevention of shunt failure. We herein report the first literature meta-analysis of image guidance and shunt revision rate in the pediatric population. METHODS Principal online databases were searched for English-language articles published between January, 1980, and December, 2021. Analysis was limited to articles that included patients younger than 18 years of age at the time of primary V-P shunt. Articles reporting combined results of free-hand and image-guided placement of ventricular catheter (VC) were included. The main outcome measure of the study was the revision rate in relation to the intraoperative tools. Secondary variables collected were the age of the patient and ventricle size. Statistical analyses and meta-analysis plots were done via R and RStudio. Heterogeneity was formally assessed using Q, I2, and τ2 statistics. To examine publication bias was performed a funnel plot analysis. RESULT A total of 9 studies involving 2017 pediatric patients were included in the meta-analysis. 55.9% of procedures were carried out with the aid of intraoperative tools, while 44.1% procedures were conducted free hand. The intraoperative tools used were ultrasound (9.1%), electromagnetic neuronavigation (21.07%), endoscope (67.32%), and combined images (2.4%).The image-guided placement of VC was not statistically associated with a lower revision rate. The pooled OR was 0.97 [CI 95% 0.88-1.07] with an I2 statistics of 34%, t2 of 0.018 and a p-value of 0.15 at heterogeneity analysis. CONCLUSION Our analysis suggest images guidance during VC shunt placement does not statistically affect shunt survival. Nevertheless, intraoperative tools can support the surgeon especially in patients with difficult anatomy, slit ventricles or complex loculated hydrocephalus.
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Spindler P, Fiss I, Giese H, Hermann E, Lemcke J, Schuhmann MU, Thomale UW, Schaumann A. Angulation towards coronal convexity measure and catheter length indication improves the quality of ventricular catheter placement - a smartphone-assisted guidance technique. World Neurosurg 2021; 159:e221-e231. [PMID: 34954440 DOI: 10.1016/j.wneu.2021.12.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/09/2021] [Accepted: 12/10/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Accurate placement of a ventricular catheter is crucial to reduce the risk of shunt failure. In the randomized, prospective, multicenter GAVCA trial, which evaluated the quality of ventricular catheter placement, the subgroup of patients with detailed length marked ventricular catheters (dVC) reflected a difference in the primary endpoint of optimal VC placement in contrast to the subgroup of patients with simplified length marked ventricular catheters (sVC). Objective of this analysis is to compare the dVC-group with the sVC-group as well as the smartphone-assisted guidance technique (GA) with the standard freehand technique (F) for catheter placement. METHODS We performed a further analysis of the GAVCA trial in two steps: 1st part) detailed length marked VCs (providing detailed distance from tip to base (3-13cm) in 0.5cm markings) compared to simplified length marked VCs with length indication at 5 cm and 10 cm from tip to base and 2nd part) comparing the smartphone-assisted guidance technique vs. freehand technique in the dVC-group. RESULTS 1st part) Data of 137 patients (104 dVC patients vs. 33 sVC patients) was eligible for this analysis. Optimal VC placement was achieved in 72.1% of the dVC-group and 39.4% of the sVC-group (p=<0.001, odds ratio (OR) 3.9, 95% CI 1.7-9.3). 2nd part) The 104 dVC patients underwent a subgroup analysis concerning the catheter placement using different techniques for catheter placement (54 guidance technique (GA) vs. 50 freehand technique (F). Optimal catheter placement was achieved in 81.5% of the GA group and 62.0% of the F group (p=0.03, odds ratio 2.7, 95% CI 1.1-6.8). All patients who underwent guidance technique ventricular catheter placement (GA) were successful on primary puncture while for 8.7% of patients in the freehand group (F), multiple attempts were necessary (p=0.03). CONCLUSIONS This analysis suggests the combination of a smartphone-assisted guidance technique (GA) and use of a detailed length marked ventricular catheter (dVC) to improve the rate of accurate ventricular catheter placement. Compared with freehand technique (F), patients' safety is increased by a reduction of unsuccessful ventricular catheter placement attempts.
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Affiliation(s)
- Philipp Spindler
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Ingo Fiss
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Henrik Giese
- Department of Neurosurgery, Universitätsklinikum, Heidelberg, Heidelberg, Germany
| | - Elvis Hermann
- Department of Neurosurgery, Medizinische Hochschule Hannover, Hannover, Germany
| | - Johannes Lemcke
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Martin U Schuhmann
- Department of Neurosurgery, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Ulrich-Wilhelm Thomale
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Schaumann
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
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Ventriculoatrial shunt as a feasible regimen for certain patients of hydrocephalus: clinical features and surgical management. Acta Neurol Belg 2021; 121:403-408. [PMID: 31273606 DOI: 10.1007/s13760-019-01180-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/27/2019] [Indexed: 12/26/2022]
Abstract
Ventriculoatrial (VA) shunt is one of the most commonly used solutions for hydrocephalus. In recent years, the number of VA shunt has decreased worldwide, given the perceived technical challenges and the potentially serious complications associated with VA shunt. However, VA shunt remains as a viable treatment option for hydrocephalus in selected patients. Novel placement strategies and monitoring methods have been developed to reduce complications following VA shunt. In this article, we reported that seven consecutive cases who received a VA shunt. VA shunts were applied in seven hydrocephalic patients who experienced previous ventriculoperitoneal (VP) shunt failures or had contraindications to abdominal catheter placement. The insertion of VA shunt catheters was guided with the aid of intraoperative electromagnetic neuronavigation and electrocardiographic technique. There were three female and four male patients with a mean age of 46 years (range 22-68 years) received VA shunts under the guidance of electromagnetic neuronavigation and electrocardiographic method intraoperatively. In all cases, postoperative cranial CT scans and chest radiography demonstrated appropriate positioning of the catheter tips. And no postoperative complications occurred during the follow-up period of 3-26 months. VA shunts are potential favorable alternatives for patients who cannot tolerate VP shunts. It is noteworthy that VA is not free of complications. Intraoperative application of electromagnetic neuronavigation and electrocardiographic technique contributes to safe and optimal catheter placement of VA shunts.
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Polemikos M, Kiepe F, Al-Afif S, Bronzlik P, Krauss JK. When Fat Hits the Brain: Intraventricular and Subarachnoid Fat Migration Secondary to a Complex Sacropelvic Fracture-Diagnosis and Treatment. J Neurol Surg A Cent Eur Neurosurg 2021; 83:290-293. [PMID: 33618409 DOI: 10.1055/s-0041-1722967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Massive migration of fat droplets in the ventricles and the subarachnoid space is a very rare sequel of spinal trauma. Owing to its rarity, knowledge about treatment and outcome remains limited. We report on the uncommon occurrence of massive subarachnoid and intraventricular fat dissemination in a 41-year-old man who suffered a complex sacropelvic fracture with spondylopelvic dissociation but who had no head injury. We show that early placement of an external ventricular drain with prolonged drainage for washout of the fat depots can prevent chronic hydrocephalus and subsequent shunt dependency.
