Utilizing preprocedural CT scans to identify patients at risk for suboptimal external ventricular drain placement with the freehand insertion technique

Wilson, Mitchell P; O’Kelly, Cian; Jack, Andrew; Rempel, Jeremy

doi:10.3171/2018.1.jns172839

Cited by 6 publications

(4 citation statements)

References 24 publications

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“…1,[7][8][9] In a recent study, the use of the freehand technique was identified as the primary risk factor for inaccurate placement when compared with image-guided techniques. 10 An augmented-reality (AR) head-mounted device (HMD) that can function as a stand-alone unit, capable of tracking the patient's position while displaying an exact overlay of anatomical structures and surgical plans, has the potential to facilitate the learning process and improve the accuracy of EVD placement in everyday neurosurgical practice. 11,12 To further evaluate the efficacy of EVD placement using AR assistance, a software solution utilizing the Holo-Lens (Microsoft Corp.) HMD was developed to facilitate AR-assisted EVD placements.…”

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confidence: 99%

The effect of augmented reality on the accuracy and learning curve of external ventricular drain placement

Gestel

Frantz

Vannerom

et al. 2021

Neurosurgical Focus

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OBJECTIVE The traditional freehand technique for external ventricular drain (EVD) placement is most frequently used, but remains the primary risk factor for inaccurate drain placement. As this procedure could benefit from image guidance, the authors set forth to demonstrate the impact of augmented-reality (AR) assistance on the accuracy and learning curve of EVD placement compared with the freehand technique. METHODS Sixteen medical students performed a total of 128 EVD placements on a custom-made phantom head, both before and after receiving a standardized training session. They were guided by either the freehand technique or by AR, which provided an anatomical overlay and tailored guidance for EVD placement through inside-out infrared tracking. The outcome was quantified by the metric accuracy of EVD placement as well as by its clinical quality. RESULTS The mean target error was significantly impacted by either AR (p = 0.003) or training (p = 0.02) in a direct comparison with the untrained freehand performance. Both untrained (11.9 ± 4.5 mm) and trained (12.2 ± 4.7 mm) AR performances were significantly better than the untrained freehand performance (19.9 ± 4.2 mm), which improved after training (13.5 ± 4.7 mm). The quality of EVD placement as assessed by the modified Kakarla scale (mKS) was significantly impacted by AR guidance (p = 0.005) but not by training (p = 0.07). Both untrained and trained AR performances (59.4% mKS grade 1 for both) were significantly better than the untrained freehand performance (25.0% mKS grade 1). Spatial aptitude testing revealed a correlation between perceptual ability and untrained AR-guided performance (r = 0.63). CONCLUSIONS Compared with the freehand technique, AR guidance for EVD placement yielded a higher outcome accuracy and quality for procedure novices. With AR, untrained individuals performed as well as trained individuals, which indicates that AR guidance not only improved performance but also positively impacted the learning curve. Future efforts will focus on the translation and evaluation of AR for EVD placement in the clinical setting.

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confidence: 99%

The effect of augmented reality on the accuracy and learning curve of external ventricular drain placement

Gestel

Frantz

Vannerom

et al. 2021

Neurosurgical Focus

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“…Given the need for increased accuracy in correctly placing an EVD, it is essential that training models represent the anatomical structure and consistency of the human brain as closely as possible. 11 Moreover, it is necessary that this training be active and performed using the same instruments as appear in the actual clinical setting. While current models attempt to satisfy these requirements, the use of hard plastics and cadaver brains is unrealistic because of their consistency and structure and because they are neither easily accessible nor reusable.…”

Section: Discussionmentioning

confidence: 99%

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

Todnem

Nguyen

Reddy

et al. 2021

Journal of Neurosurgery

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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.

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“…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, 2008Lee et al, , 2020Mahan 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).…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2021

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BackgroundExternal ventricular drain (EVD) placement is mandatory for several pathologies. The misplacement rate of the EVD varies widely in literature, ranging from 12.3 to 60%. The purpose of this simulation study is to provide preliminary data about the possibility of increasing the safety of one of the most common life-saving procedures in neurosurgery by testing a new device for EVD placement.MethodsWe used a novel guide for positioning the ventricular catheter (patent RM2014A000376). The trajectory was assessed using 25 anonymized head CT scans. The data sets were used to conduct three-dimensional computer-based and combined navigation and augmented reality-based simulations using plaster models. The data set inclusion criteria were volumetric head CT scan, without midline shift, of patients older than 18. Evans’ index was used to quantify the ventricle’s size. We excluded patients with slit ventricles, midline shift, skull fractures, or complex skull malformations. The proximal end of the device was tested on the cadaver.ResultsThe cadaveric tests proved that a surgeon could use the device without any external help. The multimodal simulation showed Kakarla grade 1 in all cases but one (grade 2) on both sides, after right and left EVD placement. The mean Evans’ index was 0.28. The geometric principles that explain the device’s efficacy can be summarized by studying the properties of circumference and chord. The contact occurs, for each section considered, at the extreme points of the chord. Its axis, perpendicular to the plane tangent to the spherical surface at the entry point, corresponds to the direction of entry of the catheter guided by the instrument.ConclusionAccording to our multimodal simulation on cadavers, 3D computer-based simulation, 3D plaster modeling, 3D neuronavigation, and augmented reality, the device promises to offer safer and effective EVD placement. Further validation in future clinical studies is recommended.

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Utilizing preprocedural CT scans to identify patients at risk for suboptimal external ventricular drain placement with the freehand insertion technique

Cited by 6 publications

References 24 publications

The effect of augmented reality on the accuracy and learning curve of external ventricular drain placement

The effect of augmented reality on the accuracy and learning curve of external ventricular drain placement

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

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

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