Utility of Preoperative Simulation for Ventricular Catheter Placement via a Parieto-Occipital Approach in Normal-Pressure Hydrocephalus

2018 ◽  
Vol 16 (6) ◽  
pp. 647-657 ◽  
Author(s):  
Shigeki Yamada ◽  
Masatsune Ishikawa ◽  
Kazuo Yamamoto
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Catheter Placement ◽  
Optimal Placement ◽  
Shunt Revision ◽  
Slip Angle ◽  
Ventricular Catheter ◽  
Ventricular Catheters ◽  
Preoperative Simulation ◽  
The Mean

Abstract BACKGROUND Freehand ventricular catheter placement has been reported to have poor accuracy. OBJECTIVE To investigate whether preoperative computational simulation using diagnostic images improves the accuracy of ventricular catheter placement. METHODS This study included 113 consecutive patients with normal-pressure hydrocephalus (NPH), who underwent ventriculoperitoneal shunting via a parieto-occipital approach. The locations of the ventricular catheter placement in the last 48 patients with preoperative virtual simulation on the 3-dimensional workstation were compared with those in the initial 65 patients without simulation. Catheter locations were classified into 3 categories: optimal, suboptimal, and poor placements. Additionally, slip angles were measured between the ventricular catheter and optimal direction. RESULTS All patients with preoperative simulations had optimally placed ventricular catheters; the mean slip angle for this group was 2.8°. Among the 65 patients without simulations, 46 (70.8%) had optimal placement, whereas 10 (15.4%) and 9 (13.8%) had suboptimal and poor placements, respectively; the mean slip angle for the nonsimulation group was 8.6°. The slip angles for all patients in the preoperative simulation group were within 7°, whereas those for 31 (47.7%) and 10 (15.4%) patients in the nonsimulation group were within 7° and over 14°, respectively. All patients with preoperative simulations experienced improved symptoms and did not require shunt revision during the follow-up period, whereas 5 patients (7.7%) without preoperative simulations required shunt revisions for different reasons. CONCLUSION Preoperative simulation facilitates accurate placement of ventricular catheters via a parieto-occipital approach. Minimally invasive and precise shunt catheter placement is particularly desirable for elderly patients with NPH.

scholarly journals Intraoperative Fiber-Optic Endoscopy for Ventricular Catheter Insertion

2001 ◽  
Vol 28 (1) ◽  
pp. 56-60 ◽  
Author(s):  
Philip V. Theodosopoulos ◽  
Aviva Abosch ◽  
Michael W. McDermott
Keyword(s):  
Fiber Optic ◽  
Catheter Placement ◽  
Ventricular Catheter ◽  
Neurosurgical Procedure ◽  
Significant Difference ◽  
Catheter Tip ◽  
Endoscopic Guidance ◽  
Ventricular Catheters ◽  
Tip Position ◽  
Optic Endoscopy

ABSTRACT:Objective:Ventricular catheter placement is a common neurosurgical procedure often resulting in inaccurate intraventricular positioning. We conducted a comparison of the accuracy of endoscopic and conventional ventricular catheter placement in adults.Methods:A retrospective analysis of data was performed on 37 consecutive patients undergoing ventriculo-peritoneal shunt (VPS) insertion with endoscopy and 40 randomly selected, unmatched patients undergoing VPS insertion without endoscopy, for the treatment of hydrocephalus of varied etiology. A grading system for catheter tip position was developed consisting of five intraventricular zones, V1-V5, and three intraparenchymal zones, A, B, C. Zones V1 for the frontal approaches and V1 or V2 for the occipital approaches were the optimal catheter tip locations. Postoperative scans of each patient were used to grade the accuracy of ventricular catheter placement.Results:Seventy-six percent of all endoscopic ventricular catheters were in zone V1 and 100% were within zones V1-V3. No endoscopically inserted catheters were observed in zones V4, V5 or intraparenchymally. Thirty-eight percent of the conventionally placed catheters were in zone V1, 53% in zones V1-3 and 15% intraparenchymally. There was a statistically significant difference in the percentage of catheters in optimal location versus in any other location, favoring endoscopic guidance (p<0.001).Conclusion:We conclude that endoscopic ventricular catheter placement provides improved positioning accuracy than conventional techniques.

