Freehand ventricular catheter placement [Neurosurgery Wiki]

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====== Freehand ventricular catheter placement ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1x3FUw-Ho0YICNt_V_leBgWKCZZ2CaaoTwuSZT8drmsTxd-EhX/?limit=15&utm_campaign=pubmed-2&fc=20240211061159}}

The standard method of Freehand [[ventricular catheter]] [[placement]] is a technique using surface anatomical landmarks. However, the standard freehand EVD technique results in catheter malpositioning in up to 60.1% of procedures
((Hopfgartner A, Burns D, Suppiah S, Martin AR, Hardisty M, Whyne CM. Bullseye EVD: preclinical evaluation of an intra-procedural system to confirm external ventricular drainage catheter positioning. Int J Comput Assist Radiol Surg. 2022 May 28. doi: 10.1007/s11548-022-02679-z. Epub ahead of print. PMID: 35633491.)).
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It should be noted that neurosurgeons typically measure the success of freehand ventricular catheter placement by the free flow of [[cerebrospinal fluid]] (CSF) from the distal end of the ventricular catheter
((Paramore CG, Turner DA. Relative risks of ventriculostomy infection and morbidity. Acta Neurochir (Wien). 1994;127(1-2):79-84. doi:10.1007/BF01808552)).
However, this in itself is falsely reassuring, as a large percentage of ventricular catheter tips have been observed in CSF spaces other than the [[frontal horn]] of the [[lateral ventricle]] (e.g. [[subarachnoid space]]) even though there was CSF drainage at the start
((Shtaya A, Roach J, Sadek AR, Gaastra B, Hempenstall J, Bulters D. Image guidance and improved accuracy of external ventricular drain tip position particularly in patients with small ventricles [published online ahead of print, 2018 May 1]. J Neurosurg. 2018;1-6. doi:10.3171/2017.11.JNS171892))
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To avoid [[shunt dysfunction]], it is essential to place the [[ventricular catheter]] tip above the [[foramen of Monro]]. 

Supposing that a convex of skull matches to a sphere, in which the foramen of Monro is the center, a perpendicular direction from the surface of the sphere to inside always directs toward the center. The authors identified the range of skull where corresponded to the sphere by magnetic resonance imaging assessment and utilized tripod to achieve exactly perpendicular insertion of ventricular catheter. And an optimal length of catheter insertion was investigated by navigation system.

The anterior-posterior range of the spherical portion was from coronal suture to 20mm anterior, and the lateral range of it was between 15 and 35mm lateral from sagittal suture. The optimal catheter length for insertion was between 55 and 58mm from the brain surface. Ideal placement of a ventricular catheter tip was achieved in more than 90% of cases (31/34) with this technique
((Yamada SM, Yamada S, Goto Y, Nakaguchi H, Murakami M, Hoya K, Matsuno A. A
simple and consistent technique for ventricular catheter insertion using a
tripod. Clin Neurol Neurosurg. 2012 Jul;114(6):622-6. doi:
10.1016/j.clineuro.2011.12.025. Epub 2012 Jan 11. PubMed PMID: 22244253.)).
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A 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
((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 Feb;31(2):235-41. doi: 10.1007/s00381-014-2611-4. 
Epub 2015 Jan 7. PubMed PMID: 25564197.
)).
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[[Free-hand]] insertion is associated with a significant [[ventricular catheter misplacement]] rate. Consequently, several expensive alternative methods that are unfortunately not available worldwide have been used. 

Patients who underwent ventriculostomy placement in the [[ICU]] differed in important ways (i.e. indication for placement and the administration of pre-procedure prophylactic [[antibiotic]]s) from [[patient]]s treated in the OR. However, the available data suggests that complications of [[hemorrhage]], [[infection]], and non-functional [[drain]]s may be mitigated by [[ventriculostomy]] placement in the OR
((http://www.clineu-journal.com/article/S0303-8467(14)00388-6/abstract)).

Techniques to accurately place [[ventricular catheter]]s and new [[valve]] designs that effectively control ventricular size might reduce [[shunt malfunction]]
((Tuli S, O'Hayon B, Drake J, Clarke M, Kestle J. Change in ventricular size and
effect of ventricular catheter placement in pediatric patients with shunted
hydrocephalus. Neurosurgery. 1999 Dec;45(6):1329-33; discussion 1333-5. PubMed
PMID: 10598700.
)).

