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Robertson FC, Abd-El-Barr MM, Mukundan S, Gormley WB. Ventriculostomy-associated hemorrhage: a risk assessment by radiographic simulation. J Neurosurg 2017; 127:532-536. [DOI: 10.3171/2016.8.jns16538] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEVentriculostomy entry sites are commonly selected by freehand estimation of Kocher's point or approximations from skull landmarks and a trajectory toward the ipsilateral frontal horn of the lateral ventricles. A recognized ventriculostomy complication is intracranial hemorrhage from cortical vessel damage; reported rates range from 1% to 41%. In this report, the authors assess hemorrhagic risk by simulating traditional ventriculostomy trajectories and using CT angiography (CTA) with venography (CTV) data to identify potential complications, specifically from cortical draining veins.METHODSRadiographic analysis was completed on 50 consecutive dynamic CTA/CTV studies obtained at a tertiary-care academic neurosurgery department. Image sections were 0.5 mm thick, and analysis was performed on a venous phase that demonstrated high-quality opacification of the cortical veins and sagittal sinus. Virtual ventriculostomy trajectories were determined for right and left sides using medical diagnostic imaging software. Entry points were measured along the skull surface, 10 cm posteriorly from the nasion, and 3 cm laterally for both left and right sides. Cannulation was simulated perpendicular to the skull surface. Distances between the software-traced cortical vessels and the virtual catheter were measured. To approximate vessel injury by twist drill and ventricular catheter placement, veins within a 3-mm radius were considered a hemorrhage risk.RESULTSIn 100 virtual lines through Kocher's point toward the ipsilateral ventricle, 19% were predicted to cause cortical vein injury and suspected hemorrhage (radius ≤ 3 mm). Little difference existed between cerebral hemispheres (right 18%, left 20%). The average (± SD) distance from the trajectory line and a cortical vein was 7.23 ± 4.52 mm. In all 19 images that predicted vessel injury, a site of entry for an avascular zone near Kocher's point could be achieved by moving the trajectory less than 1.0 cm laterally and less than 1.0 cm along the anterior/posterior axis, suggesting that empirical measures are suboptimal, and that patient-specific coordinates based on preprocedural CTA/CVA imaging may optimize ventriculostomy in the future.CONCLUSIONSIn this institutional radiographic imaging analysis, traditional methods of ventriculostomy site selection predicted significant rates of cortical vein injury, matching described rates in the literature. CTA/CTV imaging potentiates identification of patient-specific cannulation sites and custom trajectories that avoid cortical vessels, which may lessen the risk of intracranial hemorrhage during ventriculostomy placement. Further development of this software is underway to facilitate stereotactic ventriculostomy and improve outcomes.
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Affiliation(s)
| | - Muhammad M. Abd-El-Barr
- 1Harvard Medical School; and
- 3Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Srinivasan Mukundan
- 1Harvard Medical School; and
- 3Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - William B. Gormley
- 1Harvard Medical School; and
- 3Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Yoon SY, Kwak Y, Park J. Adjustable Ghajar Guide Technique for Accurate Placement of Ventricular Catheters: A Pilot Study. J Korean Neurosurg Soc 2017; 60:604-609. [PMID: 28881125 PMCID: PMC5594620 DOI: 10.3340/jkns.2016.1011.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 05/19/2017] [Accepted: 06/13/2017] [Indexed: 11/30/2022] Open
Abstract