Ventriculoperitoneal Shunting of Idiopathic Normal Pressure Hydrocephalus Increases Midbrain Size: A Potential Mechanism for Gait Improvement

Neurosurgery ◽  
2006 ◽  
Vol 59 (4) ◽  
pp. 847-851 ◽  
Author(s):  
J Mocco ◽  
Matthew I. Tomey ◽  
Ricardo J. Komotar ◽  
William J. Mack ◽  
Steven J. Frucht ◽  
...  
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Ventriculoperitoneal Shunt ◽  
Medical Center ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Cross Sectional ◽  
Mean Values ◽  
Shunt Placement ◽  
Ventriculoperitoneal Shunting ◽  
The Mean

Abstract OBJECTIVE: Idiopathic normal pressure hydrocephalus (INPH) is characterized by a classic clinical triad of symptoms, including dementia, urinary incontinence, and gait disturbance. Recent work has demonstrated that the maximal midbrain anteroposterior (AP) diameter is significantly smaller in patients with INPH than in healthy, age-matched controls. The current study was undertaken to determine the effect of ventriculoperitoneal shunt placement on midbrain dimensions in INPH patients. METHODS: Twelve consecutive INPH patients undergoing ventriculoperitoneal shunt placement with pre- and postoperative computed tomographic scans at the Columbia University Medical Center were enrolled. Each patient's pre- and postoperative maximum AP and left-to-right diameters of the midbrain at the pontomesencephalic junction were independently measured in a blinded fashion by two of the authors. The average value of each dimension was computed by calculating the mean values of the measurements of the two observers. RESULTS: Both the mean AP diameter (preoperative mean, 2.06 ± 0.04 cm; postoperative mean, 2.27 ± 0.05; P = 0.0007) and left-to-right diameter (preoperative mean, 2.80 ± 0.07; postoperative mean, 3.03 ± 0.08; P = 0.0029) increased from pre- to postoperative imaging. The approximate cross-sectional area determined as the product of AP and left-to-right diameters also increased from pre- to postoperative images (preoperative mean, 5.79 ± 0.22 cm2; postoperative mean, 6.90 ± 0.25 cm2; P = 0.00049). CONCLUSION: This study provides supportive evidence that midbrain cytoarchitecture may play a role in the pathophysiology and post-ventriculoperitoneal shunt gait improvement of INPH patients.

scholarly journals The accuracy of ventricular catheter placement: does it influence shunt revision rates?

2006 ◽  
Vol 3 (S1) ◽  
Author(s):  
Stephen Price ◽  
Tom Santarius ◽  
Hugh Richards ◽  
Gemma Whiting ◽  
Husam Georges ◽  
...  
Keyword(s):  
Catheter Placement ◽  
Shunt Revision ◽  
Ventricular Catheter

scholarly journals Response of cerebral blood flow and cerebrovascular reactivity to acetazolamide in patients with dementia and idiopathic normal-pressure hydrocephalus

1999 ◽  
Vol 7 (4) ◽  
pp. E11
Author(s):  
Chia-Cheng Chang ◽  
Nobumasa Kuwana ◽  
Susumu Ito ◽  
Tadashi Ikegami
Keyword(s):  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Normal Pressure Hydrocephalus ◽  
Photon Emission ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Cerebrovascular Reactivity ◽  
Significant Difference ◽  
The Mean ◽  
Normal Controls

