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Sargut TA, Thomale UW, Schulz M, Schaumann A, Schneider UC, Bayerl SH, Spindler P, Vajkoczy P, Ferdowssian K. Navigated bedside implantation of external ventricular drains with mobile health guidance: technical note and case series. Acta Neurochir (Wien) 2024; 166:76. [PMID: 38340225 PMCID: PMC10858832 DOI: 10.1007/s00701-024-05955-w] [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: 09/15/2023] [Accepted: 11/27/2023] [Indexed: 02/12/2024]
Abstract
PURPOSE External ventricular drain (EVD) implantation is one of the fundamental procedures of emergency neurosurgery usually performed freehand at bedside or in the operating room using anatomical landmarks. However, this technique is frequently associated with malpositioning leading to complications or dysfunction. Here, we describe a novel navigated bedside EVD insertion technique, which is evaluated in a clinical case series with the aim of safety, accuracy, and efficiency in neurosurgical emergency settings. METHODS From 2021 to 2022, a mobile health-assisted navigation instrument (Thomale Guide, Christoph Miethke, Potsdam, Germany) was used alongside a battery-powered single-use drill (Phasor Health, Houston, USA) for bedside EVD placement in representative neurosurgical pathologies in emergency situations requiring ventricular cerebrospinal fluid (CSF) relief and intracranial pressure (ICP) monitoring. RESULTS In all 12 patients (8 female and 4 male), navigated bedside EVDs were placed around the foramen of Monro at the first ventriculostomy attempt. The most frequent indication was aneurysmal subarachnoid hemorrhage. Mean operating time was 25.8 ± 15.0 min. None of the EVDs had to be revised due to malpositioning or dysfunction. Two EVDs were converted into a ventriculoperitoneal shunt. Drainage volume was 41.3 ± 37.1 ml per day in mean. Mean length of stay of an EVD was 6.25 ± 2.8 days. Complications included one postoperative subdural hematoma and cerebrospinal fluid infection, respectively. CONCLUSION Combining a mobile health-assisted navigation instrument with a battery-powered drill and an appropriate ventricular catheter may enable and enhance safety, accuracy, and efficiency in bedside EVD implantation in various pathologies of emergency neurosurgery without adding relevant efforts.
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Affiliation(s)
- Tarik Alp Sargut
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ulrich-Wilhelm Thomale
- Division of Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Matthias Schulz
- Division of Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Andreas Schaumann
- Division of Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | | | - Simon Heinrich Bayerl
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Philipp Spindler
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kiarash Ferdowssian
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
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Roblot P, Lefevre E, David R, Pardo PL, Mongardi L, Denat L, Tourdias T, Liguoro D, Jecko V, Vignes JR. Skin landmarks as ideal entry points for ventricular drainage, a radiological study. SURGICAL AND RADIOLOGIC ANATOMY : SRA 2022; 44:1385-1390. [PMID: 36151224 DOI: 10.1007/s00276-022-03019-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 09/14/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Ventricular drainage remains a usual but challenging procedure for neurosurgical trainees. The objective of the study was to describe reliable skin landmarks for ideal entry points (IEPs) to catheterize brain ventricles via frontal and parieto-occipital approaches. METHODS We included 30 subjects who underwent brain MRI and simulated the ideal catheterization trajectories of lateral ventricles using anterior and posterior approaches and localized skin surface IEPs. The optimal frontal target was the interventricular foramen and that for the parieto-occipital approach was the atrium. We measured the distances between these IEPs and easily identifiable skin landmarks. RESULTS The frontal IEP was localized to 116.8 ± 9.3 mm behind the nasion on the sagittal plane and to 39.7 ± 4.9 mm lateral to the midline on the coronal plane. The ideal catheter length was estimated to be 68.4 ± 6.4 mm from the skin surface to the interventricular foramen. The parieto-occipital point was localized to 62.9 ± 7.4 mm above the ipsilateral tragus on the coronal plane and to 53.1 ± 9.1 mm behind the tragus on the axial plane. The ideal catheter length was estimated to be 48.3 ± 9.6 mm. CONCLUSION The IEP for the frontal approach was localized to 11 cm above the nasion and 4 cm lateral to the midline. The IEP for the parieto-occipital approach was 5.5 cm behind and 6 cm above the tragus. These measurements lightly differ from the classical descriptions of Kocher's point and Keen's point and seem relevant to neurosurgical practice while using an orthogonal insertion.