Objective An adjustable Ghajar guide is presented to improve the accuracy of the original Ghajar guide technique. The accuracy of the adjustable Ghajar guide technique is also investigated. Methods The coronal adjustment angle from the orthogonal catheter trajectory at Kocher’s point is determined based on coronal head images using an electronic picture archiving and communication system. For the adjustable Ghajar guide, a protractor is mounted on a C-shaped basal plate that is placed in contact with the margin of a burrhole, keeping the central 0° line of the protractor orthogonal to the calvarial surface. A catheter guide, which is moved along the protractor and fixed at the pre-determined adjustment angle, is then used to guide the ventricular catheter into the frontal horn adjacent to the foramen of Monro. The adjustable Ghajar guide technique was applied to 20 patients, while a freehand technique based on the surface anatomy of the head was applied to another 47 patients. The accuracy of the ventricular catheter placement was then evaluated using postoperative computed tomography scans. Results For the adjustable Ghajar guide technique (AGT) patients, the bicaudate index ranged from 0.23 to 0.33 (mean±standard deviation [SD]: 0.27±0.03) and the adjustment angle ranged from 0° to 10° (mean±SD: 5.2°±3.2°). All the AGT patients experienced successful cerebrospinal fluid diversion with only one pass of the catheter. Optimal placement of the ventricular catheter in the ipsilateral frontal horn approximating the foramen of Monro (grade 1) was achieved in 19 patients (95.0%), while a suboptimal trajectory into a lateral corner of the frontal horn passing along a lateral wall of the frontal horn (grade 3) occurred in 1 patient (5.0%). Thus, the AGT patients experienced a significantly higher incidence of optimal catheter placement than the freehand catheterized patients (95.0% vs. 68.3%, p=0.024). Moreover, none of the AGT patients experienced any tract hemorrhages along the catheter or procedure-related complications. Conclusion The proposed adjustable Ghajar guide technique, using angular adjustment in the coronal plane from the orthogonal trajectory at Kocher’s point, facilitates accurate freehand placement of a ventricular catheter for hydrocephalic patients.
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Affiliation(s)
- Sang-Youl Yoon
- Department of Neurosurgery and Research Center for Neurosurgical Robotic Systems, Kyungpook National University School of Medicine, Daegu, Korea
| | - Youngseok Kwak
- Department of Neurosurgery and Research Center for Neurosurgical Robotic Systems, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jaechan Park
- Department of Neurosurgery and Research Center for Neurosurgical Robotic Systems, Kyungpook National University School of Medicine, Daegu, Korea
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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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Heyman J, Ved R, Amato-Watkins A, Bhatti I, Te Water Naude J, Gibbon F, Leach P. Outcomes of ventriculoperitoneal shunt insertion in the management of idiopathic intracranial hypertension in children. Childs Nerv Syst 2017; 33:1309-1315. [PMID: 28536838 PMCID: PMC5527065 DOI: 10.1007/s00381-017-3423-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 04/19/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE The ventriculoperitoneal (VP) shunt has become the procedure of choice for treatment of idiopathic intracranial hypertension (IIH). We aimed to assess the efficacy of frameless stereotactic placement of VP shunts for the management of medically resistant IIH in children and to assess the role of gender and obesity in the aetiology of the condition. METHODS This is a retrospective analysis of the case notes of 10 patients treated surgically at the University Hospital of Wales in Cardiff, from May 2006 to September 2012. RESULTS VP shunts were successful in relieving headache, papilloedema and stabilising vision. No sex predilection was identified, and increased BMI was a feature throughout the population, regardless of age. CONCLUSIONS Neuronavigated VP shunt insertion is an effective mode of treatment for medically resistant IIH in children. The aetiological picture in children does not seem to be dominated by obesity, as in adults. Literature on childhood IIH is sparse, and larger scale, comparative studies would be of benefit to treating clinicians.
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Affiliation(s)
- J. Heyman
- Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Ronak Ved
- Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK. .,Department of Neurosurgery, University Hospital of Wales, B4 Office, Cardiff, CF14 4XW, UK.