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Affiliation(s)
- Manolis Polemikos
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Felix Kiepe
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Shadi Al-Afif
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Paul Bronzlik
- Institute for Diagnostic and Interventional Neuroradiology, Hannover Medical School, MHH, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
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Srinivas D, Tyagi G, Singh G. Shunt Implants – Past, Present and Future. Neurol India 2021; 69:S463-S470. [DOI: 10.4103/0028-3886.332263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Chest Implantation of Adjustable Gravitational Valves: An Easy, Safe, and Stable Alternative to Control Symptomatic Overdrainage in Shunted Children. World Neurosurg 2020; 146:90-94. [PMID: 33171320 DOI: 10.1016/j.wneu.2020.11.001] [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: 10/01/2020] [Revised: 10/31/2020] [Accepted: 11/02/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Shunt overdrainage is a potential complication in pediatric hydrocephalus. The addition of adjustable gravitational units to previous shunt systems has been proposed as effective management for this problem. These devices have been traditionally implanted over the occipital bone. We propose chest implantation as an easier, safer, and more stable alternative in the pediatric population, especially in those cases with parieto-occipital shunts. METHODS This study comprises a retrospective analysis from a unicentric case series of pediatric patients affected by overdrainage and managed with adjustable gravitational valves implanted in the chest. The device implantation technique is described in detail and takes no more than 15 minutes. RESULTS Thirty-seven patients met the criteria. The mean age of implantation was 9.62 years. The mean follow-up in the series was 38 months. The mean number of pressure adjustments was 2.48. The mean "deviation angle" of the device to the longitudinal body axis was 5.8°. The complications per year of shunt were <0.02 with no disconnection of the catheters in any case during follow-up. CONCLUSIONS In our experience, chest implantation for adjustable gravitational devices was a suitable shunt modification in pediatric patients suffering from overdrainage.
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Bauer DF, Baird LC, Klimo P, Mazzola CA, Nikas DC, Tamber MS, Flannery AM. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Treatment of Pediatric Hydrocephalus: Update of the 2014 Guidelines. Neurosurgery 2020; 87:1071-1075. [DOI: 10.1093/neuros/nyaa434] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 11/13/2022] Open
Abstract
ABSTRACT
BACKGROUND
The Congress of Neurological Surgeons reviews its guidelines according to the Institute of Medicine's recommended best practice of reviewing guidelines every 5 yrs. The authors performed a planned 5-yr review of the medical literature used to develop the “Pediatric hydrocephalus: systematic literature review and evidence-based guidelines” and determined the need for an update to the original guideline based on new available evidence.
OBJECTIVE
To perform an update to include the current medical literature for the “Pediatric hydrocephalus: systematic literature review and evidence-based guidelines”, originally published in 2014.
METHODS
The Guidelines Task Force used the search terms and strategies consistent with the original guidelines to search PubMed and Cochrane Central for relevant literature published between March 2012 and November 2019. The same inclusion/exclusion criteria were also used to screen abstracts and to perform the full-text review. Full text articles were then reviewed and when appropriate, included as evidence and recommendations were added or changed accordingly.
RESULTS
A total of 41 studies yielded by the updated search met inclusion criteria and were included in this update.
CONCLUSION
New literature resulting from the update yielded a new recommendation in Part 2, which states that neuro-endoscopic lavage is a feasible and safe option for the removal of intraventricular clots and may lower the rate of shunt placement (Level III). Additionally a recommendation in part 7 of the guideline now states that antibiotic-impregnated shunt tubing reduces the risk of shunt infection compared with conventional silicone hardware and should be used for children who require placement of a shunt (Level I). <https://www.cns.org/guidelines/browse-guidelines-detail/pediatric-hydrocephalus-guideline>
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Affiliation(s)
- David F Bauer
- Department of Neurosurgery, Texas Children's Hospital, Pediatric Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Lissa C Baird
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paul Klimo
- Semmes Murphey Department of Neurosurgery, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Catherine A Mazzola
- Goryeb Children’s Hospital, Morristown, New Jersey, Rutgers Department of Neurological Surgery, Newark, New Jersey
| | - Dimitrios C Nikas
- Division of Pediatric Neurosurgery, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Mandeep S Tamber
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ann Marie Flannery
- Kids Specialty Center, Women's & Children's Hospital, Lafayette, Louisiana
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Awad IA, Polster SP, Carrión-Penagos J, Thompson RE, Cao Y, Stadnik A, Money PL, Fam MD, Koskimäki J, Girard R, Lane K, McBee N, Ziai W, Hao Y, Dodd R, Carlson AP, Camarata PJ, Caron JL, Harrigan MR, Gregson BA, Mendelow AD, Zuccarello M, Hanley DF. Surgical Performance Determines Functional Outcome Benefit in the Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) Procedure. Neurosurgery 2020; 84:1157-1168. [PMID: 30891610 DOI: 10.1093/neuros/nyz077] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 02/14/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Minimally invasive surgery procedures, including stereotactic catheter aspiration and clearance of intracerebral hemorrhage (ICH) with recombinant tissue plasminogen activator hold a promise to improve outcome of supratentorial brain hemorrhage, a morbid and disabling type of stroke. A recently completed Phase III randomized trial showed improved mortality but was neutral on the primary outcome (modified Rankin scale score 0 to 3 at 1 yr). OBJECTIVE To assess surgical performance and its impact on the extent of ICH evacuation and functional outcomes. METHODS Univariate and multivariate models were used to assess the extent of hematoma evacuation efficacy in relation to mRS 0 to 3 outcome and postulated factors related to patient, disease, and protocol adherence in the surgical arm (n = 242) of the MISTIE trial. RESULTS Greater ICH reduction has a higher likelihood of achieving mRS of 0 to 3 with a minimum evacuation threshold of ≤15 mL end of treatment ICH volume or ≥70% volume reduction when controlling for disease severity factors. Mortality benefit was achieved at ≤30 mL end of treatment ICH volume, or >53% volume reduction. Initial hematoma volume, history of hypertension, irregular-shaped hematoma, number of alteplase doses given, surgical protocol deviations, and catheter manipulation problems were significant factors in failing to achieve ≤15 mL goal evacuation. Greater surgeon/site experiences were associated with avoiding poor hematoma evacuation. CONCLUSION This is the first surgical trial reporting thresholds for reduction of ICH volume correlating with improved mortality and functional outcomes. To realize the benefit of surgery, protocol objectives, surgeon education, technical enhancements, and case selection should be focused on this goal.