The responses of cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) to administration of acetazolamide were investigated in 16 patients with dementia and ventriculomegaly to clarify the cerebral hemodynamics in patients with idiopathic normal-pressure hydrocephalus (NPH). The mean CBF velocity in the whole brain was measured by the Patlak plot method by using technetium-99m hexamethylpropyleneamine oxime single-photon emission computerized tomography. The CVR values were obtained from the response to administration of 500 mg of acetazolamide and calculated as the percentage of change from the baseline mean CBF value. The mean CBF value was significantly reduced (p < 0.01) in six patients with (35.2 ± 5 ml/100 g/minute) and 10 patients without (33.5 ± 2.8 ml/100 g/minute) NPH compared with the age-matched normal controls (40.8 ± 3.2 ml/100 g/minute), showing no significant difference. The CVR was significantly impaired in patients with NPH (0.8 ± 1.7%; p < 0.001), whereas in patients without NPH preserved CVR (11.3 ± 3%) was demonstrated compared with the normal controls (14.7 ± 1.1%). In patients with NPH a significantly lower CVR (p < 0.001) was shown than in those without NPH. The CVR significantly increased (p < 0.001) after placement of a shunt in patients with NPH. Reductions in both CBF and CVR may be diagnostic indicators of NPH in patients with dementia in whom ventriculomegaly is present. In patients with dementia and idiopathic NPH both reduced CBF and extremely impaired CVR are shown. The results of the present study suggest that ischemia due to the process of NPH is responsible for the reduction of CBF and manifestation of symptoms in patients with idiopathic NPH.

scholarly journals Cerebrospinal fluid closing pressure-guided tap test for the diagnosis of idiopathic normal pressure hydrocephalus: A descriptive cross-sectional study

2020 ◽  
Vol 11 ◽  
pp. 315
Author(s):  
Diego Fernando Gómez-Amarillo ◽  
Luis Fernando Pulido ◽  
Isabella Mejía ◽  
Catalina García-Baena ◽  
María Fernanda Cárdenas ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Cross Sectional Study ◽  
Sectional Study ◽  
Opening Pressure ◽  
Cross Sectional ◽  
Tap Test ◽  
The Mean ◽  
Closing Pressure

Background: Tap test improves symptoms of idiopathic normal pressure hydrocephalus (iNPH); hence, it is widely used as a diagnostic procedure. However, it has a low sensitivity and there is no consensus on the parameters that should be used nor the volume to be extracted. We propose draining cerebrospinal fluid (CSF) during tap test until a closing pressure of 0 cm H2O is reached as a standard practice. We use this method with all our patients at our clinic. Methods: This is a descriptive cross-sectional study where all patients with presumptive diagnosis of iNPH from January 2014 to December 2019 were included in the study. We used a univariate descriptive analysis and stratified analysis to compare the opening pressure and the volume of CSF extracted during the lumbar puncture, between patients in whom a diagnosis of iNPH was confirmed and those in which it was discarded. Results: A total of 92 patients were included in the study. The mean age at the time of presentation was 79.4 years and 63 patients were male. The diagnosis of iNPH was confirmed in 73.9% patients. The mean opening pressure was 14.4 cm H2O mean volume of CSF extracted was 43.4 mL. Conclusion: CSF extraction guided by a closing pressure of 0 cm H2O instead of tap test with a fixed volume of CSF alone may be an effective method of optimizing iNPH symptomatic improvement and diagnosis.

Lumbar drain trial outcomes of normal pressure hydrocephalus: a single-center experience of 254 patients

2020 ◽  
Vol 132 (1) ◽  
pp. 306-312 ◽  
Author(s):  
Tarek Y. El Ahmadieh ◽  
Eva M. Wu ◽  
Benjamin Kafka ◽  
James P. Caruso ◽  
Om J. Neeley ◽  
...  
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Insertion Site ◽  
Normal Pressure ◽  
Csf Leak ◽  
Complication Rates ◽  
Lumbar Drain ◽  
Ventriculoperitoneal Shunting ◽  
History Of ◽  
Subarachnoid Spaces ◽  
The Mean

OBJECTIVEA short-term lumbar drain (LD) trial is commonly used to assess the response of normal pressure hydrocephalus (NPH) patients to CSF diversion. However, it remains unknown whether the predictors of passing an LD trial match the predictors of improvement after ventriculoperitoneal shunting. The aim of this study was to examine outcomes, complication rates, and associations between predictors and outcomes after an LD trial in patients with NPH.METHODSThe authors retrospectively reviewed the records of 254 patients with probable NPH who underwent an LD trial between March 2008 and September 2017. Multivariate regression models were constructed to examine predictors of passing the LD trial. Complications associated with the LD trial procedure were recorded.RESULTSThe mean patient age was 77 years and 56.7% were male. The mean durations of gait disturbance, cognitive decline, and urinary incontinence were 29 months, 32 months, and 28 months, respectively. Of the 254 patients, 30% and 16% reported objective and subjective improvement after the LD trial, respectively. Complications included a sheared LD catheter, meningitis, lumbar epidural abscess, CSF leak at insertion site, transient lower extremity numbness, slurred speech, refractory headaches, and hyponatremia. Multivariate analyses using MAX-R revealed that a prior history of stroke predicted worse outcomes, while disproportionate subarachnoid spaces (uneven enlargement of supratentorial spaces) predicted better outcomes after the LD trial (r2 = 0.12, p < 0.05).CONCLUSIONSThe LD trial is generally safe and well tolerated. The best predictors of passing the LD trial include a negative history of stroke and having disproportionate subarachnoid spaces.

