- Neurosurgical Clinic, Klinikum Frankfurt- Höchst, Frankfurt am Main, FFM- Höchst, Germany
Mario N. Carvi Nievas
Neurosurgical Clinic, Klinikum Frankfurt- Höchst, Frankfurt am Main, FFM- Höchst, Germany
DOI:10.4103/2152-7806.78241Copyright: © 2011 Nievas MNC This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Carvi Nievas MN. Neuronavigation-assisted single transseptal catheter implantation and shunt in patients with posthemorrhagic hydrocephalus and accentuated lateral ventricles dilatation. Surg Neurol Int 23-Mar-2011;2:34
How to cite this URL: Carvi Nievas MN. Neuronavigation-assisted single transseptal catheter implantation and shunt in patients with posthemorrhagic hydrocephalus and accentuated lateral ventricles dilatation. Surg Neurol Int 23-Mar-2011;2:34. Available from: http://sni.wpengine.com/surgicalint_articles/neuronavigation-assisted-single-transseptal-catheter-implantation-and-shunt-in-patients-with-posthemorrhagic-hydrocephalus-and-accentuated-lateral-ventricles-dilatation/
Background:To assess the treatment of posthemorrhagic hydrocephalus with accentuated lateral ventricles dilatation by employing a single biventricular neuronavigation-assisted transseptal-implanted catheter with programmable valve and distal peritoneal derivation.
Methods:A neuronavigation-assisted single transseptal biventricular catheter implantation with distal peritoneal shunt system was performed in 11 patients with posthemorrhagic hydrocephalus and accentuated lateral ventricles dilatations between 2001 and 2010. Patients with concomitant third ventricle dilatation were excluded. Several sequential frustrated attempts of temporary drainage occlusion on both sides confirmed the isolation of the lateral ventricles. Neuronavigation was employed to accurately establish the catheter surgical corridor (trajectory) across the lateral ventricles and throughout the septum pellucidum. The neurological and radiological outcomes were assessed at least 6 months after the procedure.
Results:Catheter implantation was successfully performed in all patients. Only one catheter was found to be monoventricular on delayed computer tomography controls. Procedure-related complications (bleeding of infections) were not observed. No additional neurological deficits were found after shunt surgery. Six months after procedure, none required additional ventricular catheter implantations or shunt revisions. Radiological and clinical controls confirmed the shunt function and the improved neurological status of all patients.
Conclusion:Single neuronavigation-assisted transseptal-implanted biventricular catheter is a valid option for the treatment of posthemorrhagic hydrocephalus with accentuated lateral ventricles dilatation. This technique reduces the number of catheters and minimizes the complexity and timing of the surgical procedure as well as potential infection's risks associated with the use of multiple shunting systems.
Keywords: Posthemorrhagic biventricular hydrocephalus, transseptal catheter
Massive supratentorial intraventricular hemorrhage (IVH) can occlude both foramina of Monro and often result in serious clinical complications in adults as well as premature children. At admission, most of these patients require a biventricular external drainage. After clearing of the cerebrospinal fluid (CSF), the patient's clinical follow-up and their computed tomography (CT) scans and magnetic resonance images (MRIs) determine the residual distal CSF obstruction and the needs for shunt procedures.
Usually, in patients with a residual accentuated dilatation of both lateral ventricles due to the occlusion from both foramina of Monro, a biventricular catheter derivation with a Y-connector or two separated shunt systems will be commonly employed. Recent advances in endoscopy and neuronavigation techniques have additionally expanded the treatment's options for these patients. Endoscopic third ventriculostomy and image-guided endoscopic fenestration of the septum pellucidum has been reported to treat different forms of hydrocephalus.[
A neuronavigation-assisted single transseptal biventricular catheter implantation with distal peritoneal shunt system was performed in 11 patients with posthemorrhagic hydrocephalus and accentuated lateral ventricles dilatations between 2001 and 2010. In all these cases, following a biventricular external drainage or lysis of intraventricular clot, the size and morphology of the third ventricle were not disturbed. However, all patients showed a progressive dilatation of both lateral ventricles on repeated radiological studies. Moreover, sequential attempts of temporary drainage occlusion on both sides were unsuccessful. A unilateral ventriculoperitoneal (VP) shunt insertion was considered inappropriate to treat these patients. The patients’ clinical features are listed in
Neuronavigation was employed to accurately establish the catheter surgical corridor (trajectory) across the lateral ventricles and throughout the septum pellucidum. Free-hand transseptal biventricular catheter implantation was performed under assistance from the Vector Vision (2) neuronavigation systems (BrainLab AG, Munich, Germany). The frontal entry point was located 3.2-4.6 cm from the middle line and 1.8-3.2 cm in front of the coronal suture. The target point was set 0.8-1.5 cm behind the genu of the corpus callosum and at least 1 cm above the fornix. To evaluate the impact of this technique, the inpatients charts, the neurological outcome [assessed 6 months after the event with the Glasgow outcome scale (GOS)], the postoperative radiological examinations, and ultrasound examinations were individually reviewed.
Accurate planning of the approach and determination of the ideal trajectory were possible in all the cases.
(a): Case 6 of Table 1 with IVH associated with prematurity. Upper: neuronavigation-assisted catheter implantation. Lower: control CT scan with implanted catheter. (b) Case 5 of Table 1 with IVH associated ruptured aneurysm. Upper: initial CT scans. Lower: angiography showing the applied clip and navigation delayed transseptal catheter implantation. (c) Case 7 of
Catheter implantation across the septum pellucidum was successfully performed in all patients.
Upper row: Case 2 of Table 1. (a) Admission CT scan. (b) Preoperative DSA showing a left AVM as bleeding source. (c) Postoperative CT scan after removal of the AVM and delayed shunt implantation. Arrow showing neuronavigation-assisted transseptal implanted catheter. Lower row: Case 1 of
In clinical practice, the number of cases with a residual biventricular hydrocephalus following massive IVH is small. In this study, massive IVH presented with different etiologies and specific individual treatments for each bleeding source. However, in all these patients, the common accentuated neurological deterioration at admission with a Glasgow coma scale from less than 7 points always made necessary the early minimal invasive and effective treatment of the acute hydrocephalus. Several facts make the acute treatment of the hydrocephalus a first priority. Nishikawa et al. found that IVH volume, acute hydrocephalus and poor initial level of consciousness were factors significantly associated with an unfavorable prognosis.[
IVH was also found to have a negative influence on the development of chronic hydrocephalus in children.[
Several authors have previously analyzed the possible use of intraventricular fibrinolysis for IVH associated with initial occlusive hydrocephalus.[
Another minimal invasive procedure employing image-guided neuroendoscopy is being increasingly used in an attempt to reduce the morbidity associated with shunt devices. This procedure has a particularly useful application in the pediatric population for the treatment of complex hydrocephalus and arachnoid cysts.[
A neuroendoscopic fenestration of the septum pellucidum has been previously described as beneficial in cases of unilateral hydrocephalus.[
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