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Affiliation(s)
- Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Sean P Polster
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Julián Carrión-Penagos
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Richard E Thompson
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Ying Cao
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Agnieszka Stadnik
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Patricia Lynn Money
- Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Maged D Fam
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Janne Koskimäki
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois
| | - Karen Lane
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Nichol McBee
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Wendy Ziai
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Yi Hao
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
| | - Robert Dodd
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Paul J Camarata
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - Jean-Louis Caron
- Department of Neurosurgery, University of Texas, San Antonio, Texas
| | - Mark R Harrigan
- Division of Neurosurgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Barbara A Gregson
- Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - A David Mendelow
- Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins University Medical Institutions, Baltimore, Maryland
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Thomale UW, Schaumann A, Stockhammer F, Giese H, Schuster D, Kästner S, Ahmadi AS, Polemikos M, Bock HC, Gölz L, Lemcke J, Hermann E, Schuhmann MU, Beez T, Fritsch M, Orakcioglu B, Vajkoczy P, Rohde V, Bohner G. GAVCA Study: Randomized, Multicenter Trial to Evaluate the Quality of Ventricular Catheter Placement with a Mobile Health Assisted Guidance Technique. Neurosurgery 2019; 83:252-262. [PMID: 28973670 PMCID: PMC6140776 DOI: 10.1093/neuros/nyx420] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 07/25/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Freehand ventricular catheter placement may represent limited accuracy for the surgeon's intent to achieve primary optimal catheter position. OBJECTIVE To investigate the accuracy of a ventricular catheter guide assisted by a simple mobile health application (mhealth app) in a multicenter, randomized, controlled, simple blinded study (GAVCA study). METHODS In total, 139 eligible patients were enrolled in 9 centers. Catheter placement was evaluated by 3 different components: number of ventricular cannulation attempts, a grading scale, and the anatomical position of the catheter tip. The primary endpoint was the rate of primary cannulation of grade I catheter position in the ipsilateral ventricle. The secondary endpoints were rate of intraventricular position of the catheter's perforations, early ventricular catheter failure, and complications. RESULTS The primary endpoint was reached in 70% of the guided group vs 56.5% (freehand group; odds ratio 1.79, 95% confidence interval 0.89-3.61). The primary successful puncture rate was 100% vs 91.3% (P = .012). Catheter perforations were located completely inside the ventricle in 81.4% (guided group) and 65.2% (freehand group; odds ratio 2.34, 95% confidence interval 1.07-5.1). No differences occurred in early ventricular catheter failure, complication rate, duration of surgery, or hospital stay. CONCLUSION The guided ventricular catheter application proved to be a safe and simple method. The primary endpoint revealed a nonsignificant improvement of optimal catheter placement among the groups. Long-term follow-up is necessary in order to evaluate differences in catheter survival among shunted patients.
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Affiliation(s)
- Ulrich-Wilhelm Thomale
- Pediatric Neurosurgery and Department of Neurosurgery, Campus Virchow Klini-kum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Schaumann
- Pediatric Neurosurgery and Department of Neurosurgery, Campus Virchow Klini-kum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Florian Stockhammer
- Pediatric Neurosurgery and Department of Neurosurgery, Universi-tätsmedizin Göttingen, Göttingen, Germany
| | - Henrik Giese
- Department of Neurosurgery, Universitä-tsklinikum, Heidelberg, Heidelberg, Germany
| | - Dhani Schuster
- Department of Neurosurgery, Dietrich-Bonhoeffer-Klinikum, Neubrandenburg, Germa-ny
| | | | | | - Manolis Polemikos
- Department of Neu-rosurgery, Medizinische Hochschule Hannover, Hannover, Germany
| | - Hans-Christoph Bock
- Pediatric Neurosurgery and Department of Neurosurgery, Universi-tätsmedizin Göttingen, Göttingen, Germany
| | - Leonie Gölz
- Department of Neuro-surgery, Unfallkrankenhaus, Berlin Marzahn, Berlin, Germany
| | - Johannes Lemcke
- Department of Neuro-surgery, Unfallkrankenhaus, Berlin Marzahn, Berlin, Germany
| | - Elvis Hermann
- Department of Neu-rosurgery, Medizinische Hochschule Hannover, Hannover, Germany
| | - Martin U Schuhmann
- Department of Neurosurgery, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Thomas Beez
- Department of Neurosurgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Michael Fritsch
- Department of Neurosurgery, Dietrich-Bonhoeffer-Klinikum, Neubrandenburg, Germa-ny
| | - Berk Orakcioglu
- Department of Neurosurgery, Universitä-tsklinikum, Heidelberg, Heidelberg, Germany
| | - Peter Vajkoczy
- Pediatric Neurosurgery and Department of Neurosurgery, Campus Virchow Klini-kum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Veit Rohde
- Pediatric Neurosurgery and Department of Neurosurgery, Universi-tätsmedizin Göttingen, Göttingen, Germany
| | - Georg Bohner
- Department of Neuroradiology, Campus Virchow Klinikum, Universitätsmedizin Berlin, Berlin, Germany
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Ajmera S, Motiwala M, Khan NR, Smith LJ, Giles K, Vaughn B, Klimo P. Image Guidance for Ventricular Shunt Surgery: An Analysis of Hospital Charges. Neurosurgery 2019; 85:E765-E770. [DOI: 10.1093/neuros/nyz090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 03/04/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Image guidance for shunt surgery results in more accurate proximal catheter placement. However, reduction in shunt failure remains unclear in the literature. There have been no prior studies evaluating the cost effectiveness of neuronavigation for shunt surgery.
OBJECTIVE
To perform a cost analysis using available hospital charges of hypothetical shunt surgery performed with/without electromagnetic neuronavigation (EMN).
METHODS
Hospital charges were collected for physician fees, radiology, operating room (OR) time and supplies, postanesthesia care unit, hospitalization days, laboratory, and medications. Index shunt surgery charges (de novo or revision) were totaled and the difference calculated. This difference was compared with hospital charges for shunt revision surgery performed under 2 clinical scenarios: (1) same hospital stay as the index surgery; and (2) readmission through the emergency department.
RESULTS
Costs for freehand de novo and revision shunt surgery were $23 946.22 and $23 359.22, respectively. For stealth-guided de novo and revision surgery, the costs were $33 646.94 and $33 059.94, a difference of $9700.72. The largest charge increase was due to additional OR time (34 min; $4794), followed by disposable EMN equipment ($2672). Total effective charges to revise the shunt for scenarios 1 and 2 were $34 622.94 and $35 934.94, respectively. The cost ratios between the total revision charges for both scenarios and the difference in freehand vs EMN-assisted shunt surgery ($9700.72) were 3.57 and 3.70, respectively.
CONCLUSION
From an economic standpoint and within the limitations of our models, the number needed to prevent must be 4 or less for the use of neuronavigation to be considered cost effective.
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Affiliation(s)
- Sonia Ajmera
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mustafa Motiwala
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Nickalus R Khan
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | | | | | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
- Semmes Murphey, Memphis, Tennessee
- Le Bonheur Children's Hospital, Memphis, Tennessee
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Placement of Ommaya Reservoirs Using Electromagnetic Neuronavigation and Neuroendoscopy: A Retrospective Study with Cost-Benefit Analysis. World Neurosurg 2018; 122:e723-e728. [PMID: 30404054 DOI: 10.1016/j.wneu.2018.10.127] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 10/18/2018] [Accepted: 10/20/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Placement of intraventricular catheters in oncology patients is associated with high complication rates. Placing Ommaya reservoirs with the zero-error precision protocol (ZEPP), a combination of neuronavigation (AxiEM stereotactic navigation) and direct verification of catheter tip placement with a flexible neuroendoscope, is associated with decreased complication rates as a result of increased catheter placement accuracy. However, the ZEPP costs more than traditional methods of catheter placement, and the question of whether this increased accuracy with the ZEPP is cost-effective is unknown. METHODS We performed a single-center retrospective chart review of 50 consecutive ommaya reservoir patient placements between 2010 and 2017. Twenty-five ventricular catheters were placed using the ZEPP protocol, and 25 ventricular catheters were placed using only AxiEM stealth navigation. Postoperative catheter accuracy and complication rates were assessed. A cost-benefit analysis was then conducted to determine if the overall cost for placing Ommaya reservoirs with the ZEPP was effective compared with the alternative method of using neuronavigation alone. RESULTS In the non-ZEPP cohort, 10 of 25 catheters were placed within the optimal location compared with 25 of 25 catheters placed in the ZEPP cohort. Three complications occurred in the non-ZEPP cohort: 2 malpositioned catheters required surgical revision and 1 catheter-related hemorrhage resulted in a prolonged stay in the intensive care unit. No complications occurred in the ZEPP cohort. A cost-benefit analysis showed $4784 savings per patient with ZEPP utilization because of the high complication-associated costs. CONCLUSIONS Implementation of the ZEPP for verifying ventricular catheter placement in Ommaya reservoirs improved catheter tip accuracy, resulted in lower complication rates, and was more cost-effective when compared with the non-ZEPP cohort, which used only neuronavigation. The ZEPP can be used for ventricular shunt catheter placement to decrease complications and verify catheter tip accuracy in Ommaya or standard ventriculoperitoneal shunts.