| | - A. Amato-Watkins
- Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - I. Bhatti
- Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - J. Te Water Naude
- Department of Paediatric Neurology, University Hospital of Wales, Cardiff, UK
| | - F. Gibbon
- Department of Paediatric Neurology, University Hospital of Wales, Cardiff, UK
| | - P. Leach
- Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK
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Park J, Son W, Park KS, Kim MY, Lee J. Calvarial slope affecting accuracy of Ghajar Guide technique for ventricular catheter placement. J Neurosurg 2015; 124:1429-33. [PMID: 26544778 DOI: 10.3171/2015.5.jns15226] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The Ghajar Guide technique is used to direct a ventricular catheter at a 90° angle to the skull surface at Kocher's point. However, the human calvaria is not completely spherical. Lateral to the sagittal midline, the calvaria slopes downward with individual variation and thereby affects the accuracy of ventricular catheter placement. Accordingly, the authors investigated the accuracy of the orthogonal catheter trajectory using radiographic simulation and examined the effect of the calvarial slope on this accuracy. METHODS A catheter trajectory orthogonal to the skull surface at Kocher's point and the ideal catheter trajectory to the foramen of Monro were drawn bilaterally on coronal head images of 52 patients with hydrocephalus. The correction angle, the difference between the 2 catheter trajectories, was then measured. Meanwhile, the calvarial slope was measured around Kocher's point by using a coronal head image. The correlation between the correction angle and factors such as the calvarial slope and bicaudate index was then assessed using a Pearson correlation analysis. RESULTS The ventricular catheter trajectory orthogonal to the skull at Kocher's point in the patients with hydrocephalus led to a catheter trajectory into the ipsilateral (70.2%) or contralateral (29.8%) lateral ventricles. The correction angles ranged from -3.3° to 16.4° (mean ± SD 5.7° ± 3.7°). In 87 (83.7%) head sides, lateral deviation from the orthogonal trajectory was required to approximate the ideal trajectory, and the correction angle ranged from 2.0° to 16.4° (mean 6.7° ± 2.9°). The calvarial slope in the 104 head sides ranged from 15.6° to 32.5° (mean 24.2° ± 3.1°). Pearson correlation analysis revealed a strong positive correlation (r = 0.733) between the calvarial slope and the correction angle. CONCLUSIONS The accuracy of ventricular catheter placement using the Ghajar Guide technique is affected primarily by the calvarial slope around Kocher's point. A radiographic analysis of a preoperative coronal head image can be used to estimate the accuracy of ventricular catheter placement and enable adjustment to approximate the ideal catheter trajectory.
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Affiliation(s)
- Jaechan Park
- Department of Neurosurgery.,Research Center for Neurosurgical Robotic Systems, and
| | - Wonsoo Son
- Department of Neurosurgery.,Research Center for Neurosurgical Robotic Systems, and
| | - Ki-Su Park
- Department of Neurosurgery.,Research Center for Neurosurgical Robotic Systems, and
| | - Min Young Kim
- Research Center for Neurosurgical Robotic Systems, and
| | - Joomi Lee
- Cell & Matrix Research Institute, Kyungpook National University, Daegu, Republic of Korea
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Kim D, Son W, Park J. Guiding protractor for accurate freehand placement of ventricular catheter in ventriculoperitoneal shunting. Acta Neurochir (Wien) 2015; 157:699-702. [PMID: 25619775 DOI: 10.1007/s00701-015-2349-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 01/08/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND While frameless stereotaxis can be used for shunt ventricular catheter placement in patients with smaller ventricles, the ventricular catheter is still commonly placed based on the surface anatomy of the head for patients with larger ventricles. Thus, surgical techniques and guides facilitating accurate and reliable freehand placement of the ventricular catheter still need to be devised. METHODS With the patient in a supine position and the axis of their head maintained horizontally, the guiding protractor is placed horizontally in the frontal burrhole at Kocher's point. Using the guiding angle between the head axis and the frontal horn of the lateral ventricle based on coronal head computed tomography (CT) or magnetic resonance (MR) images, the ventricular catheter is then placed in the catheter guide within the guiding protractor. RESULTS In 20 hydrocephalic patients with a bicaudate index >0.2 or bifrontal distance >25 mm, the ideal guiding angle ranged from 17 to 23° (mean ± standard deviation [SD], 19.6° ± 1.6°). In all these patients, ventricular catheterization was successfully achieved with only one pass of the catheter, and postoperative CT scans showed satisfactory placement of the catheter in the ipsilateral frontal horn of the lateral ventricles. CONCLUSIONS The proposed surgical technique using a guiding protractor facilitates accurate freehand placement of a ventricular catheter for patients with a bicaudate index >0.2 or bifrontal distance >25 mm.