scholarly journals The role of shuntography in diagnosis of mechanic complications after implantation of ventriculoperitoneal shunts in patients with idiopathic normal pressure hydrocephalus: a retrospective clinical evaluation

2021 ◽  
Author(s):  
Rot Sergej ◽  
Goelz Leonie ◽  
Arndt Holger ◽  
Gutowski Pawel ◽  
Meier Ullrich ◽  
...  
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Clinical Information ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Ventricular Catheter ◽  
Symptomatic Therapy ◽  
Mechanical Obstruction ◽  
Revision Operation ◽  
Distal Catheter ◽  
Mechanical Complications

Abstract Background Mechanical obstruction of ventriculoperitoneal shunt (VPS) during the first year after shunt implantation is a common complication and is widely described in the literature. In this paper, we evaluated the suitability of the shuntography for the diagnosis of mechanical complications of the VPS in patients with idiopathic normal pressure hydrocephalus (iNPH). Methods We retrospectively identified 49 patients with pathologic shuntography over of a period of 20 years in our hospital. The percentage of procedure-associated complications was determined. Results Ninety-eight percent (n = 48) of the patients who underwent shuntography showed clinical and radiographic signs of underdrainage prior to examination. Shuntography revealed mechanical complications of the VP shunt in 37% (n = 18) as a cause of clinical deterioration and following revision operation. During shuntography, mechanical obstruction was discovered in 78% (n = 14) and disconnection of shunt components in 22% (n = 4). In the obstruction group, in 50% (n = 7) the closure was detected in the ventricular catheter, in 29% (n = 4) in the distal catheter of the VPS, and in 21% (n = 3) in both sides of the VPS. In the case of an inconspicuous shuntography (63%, n = 31), the patients received symptomatic therapy (32%, n = 10) or re-adjustment of the valve setting (68%, n = 21). Fifty-seven percent of the patients who underwent surgical treatment improved clinically by at least one point according to the Kiefer score. Conclusion Shuntography can produce valuable clinical information uncovering mechanic complications after implantation VPS in patients with idiopathic normal-pressure hydrocephalus. Patients with mechanical complications of their VPS needed revision surgery and showed clinical benefit after treatment.

scholarly journals A simple and cost-effective model for ventricular catheter placement training: technical note

2020 ◽  
pp. 1-4
Author(s):  
Nathan Todnem ◽  
Khoi D. Nguyen ◽  
Vamsi Reddy ◽  
Dayton Grogan ◽  
Taylor Waitt ◽  
...  
Keyword(s):  
Medical Students ◽  
External Ventricular Drain ◽  
Test Group ◽  
Cost Effective ◽  
Ventricular System ◽  
Catheter Placement ◽  
Ventricular Catheter ◽  
Frontal Horn ◽  
Ventricular Catheters ◽  
The Brain