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14
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Takenaka T, Toyota S, Kuroda H, Kobayashi M, Kumagai T, Mori K, Taki T. Freehand Technique of an Electromagnetic Navigation System Emitter to Avoid Interference Caused by Metal Neurosurgical Instruments. World Neurosurg 2018; 118:143-147. [DOI: 10.1016/j.wneu.2018.07.071] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 07/06/2018] [Accepted: 07/07/2018] [Indexed: 11/16/2022]
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15
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Jaeger HA, Cantillon-Murphy P. Distorter Characterisation Using Mutual Inductance in Electromagnetic Tracking. SENSORS (BASEL, SWITZERLAND) 2018; 18:E3059. [PMID: 30213100 PMCID: PMC6165436 DOI: 10.3390/s18093059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/30/2018] [Accepted: 09/10/2018] [Indexed: 11/25/2022]
Abstract
Electromagnetic tracking (EMT) is playing an increasingly important role in surgical navigation, medical robotics and virtual reality development as a positional and orientation reference. Though EMT is not restricted by line-of-sight requirements, measurement errors caused by magnetic distortions in the environment remain the technology's principal shortcoming. The characterisation, reduction and compensation of these errors is a broadly researched topic, with many developed techniques relying on auxiliary tracking hardware including redundant sensor arrays, optical and inertial tracking systems. This paper describes a novel method of detecting static magnetic distortions using only the magnetic field transmitting array. An existing transmitter design is modified to enable simultaneous transmission and reception of the generated magnetic field. A mutual inductance model is developed for this transmitter design in which deviations from control measurements indicate the location, magnitude and material of the field distorter to an approximate degree. While not directly compensating for errors, this work enables users of EMT systems to optimise placement of the magnetic transmitter by characterising a distorter's effect within the tracking volume without the use of additional hardware. The discrimination capabilities of this method may also allow researchers to apply material-specific compensation techniques to minimise position error in the clinical setting.
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Affiliation(s)
- Herman Alexander Jaeger
- Department of Electrical and Electronic Engineering, School of Engineering, University College Cork, Cork, Ireland.
| | - Pádraig Cantillon-Murphy
- Department of Electrical and Electronic Engineering, School of Engineering, University College Cork, Cork, Ireland.
- Tyndall National Institute, Dyke Parade, Cork, Ireland.
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16
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Fam MD, Hanley D, Stadnik A, Zeineddine HA, Girard R, Jesselson M, Cao Y, Money L, McBee N, Bistran-Hall AJ, Mould WA, Lane K, Camarata PJ, Zuccarello M, Awad IA. Surgical Performance in Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation Phase III Clinical Trial. Neurosurgery 2018; 81:860-866. [PMID: 28402516 DOI: 10.1093/neuros/nyx123] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 02/17/2017] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Minimally invasive thrombolytic evacuation of intracerebral hematoma is being investigated in the ongoing phase III clinical trial of Minimally Invasive Surgery plus recombinant Tissue plasminogen activator for Intracerebral hemorrhage Evacuation (MISTIE III). OBJECTIVE To assess the accuracy of catheter placement and efficacy of hematoma evacuation in relation to surgical approach and surgeon experience. METHODS We performed a trial midpoint interim assessment of 123 cases that underwent the surgical procedure. Accuracy of catheter placement was prospectively assessed by the trial Surgical Center based on prearticulated criteria. Hematoma evacuation efficacy was evaluated based on absolute volume reduction, percentage hematoma evacuation, and reaching the target end-of-treatment volume of <15 mL. One of 3 surgical trajectories was used: anterior (A), posterior (B), and lobar (C). Surgeons were classified based on experience with the MISTIE procedure as prequalified, qualified with probation, and fully qualified. RESULTS The average hematoma volume was 49.7 mL (range 20.0-124), and the mean evacuation rate was 71% (range 18.4%-99.8%). First placed catheters were 58% in good position, 28% suboptimal (but suitable to dose), and 14% poor (requiring repositioning). Posterior trajectory (B) was associated with significantly higher rates of poor placement (35%, P = .01). There was no significant difference in catheter placement accuracy among surgeons of varying experience. Hematoma evacuation efficacy was not significantly different among the 3 surgical approaches or different surgeons' experience. CONCLUSION Ongoing surgical education and quality monitoring in MISTIE III have resulted in consistent rates of hematoma evacuation despite technical challenges with the surgical approaches and among surgeons of varying experience.
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Affiliation(s)
- Maged D Fam
- Clinical Trials Unit, Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine, Chicago, Illinois
| | - Daniel Hanley
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins Medical Institutions
| | - Agnieszka Stadnik
- Clinical Trials Unit, Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine, Chicago, Illinois
| | - Hussein A Zeineddine
- Clinical Trials Unit, Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine, Chicago, Illinois
| | - Romuald Girard
- Clinical Trials Unit, Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine, Chicago, Illinois
| | - Michael Jesselson
- Clinical Trials Unit, Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine, Chicago, Illinois
| | - Ying Cao
- Clinical Trials Unit, Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine, Chicago, Illinois
| | - Lynn Money
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio
| | - Nichol McBee
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins Medical Institutions
| | - Amanda J Bistran-Hall
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins Medical Institutions
| | - W Andrew Mould
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins Medical Institutions
| | - Karen Lane
- Division of Brain Injury Outcomes, Department of Neurology, Johns Hopkins Medical Institutions
| | - Paul J Camarata
- Department of Neurosurgery, University of Kansas School of Medicine, Kansas City, Kansas; Investigators of the MISTIE III Trial
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio
| | - Issam A Awad
- Clinical Trials Unit, Neurovascular Surgery Program, Section of Neurosurgery, University of Chicago Medicine, Chicago, Illinois
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17
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Khan NR, DeCuypere M, Vaughn BN, Klimo P. Image Guidance for Ventricular Shunt Surgery: An Analysis of Ventricular Size and Proximal Revision Rates. Neurosurgery 2018; 84:624-635. [DOI: 10.1093/neuros/nyy074] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 02/21/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Nickalus R Khan
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Michael DeCuypere
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
- Semmes Murphey, Memphis, Tennessee
- Le Bonheur Children's Hospital, Memphis, Tennessee
| | | | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
- Semmes Murphey, Memphis, Tennessee
- Le Bonheur Children's Hospital, Memphis, Tennessee
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18
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Infected multilocular hydrocephalus treated by rigid and flexible endoscopes with electromagnetic-guided neuronavigation: a case report. Childs Nerv Syst 2018; 34:169-171. [PMID: 28871368 DOI: 10.1007/s00381-017-3585-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 08/28/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Endoscopic surgery assisted by a navigation system has greatly aided treatment of infected multilocular hydrocephalus, especially in children. CASE REPORT We describe a 2-year-old boy with multilocular hydrocephalus caused by repeated shunt infection, presenting with fever and vomiting. Magnetic resonance images (MRI) showed extraventricular cysts and severe ventricular deformity. There were three ventriculoperitoneal shunts and one residual ventricular catheter. With a flexible endoscope, we fenestrated the wall of extraventricular cysts and removed the residual catheter. We then used a rigid endoscope to fenestrate ventricular components. Both procedures were guided by electromagnetic (EM) navigation, and hydrocephalus was controlled with one ventricular catheter. CONCLUSION We have successfully treated a case suffered from infected multilocular hydrocephalus in infants using rigid and flexible endoscopes combined with EM navigation.