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Affiliation(s)
- Paul Roblot
- Department of Neurosurgery A, University Hospital of Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux Cedex, France. .,Laboratory for Experimental Surgery, DETERCA Pr Vignes, University of Bordeaux, Bordeaux, France.
| | - Etienne Lefevre
- Department of Neurosurgery, APHP, Hôpital de La Pitié-Salpêtrière, 75013, Paris, France
| | - Romain David
- Physical and Rehabilitation Medicine Unit, PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, University of Poitiers, 86000, Poitiers, France
| | - Pier-Luka Pardo
- Laboratory for Experimental Surgery, DETERCA Pr Vignes, University of Bordeaux, Bordeaux, France
| | - Lorenzo Mongardi
- Department of Neurosurgery A, University Hospital of Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux Cedex, France.,Laboratory for Experimental Surgery, DETERCA Pr Vignes, University of Bordeaux, Bordeaux, France
| | - Laurent Denat
- Institute of Bioimaging, University of Bordeaux, 33000, Bordeaux, France
| | - Thomas Tourdias
- Institute of Bioimaging, University of Bordeaux, 33000, Bordeaux, France.,Department of Diagnostic and Therapeutic Neuroimaging, Pellegrin Hospital, Place Amélie-Raba-Léon, 33000, Bordeaux, France
| | - Dominique Liguoro
- Department of Neurosurgery A, University Hospital of Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux Cedex, France.,Laboratory of Anatomy, University of Bordeaux, 33000, Bordeaux, France
| | - Vincent Jecko
- Department of Neurosurgery A, University Hospital of Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux Cedex, France
| | - Jean-Rodolphe Vignes
- Department of Neurosurgery A, University Hospital of Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux Cedex, France.,Laboratory for Experimental Surgery, DETERCA Pr Vignes, University of Bordeaux, Bordeaux, France
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3
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Updates on techniques and technology to optimize external ventricular drain placement: A review of the literature. Clin Neurol Neurosurg 2022; 213:107126. [DOI: 10.1016/j.clineuro.2022.107126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 11/23/2022]
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Stuart MJ, Antony J, Withers TK, Ng W. Systematic review and meta-analysis of external ventricular drain placement accuracy and narrative review of guidance devices. J Clin Neurosci 2021; 94:140-151. [PMID: 34863429 DOI: 10.1016/j.jocn.2021.10.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/04/2021] [Accepted: 10/08/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Insertion of external ventricular drain (EVD) is one of the most common neurosurgical procedures performed worldwide. This is generally performed freehand, on the basis of anatomical landmarks. There is significant variability in the reported accuracy of freehand placement, lacking Level I evidence. We present the first meta-analysis of freehand EVD placement accuracy and technologies or techniques to enhance accuracy. METHODS We report a systematic review of the Pubmed, Embase, and Cochrane Central databases according to MOOSE (Meta-analysis Of Observational Studies) guidelines. 37 studies were included for qualitative analysis and 19 studies (2983 cases) for quantitative analysis. RESULTS There is substantial heterogeneity in the outcome measures used to report EVD placement accuracy. Of those nineteen studies reporting accuracy using the Kakarla grading system the mean rate of ideal ipsilateral frontal horn placement was 73% (standard deviation ±7%). The use of formal stereotaxic guidance is consistently reported to improve accuracy to >90%, although with variable outcome measures. However, the reported efficacy of other guidance devices or techniques is highly variable. The quality of studies directly comparing all existing non-stereotaxic devices with freehand EVD placement is poor and precludes any assertion of superiority to freehand insertion. CONCLUSIONS We provide the first meta analysis of freehand placement accuracy. There is insufficient data to perform a meta-analysis of the relative efficacy of interventions to improve accuracy. Qualitative synthesis of reports of stereotaxic guidance is suggestive of higher accuracy than freehand placement.
