Manual Occipital Ventricular Puncture for Cerebrospinal Fluid Shunt Surgery: Can Aiming Be Standardized?

Abstract

The manual occipital ventricular puncture is a standard surgical procedure, but specific targeting has not received sufficient attention despite the experience of anatomical disorientation. This study tried to identify an exact site for the ideal trajectory with this method, especially in the sagittal plane, which avoids contact with the choroid plexus that may be the major source of complications. A total of 44 consecutive adult cases undergoing cerebrospinal fluid shunting through the occipital route for hydrocephalus were retrospectively reviewed for the following: correlations between burr hole site, direction of puncture, and location of the ventricular catheter based on postsurgical radiological studies; calculation of the ideal trajectory to place the catheter tip in the anterior horn of the lateral ventricle without contact with the choroid plexus through the standard occipital burr hole. In addition, the relationships between the location of the ventricular structure, the cranial base line connecting the nasion and inion, and the size of the ventricle were evaluated. Incorrect catheter emplacement was found in five cases, which suggested that this procedure using the standard burr hole site and aim point might result in incorrect catheter placement. The ideal external aim points were widely distributed because of the variable heights of ventricular structures from the cranial baseline. No correlation between the locations of the anatomical points and ventricular size was found. The present study could not define a standard external aim point. Tailored preoperative planning of the trajectory is recommended.

A Morphometric Analysis of Commonly Used Craniometric Approaches for Freehand Ventriculoperitoneal Shunting

“…11,36,37 Our results reflect the remarkable variability of trajectory targets and corroborate previous studies that failed to identify a single landmark for these posterior approaches (Figure 10). 9,35,38 The only independent predictor for shunt revision was catheter tip location, and our observations concur with preceding studies. [1][2][3][4]6,19 We also noted that a contributing factor for achieving optimal placement was adopting Keen's point (88%, 15/17).…”

“…11,36,37 Our results reflect the remarkable variability of trajectory targets and corroborate previous studies that failed to identify a single landmark for these posterior approaches (Figure 10). 9,35,38…”

Magnetically Guided Neuronavigation of Flexible Instruments in Shunt Placement, Transsphenoidal Procedures, and Craniotomies

“…In cases of dilated ventricles, free-hand insertion of the shunt catheter is based on anatomic landmarks. However, a high degree of accuracy in trajectory planning minimizes brain trauma in instances of difficult catheter placement such as small or asymmetric ventricles, hydrocephalus owing to intraventricular space-occupying lesions (3), or occipital shunt placement (13). With brain trauma, navigated ventricular shunt placement even in small ventricles enables monitoring of intracranial pressure as well as drainage of cerebrospinal fluid.…”

Multimodal Simulation of a Novel Device for a Safe and Effective External Ventricular Drain Placement

“…The misplacement rates reported in literature are high, probably due to the use of EVD also in patients affected by midline shift or slit ventricles and in procedures performed by non-neurosurgeons in remote areas with logistic difficulties. Numerous studies have already been published about the reduction of complication after EVD, which is currently a freehand procedure, performed only according to anatomical landmarks that help to introduce the catheter perpendicularly to the burr hole; the perpendicularity is a critical element for the correct positioning of the catheter ( Gil et al, 2002 ; Shimizu et al, 2004 ; Lee et al, 2008 , 2020 ; Mahan et al, 2013 ; Patil et al, 2013 ; Jakola et al, 2014 ; Siesjö, 2014 ; Shtaya et al, 2018 ; Thomale et al, 2018 ; Wilson et al, 2018 ; Fuller et al, 2020 ; Park et al, 2020 ; Sun et al, 2020 ; Amoo et al, 2021 ; Cabrilo et al, 2021 ; Pishjoo et al, 2021 ).…”