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19
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Senger S, Antes S, Salah M, Tschan C, Linsler S, Oertel J. The view through the ventricle catheter - The new ShuntScope for the therapy of pediatric hydrocephalus. J Clin Neurosci 2017; 48:196-202. [PMID: 29102235 DOI: 10.1016/j.jocn.2017.10.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 10/11/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Correct placement of the ventricle catheter directly influences the function of cerebral shunt systems. The incidence of proximal catheter misplacement reaches up to 45%. To avoid misplacements and revisions a new intra-catheter endoscope for precise ventricle catheter placement in children was evaluated. METHODS The semi-rigid ShuntScope (Karl Storz GmbH & Co.KG, Tuttlingen, Germany) with an outer diameter of 1.0 mm and an image resolution of 10,000 pixels was used in a series of 27 children and adolescents (18 males, 9 females, age range 2 months-18 years). Indications included catheter placement in aqueductal stenting (n = 4), first time shunt placement (n = 5), burr hole reservoir insertion (n = 4), catheter placement after endoscopic procedures (n = 7) and revision surgery of the ventricle catheter (n = 7). RESULTS ShuntScope guided precise catheter placement was achieved in 26 of 27 patients. In one case of aqueductal stenting, the procedure had to be abandoned. One single wound healing problem was noted as a complications. Intraventricular image quality was always sufficient to recognize the anatomical structures. In case of catheter removal, it was helpful to identify adherent vessels or membranes. Penetration of small adhesions or thin membranes was feasible. Postoperative imaging studies demonstrated catheter tip placements analogous to the intraoperative findings. CONCLUSIONS Misplacements of shunt catheters are completely avoidable with the presented intra-catheter technique including slit ventricles or even aqueductal stenting. Potential complications can be avoided during revision surgery. The implementation of the ShuntScope is recommended in pediatric neurosurgery.
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Affiliation(s)
- Sebastian Senger
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar, Germany.
| | - Sebastian Antes
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Mohamed Salah
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Christoph Tschan
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Stefan Linsler
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Joachim Oertel
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar, Germany
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20
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Intra-catheter endoscopy for various shunting procedures-a retrospective analysis on surgical practicability, catheter placement, and failure rates. Acta Neurochir (Wien) 2017; 159:1991-1998. [PMID: 28695446 DOI: 10.1007/s00701-017-3264-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/27/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The long-term function of a cerebral shunt is directly influenced by the placement of the ventricle catheter. In this work, an intra-luminal endoscope for best possible catheter positioning was used. Practicability, postoperative imaging, and shunt failure rates were retrospectively evaluated. METHODS Between January 2012 and June 2016, an intra-catheter endoscope was applied in 71 procedures. Endoscopic technique was used for catheter placement in first-time shunting or cerebrospinal fluid reservoir insertion (n = 38), revision surgery in proximal shunt failure (n = 13), and various intraventricular stenting procedures (n = 20). Catheter positioning was graded on postoperative imaging using a four-point scale. All patients were regularly followed up (mean, 31.6 months) to recognize shunt failures. RESULTS Endoscopic application could be completed as intended in 68 of 71 procedures. Postoperative imaging could exclude complete misplacement of all catheters, but optimal positioning was only achieved in 64.7% (44/68 cases). Four catheters had to be revised due to malfunction (failure rate, 5.8%). Another five catheters had to be removed due to infectious complications or wound-healing disorders. Direct correlations between catheter complications and suboptimal catheter positioning were not seen. Slit or distorted ventricles also did not prove to be a risk factor for the observed complications. CONCLUSIONS Versatile application possibilities of the intra-catheter endoscope reflect the advantages of the technique. Independent of the performed procedure, unintended positionings or even complete catheter misplacements could be avoided. However, in more than one-third of all cases, suboptimal catheter placements became obvious. Interestingly, negative influences on later shunt failures were not seen.
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21
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Matsushima K, Komune N, Matsuo S, Kohno M. Microsurgical and Endoscopic Anatomy for Intradural Temporal Bone Drilling and Applications of the Electromagnetic Navigation System: Various Extensions of the Retrosigmoid Approach. World Neurosurg 2017; 103:620-630. [DOI: 10.1016/j.wneu.2017.04.079] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 04/11/2017] [Accepted: 04/12/2017] [Indexed: 11/28/2022]
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22
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Gilard V, Magne N, Gerardin E, Curey S, Pelletier V, Hannequin P, Derrey S. Comparison of electromagnetic neuronavigation system and free-hand method for ventricular catheter placement in internal shunt. Clin Neurol Neurosurg 2017; 158:93-97. [DOI: 10.1016/j.clineuro.2017.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 05/03/2017] [Accepted: 05/05/2017] [Indexed: 11/28/2022]
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Simultaneous combination of electromagnetic navigation with visual evoked potential in endoscopic transsphenoidal surgery: clinical experience and technical considerations. Acta Neurochir (Wien) 2017; 159:1043-1048. [PMID: 28190146 DOI: 10.1007/s00701-017-3111-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 02/01/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The combination of electromagnetic navigation with continuous monitoring techniques allows for the best available anatomic and real-time functional intraoperative monitoring. Methodological aspects and technical adaptations for this combination of methods and the results from 19 patients with tumors in the pituitary region are reported. METHODS We retrospectively identified 19 patients who were treated with transsphenoidal surgery using high-resolution endoscopy (eTSS) at our hospital between June 2015 and June 2016. All patients underwent surgery under electromagnetic navigation with visual evoked potential (VEP) monitoring. The cases were reviewed for information on disease, and the distance between the patient tracker and emitter was measured. RESULTS In 19 patients, 17 had pituitary adenomas, 1 had a Rathke cleft cyst, and 1 had an arachnoid cyst. The optimal distance between the patient tracker and emitter was 20-25 cm. VEP monitoring could be performed with unaffected recording quality under electromagnetic navigation. Also we were able to perform the registration and eTSS at this distance using both navigation and VEP monitoring. CONCLUSIONS We performed eTSS for pituitary tumor by simultaneously using electromagnetic navigation and VEP. The optimal distance between the emitter and tracker minimizes VEP monitoring noise and allows accurate electromagnetic navigation.