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Affiliation(s)
- Donghan Kim
- Department of Neurosurgery, Research Center for Neurosurgical Robotic Systems, Kyungpook National University, 50, Samduk 2-ga, Jung-gu, Daegu, 700-721, Republic of Korea
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Moran D, Kosztowski TA, Jusué-Torres I, Orkoulas-Razis D, Ward A, Carson K, Hoffberger J, Elder BD, Goodwin CR, Rigamonti D. Does CT wand guidance improve shunt placement in patients with hydrocephalus? Clin Neurol Neurosurg 2015; 132:26-30. [PMID: 25746318 DOI: 10.1016/j.clineuro.2015.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 01/30/2015] [Accepted: 02/16/2015] [Indexed: 11/26/2022]
Abstract
OBJECT To evaluate the effectiveness of stereotactic navigation in enhancing the accuracy of ventricular shunt placement in patients with hydrocephalus. METHODS A retrospective cohort study at a single institution by a single surgeon was performed. Consecutive patients who underwent implantation of a ventricular shunt for the management of hydrocephalus between July 2001 and December 2011 were included in the study, totaling 535 patients. Patients were classified as either having optimal or sub-optimal placement of the shunt into the ventricle. Multiple logistic regression analysis was used. RESULTS Overall, 93.8% of patients were found to have optimal shunt placement. On multivariate analysis, navigation use was not significantly associated with improved accuracy of shunt placement (odds ratio [OR] = 0.54; 95% confidence interval [CI] = 0.19-1.54; p = 0.25). Pseudotumor cerebri diagnosis was significantly associated with increased odds of sub-optimal shunt placement (OR = 6.41; 95% CI = 1.90-21.59; p=0.003). CONCLUSIONS CT guided navigation did not significantly improve the accuracy of ventricular shunt placement in adults with hydrocephalus for an experienced surgeon. Further studies are required to assess the utility of CT guided navigation for less experienced surgeons and patients with small or dysmorphic ventricles.
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Affiliation(s)
- Dane Moran
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, USA
| | | | | | | | - Ayobami Ward
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, USA
| | - Kathryn Carson
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Jamie Hoffberger
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, USA
| | - Benjamin D Elder
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, USA
| | - C Rory Goodwin
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, USA
| | - Daniele Rigamonti
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, USA.
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Factors affecting the accuracy of ventricular catheter placement. J Clin Neurosci 2011; 18:485-8. [DOI: 10.1016/j.jocn.2010.06.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Accepted: 06/23/2010] [Indexed: 11/18/2022]
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Woerdeman PA, Willems PWA, Noordmans HJ, van der Sprenkel JWB. The analysis of intraoperative neurosurgical instrument movement using a navigation log-file. Int J Med Robot 2007; 2:139-45. [PMID: 17520624 DOI: 10.1002/rcs.91] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The purpose of this study was to define the technical requirements of future (tele)robotic neurosurgical systems. We aimed to analyse the movements of surgical instruments during neurosurgical procedures. METHODS A commercially available neuronavigation system (StealthStation TREON(plus), Medtronic, USA) was used to determine the position and orientation of the surgical instrument. A custom-made log-mode was implemented in the software to file instrument coordinates intraoperatively. Data was collected during the debulking of malignant primary brain tumours, temporal epilepsy surgery and skull base tumour surgery. RESULTS Maximum tip displacement velocity varied, per procedure, in the range 6.6-12.7 cm/s and maximum rotational speed 21-40 degrees/s. Maximum instrument orientation differences within the volume of movement varied. The largest differences were detected during temporal epilepsy surgery (73 degrees and 52 degrees in the coronal and axial planes, respectively), while the smallest differences were detected in the debulking of an intraventricular tumour. CONCLUSIONS In this study, we have demonstrated the feasibility of motion analysis in image-guided neurosurgery. To mimic ordinary open neurosurgery, future neurosurgical (tele)robotic systems should at least support translational speeds up to 12.7 cm/s, rotational speeds up to 40 degrees/s and differences in instrument orientation of up to 73 degrees.
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Affiliation(s)
- P A Woerdeman
- Rudolf Magnus Institute of Neuroscience, Department of Neurosurgery, University Medical Center Utrecht, The Netherlands.
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