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Accurate [[ventricular drainage placement]] plays an important role in reducing the risk of [[ventriculoperitoneal shunt]] [[failure]]. 

Stereotactic- and ultrasound-guided ventricular catheter placements are significantly more accurate than freehand placement, and the use of these intraoperative guidance techniques reduced proximal shunt failure
((Wilson TJ, Stetler WR Jr, Al-Holou WN, Sullivan SE. Comparison of the accuracy of ventricular catheter placement using freehand placement, ultrasonic guidance, and stereotactic neuronavigation. J Neurosurg. 2013;119(1):66-70. doi:10.3171/2012.11.JNS111384)).

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Retrospective evaluation was performed on the head computed tomography (CT) scans of 97 patients who underwent 98 freehand pass ventriculostomy catheter placements in an ICU setting. Using the postprocedure CT scans of the patients, 3D measurements were made to calculate the accuracy of ventriculostomy catheter placement.

The mean distance (+/- standard deviation [SD]) from the catheter tip to the Monro foramen was 16 +/- 9.6 mm. The mean distance (+/- SD) from the catheter tip to the center of the bur hole was 87.4 +/- 14.0 mm. Regarding accurate catheter tip placement, 56.1% of the catheter tips were in the ipsilateral lateral ventricle, 7.1% were in the contralateral lateral ventricle, 8.2% were in the third ventricle, 6.1% were within the interhemispheric fissure, and 22.4% were within extraventricular spaces.

The accuracy of freehand ventriculostomy catheterization typically required 2 passes per successful placement, and, when successful, was 1.6 cm from the Monro foramen. More importantly, 22.4% of these catheter tips were in nonventricular spaces. Although many neurosurgeons believe that the current practice of ventriculostomy is good enough, the results of this study show that there is certainly much room for improvement
((Huyette DR, Turnbow BJ, Kaufman C, Vaslow DF, Whiting BB, Oh MY. Accuracy of
the freehand pass technique for ventriculostomy catheter placement: retrospective
assessment using computed tomography scans. J Neurosurg. 2008 Jan;108(1):88-91.
doi: 10.3171/JNS/2008/108/01/0088. PubMed PMID: 18173315.
)).

The use of image guidance technology added approximately 36 minutes to the time from when the need was identified to when successful drainage was achieved (p = 0.002), but added only 4 minutes of operative time (p = 0.12). Accuracy of placement demonstrated a statistically significant improvement in the accuracy of ventriculostomy over historical data. There were two registration failures which were converted to the traditional technique; there were no other complications arising from the use of image-guided technology. Electromagnetic image guidance is feasible and accurate. Image guidance technology eliminated unacceptably placed catheters and may reduce the risk of catheter-associated intracerebral hemorrhages
((Mahan M, Spetzler RF, Nakaji P. Electromagnetic stereotactic navigation for
external ventricular drain placement in the intensive care unit. J Clin Neurosci.
2013 Dec;20(12):1718-22. doi: 10.1016/j.jocn.2013.03.005. Epub 2013 Aug 30.
PubMed PMID: 23993898.
)).
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Bruneau et al. developed a simple [[surgical technique]] based on radio-anatomical [[landmark]]s aimed at reducing VC's misplacements.

They reproduced the preoperative imaging on the patient's head using common anatomical [[landmark]]s. This allows defining [[stereotactic]] VC [[coordinate]]s to be followed during the [[surgical procedure]].

This simple and [[cost-effective]] [[method]] improves VC [[insertion]] accuracy
((Bruneau M, Spitaels J, Riva M. Free-hand stereotactic ventricular catheter insertion technique based on radio-anatomical landmarks. How I do it [published online ahead of print, 2020 Sep 2]. Acta Neurochir (Wien). 2020;10.1007/s00701-020-04549-6. doi:10.1007/s00701-020-04549-6)).

===== Ventricular catheter misplacement =====

see [[Ventricular catheter misplacement]].

===== References =====