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24
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Polemikos M, Heissler HE, Hermann EJ, Krauss JK. Idiopathic Intracranial Hypertension in Monozygotic Female Twins: Intracranial Pressure Dynamics and Treatment Outcome. World Neurosurg 2017; 101:814.e11-814.e14. [PMID: 28300719 DOI: 10.1016/j.wneu.2017.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 02/28/2017] [Accepted: 03/02/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Familial cases of idiopathic intracranial hypertension (IIH) are exceedingly rare, and its occurrence in monozygotic twins has not been reported previously. CASE DESCRIPTION We report monozygotic female twins who developed IIH, one at age 25 years and the other at age 28 years. Continuous intracranial pressure (ICP) monitoring confirmed elevated ICP as measured initially by lumbar puncture. In both cases, successful treatment with resolution of papilledema and symptoms relief was achieved after ventriculoperitoneal shunting. CONCLUSIONS This report documents the first case of IIH in monozygotic twins and the associated changes in ICP dynamics. Interestingly, almost equivalent alterations in ICP dynamics were found in the 2 patients.
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Affiliation(s)
- Manolis Polemikos
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany.
| | - Hans E Heissler
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Elvis J Hermann
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
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25
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Hermann EJ, Polemikos M, Heissler HE, Krauss JK. Shunt Surgery in Idiopathic Intracranial Hypertension Aided by Electromagnetic Navigation. Stereotact Funct Neurosurg 2017; 95:26-33. [PMID: 28088808 DOI: 10.1159/000453277] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 11/07/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) is characterized by increased cerebrospinal fluid (CSF) pressure and normal or slit ventricles. Lumboperitoneal shunting had been favored by many investigators for CSF diversion in IIH for decades; however, it has been associated with various side effects. Because of the small ventricular size adequate positioning of a ventricular catheter is challenging. OBJECTIVES Here, we investigated the usefulness of electromagnetic (EM)-guided ventricular catheter placement for ventriculoperitoneal shunting in IIH. METHODS Eighteen patients with IIH were included in this study. The age of patients ranged from 5 to 58 years at the time of surgery (mean age: 31.8 years; median: 29 years). There were 2 children (5 and 11 years old) and 16 adults. Inclusion criteria for the study were an established clinical diagnosis of IIH, lack of improvement with medication, and the presence of small ventricles. In all patients EM-navigated placement of the ventricular catheter was performed using real-time tracking of the catheter tip for exact positioning close to the foramen of Monro. Postoperative CT scans were correlated with intraoperative screen shots to validate the position of the catheter. RESULTS In all patients EM-navigated ventricular catheter placement was achieved with a single pass. There were no intraoperative or postoperative complications. Postoperative imaging confirmed satisfactory positioning of the ventricular catheter. No proximal shunt failure was observed during the follow-up at a mean of 41.5 months (range: 7-90 months, median: 40.5 months). CONCLUSIONS EM-navigated ventricular catheter placement in shunting for IIH is a safe and straightforward technique. It obviates the need for sharp head fixation, the head of the patient can be moved during surgery, and it may reduce the revision rate during follow-up.
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Affiliation(s)
- Elvis J Hermann
- Department of Neurosurgery, Medical School Hannover, Hannover, Germany
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26
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Wang A, Tenner MS, Tobias ME, Mohan A, Kim D, Tandon A. A Novel Approach Using Electromagnetic Neuronavigation and a Flexible Neuroendoscope for Placement of Ommaya Reservoirs. World Neurosurg 2016; 96:195-201. [DOI: 10.1016/j.wneu.2016.08.127] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 08/27/2016] [Accepted: 08/30/2016] [Indexed: 10/21/2022]
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27
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Weisenberg SH, TerMaath SC, Seaver CE, Killeffer JA. Ventricular catheter development: past, present, and future. J Neurosurg 2016; 125:1504-1512. [DOI: 10.3171/2015.12.jns151181] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Cerebrospinal fluid diversion via ventricular shunting is the prevailing contemporary treatment for hydrocephalus. The CSF shunt appeared in its current form in the 1950s, and modern CSF shunts are the result of 6 decades of significant progress in neurosurgery and biomedical engineering. However, despite revolutionary advances in material science, computational design optimization, manufacturing, and sensors, the ventricular catheter (VC) component of CSF shunts today remains largely unchanged in its functionality and capabilities from its original design, even though VC obstruction remains a primary cause of shunt failure. The objective of this paper is to investigate the history of VCs, including successful and failed alterations in mechanical design and material composition, to better understand the challenges that hinder development of a more effective design.
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Affiliation(s)
| | | | | | - James A. Killeffer
- 2Division of Neurosurgery, Department of Surgery, Graduate School of Medicine, University of Tennessee, Knoxville, Tennessee
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28
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Morgenstern PF, Connors S, Reiner AS, Greenfield JP. Image Guidance for Placement of Ommaya Reservoirs: Comparison of Fluoroscopy and Frameless Stereotactic Navigation in 145 Patients. World Neurosurg 2016; 93:154-8. [PMID: 27292205 DOI: 10.1016/j.wneu.2016.04.090] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/22/2016] [Accepted: 04/25/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Ommaya reservoirs are used for administration of intrathecal chemotherapy and cerebrospinal fluid sampling. Ventricular catheter placement for these purposes requires a high degree of accuracy. Various options exist to optimize catheter placement. We analyze a cohort of patients receiving catheters using 2 different technologies. METHODS Retrospective chart review was performed on patients undergoing Ommaya reservoir placement between 2011 and 2014. Most procedures were assisted by either frameless stereotactic neuronavigation or fluoroscopic guidance with pneumoencephalogram. Catheter accuracy, revision rates, perioperative complications, and operative time were measured. Preoperative similarities and differences in diagnosis, demographics, and ventricular size were also recorded to avoid a biased assessment of our results. RESULTS One-hundred and forty-five patients were included, 57 using fluoroscopic guidance and 88 using frameless stereotaxy. Common diagnoses in both groups were lymphoma and leptomeningeal disease. Qualitative measures of catheter placement accuracy showed no significant difference between the 2 groups. Proximity to the foramen of Monro favored fluoroscopy by a small margin (8.6 mm vs. 10.2 mm, P = 0.03). Overall revision rates were not significantly different between the groups (3.5% vs. 4.5%, P = 1.00). Early surgical complications occurred in 6.8% of the frameless stereotaxy group and 1.8% of the fluoroscopy group (P = 0.25). CONCLUSIONS Ommaya reservoirs can be placed accurately using different methods. Although there are slight differences between fluoroscopy and frameless stereotaxy in quantitative accuracy and procedure time, there is no significant advantage of 1 method over the other when evaluating revision or complication rates. Technique familiarity and surgeon preference may dictate the preferred procedure.