OBJECTIVEExternal ventricular drain (EVD) placement is one of first cranial procedures neurosurgery residents are expected to perform independently. While proper training improves patient outcomes, there are few options for practicing EVD placement prior to placing the EVD in patients in a clinical setting. Proposed solutions to this include using cadaveric models and virtual simulations, but barriers exist with these as well in regard to authenticity. EVD simulators using virtual reality technologies are a promising new technique for training, but the cost of these devices poses a barrier to general/widespread accessibility among smaller programs or underserved hospitals. The authors desribe a novel, yet simple, and cost-effective technique (less than $5 per mold) for developing a brain model constructed of homemade ballistics gelatin that can be used for teaching and practicing the placement of EVD.METHODSA brain model is made with ballistics gelatin using an anatomically correct skull model as a mold. A 3D-printed ventricular system model is used to create a mold of an anatomically correct ventricular system in the brain model. A group of medical students (n = 10) were given a basic presentation about EVD placement, including standard landmarks and placement techniques, and were also shown a demonstration of EVD placement on the brain model. They were then allowed to perform an EVD placement using the brain model. The students were surveyed on their experience with using the brain model, including usability and practicality of the model. Accuracy of EVD placement by each student was also assessed, with adequate position of catheter tip being in the ipsilateral frontal horn.RESULTSThe final product is fairly inexpensive and easy to make. It is soft enough to pass a catheter through, but it is also firm enough to maintain its shape, including a cavity representing the lateral ventricles. The dense gelatin holds the catheter in its final resting position, while the two halves are separated and inspected. All participants in the test group of medical students reported that the brain model was easy to use, helped them understand the steps and technique of EVD placement, and provided good feedback on the ideal position of ventricular catheters. All of the participants in the group had adequate positioning of their ventricular catheters after one attempt.CONCLUSIONSThe presented brain model is easy to replicate, inexpensive, anatomically accurate, and provides a medium for neurosurgeons to teach and practice ventricular catheter placement in a risk-free environment.

Selection of patients with idiopathic normal-pressure hydrocephalus for shunt placement: a single-institution experience

2010 ◽  
Vol 113 (1) ◽  
pp. 64-73 ◽  
Author(s):  
Carmelo Anile ◽  
Pasquale De Bonis ◽  
Alessio Albanese ◽  
Alessandro Di Chirico ◽  
Annunziato Mangiola ◽  
...  
Keyword(s):  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Idiopathic Normal Pressure Hydrocephalus ◽  
Csf Shunt ◽  
Group Iii ◽  
Shunt Placement ◽  
Group I ◽  
Csf Hydrodynamics ◽  
The Mean ◽  
Group Ii

Object The ability to predict outcome after shunt placement in patients with idiopathic normal-pressure hydrocephalus (NPH) represents a challenge. To date, no single diagnostic tool or combination of tools has proved capable of reliably predicting whether the condition of a patient with suspected NPH will improve after a shunting procedure. In this paper, the authors report their experience with 120 patients with the goal of identifying CSF hydrodynamics criteria capable of selecting patients with idiopathic NPH. Specifically, they focused on the comparison between CSF-outflow resistance (R-out) and intracranial elastance (IE). Methods Between January 1977 and December 2005, 120 patients in whom idiopathic NPH had been diagnosed (on the basis of clinical findings and imaging) underwent CSF hydrodynamics evaluation based on an intraventricular infusion test. Ninety-six patients underwent CSF shunt placement: 32 between 1977 and 1989 (Group I) on the basis of purely clinical and radiological criteria; 44 between 1990 and 2002 (Group II) on the basis of the same criteria as Group I and because they had an IE slope > 0.25; and 20 between 2003 and 2005 (Group III) on the basis of the same criteria as Group II but with an IE slope ≥ 0.30. Outcomes were evaluated by means of both Stein-Langfitt and Larsson scores. Patients' conditions were considered improved when there was a stable decrease (at 6- and 12-month follow-up) of at least 1 point in the Stein-Langfitt score and 2 points in the Larsson score. Results Group I: while no statistically significant difference in mean R-out value between improved and unimproved cases was observed, a clear-cut IE slope value of 0.25 differentiated very sharply between unimproved and improved cases. Group II: R-out values in the 2 unimproved cases were 20 and 47 mm Hg/ml/min, respectively. The mean IE slope in the improved cases was 0.56 (range 0.30–1.4), while the IE slopes in the 2 unimproved cases were 0.26 and 0.27. Group III: the mean IE slope was 0.51 (range 0.31–0.7). The conditions of all patients improved after shunting. A significant reduction of the Evans ratio was observed in 34 (40.5%) of the 84 improved cases and in none of the unimproved cases. Conclusions Our strategy based on the analysis of CSF pulse pressure parameters seems to have a great accuracy in predicting surgical outcome in clinical practice.

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