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Affiliation(s)
- M J Stuart
- Department of Neurosurgery, Townsville University Hospital, QLD 4814, Australia; School of Medicine and Dentistry, James Cook University, Townsville, QLD 4811, Australia.
| | - J Antony
- Department of Neurosurgery, Gold Coast University Hospital, QLD 4215, Australia; School of Medicine, University of Queensland, St Lucia, QLD 4072, Australia
| | - T K Withers
- Department of Neurosurgery, Gold Coast University Hospital, QLD 4215, Australia; School of Medicine, Griffith University, QLD 4215, Australia
| | - W Ng
- Department of Neurosurgery, Gold Coast University Hospital, QLD 4215, Australia; School of Medicine, Griffith University, QLD 4215, Australia
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McLean AL, Jamjoom AAB, Poon MTC, Wang D, Phang I, Okasha M, Boissaud-Cooke M, Williams AP, Ahmed AI. Utility of image-guided external ventriculostomy: analysis of contemporary practice in the United Kingdom and Ireland. J Neurosurg 2021; 135:1146-1154. [PMID: 33513567 DOI: 10.3171/2020.8.jns20321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 08/07/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Freehand external ventricular drain (EVD) insertion is associated with a high rate of catheter misplacement. Image-guided EVD placement with neuronavigation or ultrasound has been proposed as a safer, more accurate alternative with potential to facilitate proper placement and reduce catheter malfunction risk. This study aimed to determine the impact of image-guided EVD placement on catheter tip position and drain functionality. METHODS This study is a secondary analysis of a data set from a prospective, multicenter study. Data were collated for EVD placements undertaken in the United Kingdom and Ireland from November 2014 to April 2015. In total, 21 large tertiary care academic medical centers were included. RESULTS Over the study period, 632 EVDs were inserted and 65.9% had tips lying free-floating in the CSF. Only 19.6% of insertions took place under image guidance. The use of image guidance did not significantly improve the position of the catheter tip on postoperative imaging, even when stratified by ventricular size. There was also no association between navigation use and drain blockage. CONCLUSIONS Image-guided EVD placement was not associated with an increased likelihood of achieving optimal catheter position or with a lower rate of catheter blockage. Educational efforts should aim to enhance surgeons' ability to apply the technique correctly in cases of disturbed cerebral anatomy or small ventricles to reduce procedural risks and facilitate effective catheter positioning.
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Affiliation(s)
| | - Aimun A B Jamjoom
- 2Department of Clinical Neuroscience, Western General Hospital, NHS Lothian, Edinburgh
| | | | - Difei Wang
- 4Department of Neurosurgery, Wessex Neurological Centre, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton
| | - Isaac Phang
- 5Department of Neurosurgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston
| | - Mohamed Okasha
- 6Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne
| | - Matthew Boissaud-Cooke
- 7Department of Neurosurgery, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth
| | - Adam P Williams
- 8Department of Neurosurgery, Southmead Hospital, North Bristol NHS Trust, Bristol; and
| | - Aminul I Ahmed
- 9Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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Peng A, Yang M, Zhao H, Wu Y, Zhao Y, Zhou L. Compared with conventional procedures, an intraoperative navigation system for ventriculoperitoneal shunting via the occipital horn improves outcomes in patients with hydrocephalus. Br J Neurosurg 2020; 35:292-300. [PMID: 32667226 DOI: 10.1080/02688697.2020.1789555] [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] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ventriculoperitoneal shunting (VPS) is a common neurosurgical procedure used to treat hydrocephalus. Although the use of a navigation system in VPS achieves superior results compared with conventional surgery, the relationships among clinical symptoms, ventricular catheter placement, catheter obstruction, and the postoperative Evans index have not been clearly reported. METHODS We performed a retrospective study of 40 patients with VPS (the navigation surgery group) and 31 patients with VPS (the conventional surgery group). Clinical data, follow-up times, catheterization accuracy, postoperative outcomes, cumulative survival times, and correlations between catheter placement and obstruction, symptom grade and the postoperative Evans index were analyzed. RESULTS Thirty-seven patients experienced optimal ventricular