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Affiliation(s)
- Peter F Morgenstern
- Department of Neurological Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA; Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
| | - Scott Connors
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anne S Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA; Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Bijlenga PDP, Gautschi OP, Sarrafzadeh AS, Schaller K. External Ventricular Catheter Placement: How to Improve. ACTA NEUROCHIRURGICA SUPPLEMENT 2016; 122:161-4. [DOI: 10.1007/978-3-319-22533-3_33] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Endoscopic intracranial surgery enhanced by electromagnetic-guided neuronavigation in children. Childs Nerv Syst 2015; 31:1327-33. [PMID: 25933601 DOI: 10.1007/s00381-015-2734-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 04/20/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Navigated intracranial endoscopy with conventional technique usually requires sharp head fixation. In children, especially in those younger than 1 year of age and in older children with thin skulls due to chronic hydrocephalus, sharp head fixation is not possible. Here, we studied the feasibility, safety, and accuracy of electromagnetic (EM)-navigated endoscopy in a series of children, obviating the need of sharp head fixation. METHODS Seventeen children (ten boys, seven girls) between 12 days and 16.8 years (mean age 4.3 years; median 14 months) underwent EM-navigated intracranial endoscopic surgery based on 3D MR imaging of the head. Inclusion criteria for the study were intraventricular cysts, arachnoid cysts, aqueduct stenosis for endoscopic third ventriculostomy (ETV) with distorted ventricular anatomy, the need of biopsy in intraventricular tumors, and multiloculated hydrocephalus. A total of 22 endoscopic procedures were performed. Patients were registered for navigation by surface rendering in the supine position. After confirming accuracy, they were repositioned for endoscopic surgery with the head fixed slightly on a horseshoe headholder. EM navigation was performed using a flexible stylet introduced into the working channel of a rigid endoscope. Neuronavigation accuracy was checked for deviations measured in millimeters on screenshots after the referencing procedure and during surgery in the coronal (z = vertical), axial (x = mediolateral), and sagittal (y = anteroposterior) planes. RESULTS EM-navigated endoscopy was feasible and safe. In all 17 patients, the aim of endoscopic surgery was achieved, except in one case in which a hemorrhage occurred, blurring visibility, and we proceeded with open surgery without complications for the patient. Navigation accuracy for extracranial markers such as the tragus, bregma, and nasion ranged between 1 and 2.5 mm. Accuracy for fixed anatomical structures like the optic nerve or the carotid artery varied between 2 and 4 mm, while there was a broader variance of accuracy at the target point of the cyst itself ranging between 2 and 9 mm. CONCLUSIONS EM-navigated endoscopy in children is a safe and useful technique enhancing endoscopic intracranial surgery and obviating the need of sharp head fixation. It is a good alternative to the common opto-electric navigation system in this age group.
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Electromagnetic navigation-guided surgery in the semi-sitting position for posterior fossa tumours: a safety and feasibility study. Acta Neurochir (Wien) 2015; 157:1229-37. [PMID: 25990847 DOI: 10.1007/s00701-015-2452-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 05/07/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Electromagnetic (EM)-guided neuronavigation is an innovative technique and a viable alternative to opto-electric navigation. We have performed a safety and feasibility study using EM-guided neuronavigation for posterior fossa surgery in the semi-sitting position in a selected subset of patients. METHODS Out of 284 patients with posterior fossa tumours operated upon over a period of 40 months, a subset of 15 patients was thought to possibly benefit from EM navigational guidance and was included in this study. There were six children and nine adults (aged between 8 and 84 years; mean age, 34.6 years) with different neoplasms in the brainstem or close to the midline. All patients had contrast-enhanced three-dimensional (3D) magnetic resonance imaging (MRI) of the head preoperatively. EM-guided navigation was used to identify and preserve the venous sinuses during craniotomy and to determine the trajectory to the lesion using various approaches. Neuronavigation accuracy was repeatedly checked for deviations measured in millimetres on screen shots during surgery before and after dural opening in the coronal (z = vertical), axial (x = mediolateral) and sagittal (y = anteroposterior) plane. RESULTS Referencing of the patient in the supine position was fast and easy. There was no loss of navigation accuracy after repositioning of the patient in the semi-sitting position (mean, 2.5 mm ± 0.92 mm). Identification of the pathological structure using EM navigation was achieved in all instances. Optimal angulation of the neck was selected individually to permit a comfortable position for the surgeon with full access to the lesion avoiding over-flexion. Deviation of accuracy at the surface of the target lesion ranged between 2.5 and 5.8 mm (mean, 3.9 mm ± 1.1 mm). CONCLUSIONS EM-guided neuronavigation in the semi-sitting position was safe and technically feasible. It enabled fast and accurate referencing without loss of navigation accuracy despite repositioning of the patient. In contrast to conventional opto-electric neuronavigation there were no line of sight problems.
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Nesvick CL, Khan NR, Mehta GU, Klimo P. Image Guidance in Ventricular Cerebrospinal Fluid Shunt Catheter Placement. Neurosurgery 2015; 77:321-31; discussion 331. [DOI: 10.1227/neu.0000000000000849] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Abstract
BACKGROUND:
Ventricular shunt placement for treating hydrocephalus is one of the most common neurosurgical procedures. The rate of shunt failure, however, has not appreciably changed with time.
OBJECTIVE:
To investigate whether intraoperative image guidance using ultrasound or stereotaxy contributes to accurate shunt catheter placement and survival.
METHODS:
We performed a systematic literature review using PubMed and MEDLINE databases for studies that use ultrasound and frameless stereotaxy for ventricular catheter placement for hydrocephalus. All articles assessed the accuracy of catheter tip placement and/or overall shunt survival, and the rate of accurate shunt catheter placement, the overall failure rate, and the average time to shunt failure were extracted for analysis.
RESULTS:
Although each modality (ultrasound/stereotaxy) did not increase catheter placement accuracy, a combined random-effects meta-analysis of 738 catheters (136 guided by ultrasound, 168 guided by frameless stereotaxy, and 434 freehand) demonstrated a weak benefit of image guidance (risk ratio: 1.19, 95% confidence interval: 1.02-1.39, P = .02), but this result was limited by considerable heterogeneity among studies (I2 = 86%, P < .001 by Cochrane's Q test). A meta-analysis could not be performed for shunt survival due to heterogeneity in data reporting.
CONCLUSION:
Although image guidance offers a promising solution to lower the risk of inaccurate catheter placement, which could lead to lower premature failure of ventricular shunts, our review demonstrated that there is not yet a clear benefit of these technologies. Current literature is limited to case series and cohort studies, and significant between-study heterogeneity in methodology and reporting currently limits a higher order analysis.
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Affiliation(s)
- Cody L. Nesvick
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Nickalus R. Khan
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Gautam U. Mehta
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
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Surgical treatment of distal anterior cerebral artery aneurysms aided by electromagnetic navigation CT angiography. Neurosurg Rev 2015; 38:523-30; discussion 530. [DOI: 10.1007/s10143-015-0611-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 09/03/2014] [Accepted: 11/16/2014] [Indexed: 10/24/2022]
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Beez T, Sarikaya-Seiwert S, Steiger HJ, Hänggi D. Real-time ultrasound guidance for ventricular catheter placement in pediatric cerebrospinal fluid shunts. Childs Nerv Syst 2015; 31:235-41. [PMID: 25564197 DOI: 10.1007/s00381-014-2611-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/22/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE Cerebrospinal fluid shunt failure is related to additional morbidity. Misplacement of ventricular catheters occurs in 40 % with freehand technique and is a risk factor for shunt failure. The goal of this study was to analyze the impact of intraoperative real-time ultrasound on catheter positioning and outcome in children. METHODS We compared children receiving ultrasound-guided procedures to matched historical freehand controls. Burr hole and convex probes were used (ProSound Alpha 6, Hitachi Aloka Medical Ltd., Tokyo, Japan). Catheter position was graded as grade I (optimal), II (contralateral ventricle or contact with ventricular structures), or III (misplacement). Correlation analysis was performed to identify determinants of outcome. RESULTS The study group (n = 17) was balanced with the control group (n = 14) for variables such as mean age (4.7 vs 4.3 years) and preoperative frontal occipital horn ratio (FOHR; 0.45 vs 0.43). In the study group, grade I catheter position was achieved in 6 (35%) and grade II in 11 patients (65%), compared to 2 (18%) and 3 patients (27%) in the control group. While no grade III position occurred in the study group, it was found in nine control patients (43%) (P = 0.0029). Failure rate was highest in grade III (83%) compared to grade I catheters (50%). CONCLUSIONS This analysis demonstrated an improvement of catheter positioning with ultrasound guidance. In the absence of additional burden or risks, this method should be favored over freehand technique. It remains to be demonstrated in a randomized controlled fashion to what extent improved catheter position translates into improved outcome.
