Tag: Acute hydrocephalus

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The Technique for Transorbital Ventricular Puncture: An Anatomic Approach

Operative Neurosurgery 26:64–70, 2024

Transorbital ventricular puncture is a minimally invasive described procedure with poor landmarks and anatomic references. This approach can be easily performed to save patients with intracranial hypertension, especially when it is secondary to an acute decompensated hydrocephalus. This study aims to describe anatomic structures and landmarks to facilitate the execution of transorbital puncture in emergency cases.

METHODS: We analyzed 120 head computed tomographies to show the best area to perform the procedure in the orbital roof. Two adult cadavers (4 sides) were punctured in the predetermined area. Angles, distances, landmarks, and anatomic structures were registered. This approach to the ventricular system may be performed at bedside to relieve intracranial hypertension only in specific cases.

RESULTS: The perforation point is 2.5 cm (female) or 3.0 cm (male) lateral to the midline and immediately inferior to the superciliary arch. A vertical line, parallel to midline, was drawn on the outer edge of the patient’s forehead, the needle was 45°inferiorly and 20°medially and then progressed 2.0 cm backwards to reach the bone perforation point. After that, it was advanced another 4.5cm approximately until it reached the anterior horn of the lateral ventricle.

CONCLUSION: Based on statistical and experimental evidences, we were able to establish reliable anatomic reference points to access the anterior horn of the lateral ventricle through transorbital puncture.

 

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Aneurysm location and clipping versus coiling for development of secondary normal-pressure hydrocephalus after aneurysmal subarachnoid hemorrhage

Hydrocephalus

J Neurosurg 123:1555–1561, 2015

The present study aimed to investigate aneurysm locations and treatments for ruptured cerebral aneurysms associated with secondary normal-pressure hydrocephalus (sNPH) after subarachnoid hemorrhage (SAH) by using comprehensive data from the Japanese Stroke DataBank.

Methods Among 101,165 patients with acute stroke registered between 2000 and 2013, 4693 patients (1482 men, 3211 women) were registered as having had an SAH caused by a ruptured saccular aneurysm. Of them, 1448 patients (438 men and 1010 women; mean age 61.9 ± 13.4 years) who were confirmed to have or not have coexisting acute hydrocephalus and sNPH were included for statistical analyses. Locations of the ruptured aneurysms were subcategorized into 1 of the following 4 groups: middle cerebral artery (MCA; n = 354), anterior communicating artery and anterior cerebral artery (ACA; n = 496), internal carotid artery (ICA; n = 402), and posterior circulation (n = 130). Locations of 66 of the ruptured aneurysms were unknown/unrecorded. Treatments included craniotomy and clipping alone in 1073 patients, endovascular coil embolization alone in 285 patients, and a combination of coiling and clipping in 17 patients. The age-adjusted and multivariate odds ratios from logistic regression analyses were calculated after stratification using the Fisher CT scale to investigate the effects of the hematoma volume of SAH.

Results Acute hydrocephalus was confirmed in 593 patients, and 521 patients developed sNPH. Patients with a ruptured ACA aneurysm had twice the risk for sNPH over those with a ruptured MCA aneurysm. Those with an ACA aneurysm with Fisher Grade 3 SAH had a 9-fold-higher risk for sNPH than those with an MCA aneurysm with Fisher Grade 1 or 2 SAH. Patients with a ruptured posterior circulation aneurysm did not have any significant risk for sNPH. Clipping of the ruptured aneurysm resulted in twice the risk for sNPH over coil embolization alone.

Conclusions Patients with low-grade SAH caused by a ruptured MCA aneurysm had a low risk for the development of sNPH. In contrast, patients with high-grade SAH caused by a ruptured ACA aneurysm had a higher risk for sNPH. Endovascular coiling might confer a lower risk of developing sNPH than microsurgical clipping.

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External ventricular drain insertion accuracy: is there a need for change in practice?

Neurosurgery 65:1197–1201, 2009.DOI: 10.1227/01.NEU.0000356973.39913.0B

OBJECTIVE: Free-hand insertion of an external ventricular drain (EVD) is a common emergency neurosurgical procedure, mostly performed for critically ill patients. Although EVD complications have been studied thoroughly, the accuracy of EVD positioning has been audited only occasionally.

METHODS: Post-EVD insertion computed tomographic scans performed in our unit over a 2-year period were analyzed for EVD tip location and intracranial catheter length.

RESULTS: A total of 183 post-EVD insertion scans were reviewed. Of those, 73 EVD tips (39.9%) were in the ipsilateral frontal horn of the lateral ventricle (the desired tar- get); of those, 18 (25%) required EVD revision/reinsertion. Of the others, 35 (19.1%) were in the third ventricle, 33 (18%) in the body of the lateral ventricle, 19 (10.4%) in the sub- arachnoid space, 5 (2.7%) in the contralateral frontal horn, and 18 (9.8%) within the brain parenchyma. When the EVD tip was outside the desired target, 44 of the patients (40%) required EVD revision/reinsertion procedure (P = 0.0383).

CONCLUSION: Free-hand insertion of an EVD is an inaccurate procedure, and further studies are required to assess the accuracy and feasibility of the routine use of neuro- navigation, ultrasonography, or other guidance techniques and the possible implication of the decreasing revision rate, complications, and length of hospital stay.

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