catheter placement (grade 1), three experienced suboptimal placements (grade 2), and none experienced poor ventricular catheter placement (grade 3) in the navigation surgery group. Greater improvement in postoperative symptoms (p < 0.001), including less catheter readjustment (p < 0.001), was observed in the navigation surgery group. A Kaplan-Meier analysis showed that the cumulative catheter obstruction-free survival time was longer in the navigation surgery group (p = 0.016). Moreover, catheter placement was significantly correlated with catheter obstruction (p < 0.001). Additionally, catheter obstruction was significantly correlated with the symptom grade (p < 0.001) and postoperative Evans index (p = 0.002). CONCLUSION VPS for hydrocephalus via the occipital horn with a navigation system is superior to the conventional surgical procedure in terms of clinical outcomes, the precision of ventricular catheterization, and the occurrence of complications. Catheter obstruction-free survival times were longer in the navigation surgery group and catheter placement was significantly correlated with catheter obstruction.
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Affiliation(s)
- AiJun Peng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ming Yang
- Department of Neurology, Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Hai Zhao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - YongKang Wu
- Department of Neurosurgery, Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Yi Zhao
- Department of Medical Imaging, Affiliated Hospital of Yangzhou University, Yangzhou,, China
| | - LiangXue Zhou
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
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Lee KS, Zhang JJY, Bolem N, Leong ML, Goh CP, Hassan R, Salek AAM, Sein Lwin APT, Teo K, Chou N, Nga V, Yeo TT. Freehand Insertion of External Ventricular Drainage Catheter: Evaluation of Accuracy in a Single Center. Asian J Neurosurg 2020; 15:45-50. [PMID: 32181172 PMCID: PMC7057862 DOI: 10.4103/ajns.ajns_292_19] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 01/10/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction External ventricular drain (EVD) placement is the gold standard for managing acute hydrocephalus. Freehand EVD, using surface anatomical landmarks, is performed for ventricular cannulation due to its simplicity and efficiency. This study evaluates accuracy and reason(s) for misplacements as few studies have analyzed the accuracy of freehand EVD insertion. Patients and Methods Preoperative and postoperative computed tomography scans of patients who underwent EVD insertion in 2014 were retrospectively reviewed. Diagnosis, Evans ratio, midline shift, position of burr hole, length of the catheter, and procedural complications were tabulated. The procedures were classified as satisfactory (catheter tip in the frontal horn ipsilateral lateral ventricle) and unsatisfactory. Unsatisfactory cases were further analyzed in relation to position of burr hole from midline and length of the catheter. Results Seventy-seven EVD placements in seventy patients were evaluated. The mean age of the patients was 57.5 years. About 83.1% were satisfactory placements and 11.7% were unsatisfactory in the contralateral ventricle, corpus callosum, and interhemispheric fissure. Nearly 5.2% were in extraventricular locations. Almost 2.6% EVD placements were complicated by hemorrhage and 1 catheter was reinserted. Suboptimal placements were significantly associated with longer intracranial catheter length. The mean length was 66.54 ± 10.1 mm in unsatisfactory placements compared to 58.32 ± 4.85 mm in satisfactory placements. Between the two groups, no significant difference was observed in Evans ratio, midline shift, surgeon's experience, distance of burr hole from midline, and coronal suture. Conclusion Freehand EVD insertion is safe and accurate. In small number of cases, unsatisfactory placement is related to longer catheter length.
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Affiliation(s)
- Keng Siang Lee
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - John Jiong Yang Zhang
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Nagarjun Bolem
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - May Lian Leong
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Chun Peng Goh
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Rashidul Hassan
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Al Amin Maa Salek
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | | | - Kejia Teo
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Ning Chou
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Vincent Nga
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
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