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Affiliation(s)
- Thomas Beez
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-Universität, Moorenstrasse 5, 40225, Düsseldorf, Germany,
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Jakola AS, Reinertsen I, Selbekk T, Solheim O, Lindseth F, Gulati S, Unsgård G. Three-Dimensional Ultrasound–Guided Placement of Ventricular Catheters. World Neurosurg 2014; 82:536.e5-9. [DOI: 10.1016/j.wneu.2013.08.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 08/15/2013] [Indexed: 10/26/2022]
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Non-assisted versus neuro-navigated and XperCT-guided external ventricular catheter placement: a comparative cadaver study. Acta Neurochir (Wien) 2014; 156:777-85; discussion 785. [PMID: 24567037 DOI: 10.1007/s00701-014-2026-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Accepted: 01/30/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE Accurate placement of an external ventricular drain (EVD) for the treatment of hydrocephalus is of paramount importance for its functionality and in order to minimize morbidity and complications. The aim of this study was to compare two different drain insertion assistance tools with the traditional free-hand anatomical landmark method, and to measure efficacy, safety and precision. METHODS Ten cadaver heads were prepared by opening large bone windows centered on Kocher's points on both sides. Nineteen physicians, divided in two groups (trainees and board certified neurosurgeons) performed EVD insertions. The target for the ventricular drain tip was the ipsilateral foramen of Monro. Each participant inserted the external ventricular catheter in three different ways: 1) free-hand by anatomical landmarks, 2) neuronavigation-assisted (NN), and 3) XperCT-guided (XCT). The number of ventricular hits and dangerous trajectories; time to proceed; radiation exposure of patients and physicians; distance of the catheter tip to target and size of deviations projected in the orthogonal plans were measured and compared. RESULTS Insertion using XCT increased the probability of ventricular puncture from 69.2 to 90.2 % (p = 0.02). Non-assisted placements were significantly less precise (catheter tip to target distance 14.3 ± 7.4 mm versus 9.6 ± 7.2 mm, p = 0.0003). The insertion time to proceed increased from 3.04 ± 2.06 min. to 7.3 ± 3.6 min. (p < 0.001). The X-ray exposure for XCT was 32.23 mSv, but could be reduced to 13.9 mSv if patients were initially imaged in the hybrid-operating suite. No supplementary radiation exposure is needed for NN if patients are imaged according to a navigation protocol initially. CONCLUSION This ex vivo study demonstrates a significantly improved accuracy and safety using either NN or XCT-assisted methods. Therefore, efforts should be undertaken to implement these new technologies into daily clinical practice. However, the accuracy versus urgency of an EVD placement has to be balanced, as the image-guided insertion technique will implicate a longer preparation time due to a specific image acquisition and trajectory planning.
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Heussinger N, Eyüpoglu IY, Ganslandt O, Finzel S, Trollmann R, Jüngert J. Ultrasound-guided neuronavigation improves safety of ventricular catheter insertion in preterm infants. Brain Dev 2013; 35:905-11. [PMID: 23265618 DOI: 10.1016/j.braindev.2012.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 11/21/2012] [Accepted: 11/22/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Intra-ventricular hemorrhage (IVH) is a frequent cause of shunt-dependent hydrocephalus. The management of IVH in preterm babies remains a challenge both for neonatologists and pediatric neurosurgeons, compounded by the lack of low-risk, validated therapy techniques. OBJECTIVE The aim of this study was to evaluate the feasibility and safety of a novel technique involving the ultrasound-guided placement of a central catheter connected with a Rickham-Capsule in a cohort of preterm, low-birth-weight babies with post-hemorrhagic hydrocephalus (PHH). METHODS Eight preterm infants with PHH in which a Rickham-Capsule was placed from 2008-2012 were included. Conventional surgical techniques were used in four preterm infants; whereas in the other four preterm babies ultrasound guided catheter placement was performed with an 8 MegaHertz (MHz) micro convex transducer from LOGIQ 9, GE Healthcare; whereby the anterior fontanel was used as an acoustic window. RESULTS Overall gestational age was 24-31 weeks, mean age at operation was 20.1 (7-36) days, mean birth weight 972.5±370 g, mean weight at first surgical intervention 1023.75±400.4 g. Six patients had bilateral IVH II-III°, two patients had parenchymal involvement. Using the conventional approach, incorrect catheter placement occurred in one of four patients below 1000 g, whereas none of the ultrasound guided cases needed correction. CONCLUSIONS Ultrasound-guided neuronavigation represents a relevant tool in the treatment of hydrocephalus in preterm infants through increased accuracy in placement of a central catheter connected to a Rickham-Capsule. The benefit of utilizing this form of neuronavigation needs to be assessed through corresponding standardized studies.
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Affiliation(s)
- Nicole Heussinger
- Department of Pediatrics, University of Erlangen-Nuremberg, Germany.
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Posterior Vault Distraction With Midface Distraction Without Osteotomy as a First Stage for Syndromic Craniosynostosis. J Craniofac Surg 2013; 24:1263-7. [DOI: 10.1097/scs.0b013e318286081f] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Thomale UW, Knitter T, Schaumann A, Ahmadi SA, Ziegler P, Schulz M, Miethke C. Smartphone-assisted guide for the placement of ventricular catheters. Childs Nerv Syst 2013; 29:131-9. [PMID: 23089936 DOI: 10.1007/s00381-012-1943-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 10/08/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Freehand placement of ventricular catheters (VC) is reported to be inaccurate in 10-40 %. Endoscopy, ultrasound, or neuronavigation are used in selected cases with significant technical and time-consuming efforts. We suggest a smartphone-assisted guiding tool for the placement of VC. METHODS Measurements of relevant parameters in 3D-MRI datasets in a patient cohort with narrow ventricles for a frontal precoronal VC placement were performed. In this context, a guiding tool was developed to apply the respective measures for VC placement. The guiding tool was tested in a phantom followed by CT imaging to quantify placement precision. A smartphone application was designed to assist the relevant measurements. The guide was applied in 35 patients for VC placement. RESULTS MRI measurements revealed the rectangular approach in the sagittal plane and the individual angle towards the tangent in the coronal section as relevant parameter for a frontal approach. The latter angle ranged from medial (91.96° ± 2.75°) to lateral margins (99.56° ± 4.14°) of the ventricle, which was similar in laterally shifted (±5 mm) entry points. The subsequently developed guiding tool revealed precision measurements in an agarose model with 1.1° ± 0.7° angle deviation. Using the smartphone-assisted guide in patients with narrow ventricles (frontal occipital horn ratio, 0.38 ± 0.05), a primary puncture of the ventricles was possible in all cases. No VC failure was observed during follow-up (9.1 ± 5.3 months). CONCLUSIONS VC placement in narrow ventricles requires accurate placement with simple means in an every-case routine. The suggested smartphone-assisted guide meets these criteria. Further data are planned to be collected in a prospective randomized study.
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Affiliation(s)
- U W Thomale
- Pediatric Neurosurgery, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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