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  • TITLE: Image Guided Ventricular Catheter Placement in Shunt Surgery: The University of Florida Experience

    Final Number:

    Kelvin Wilson MD; Gregory J. Murad MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2013 Annual Meeting

    Introduction: Cerebrospinal fluid (CSF) shunting is the treatment of choice for the relief of hydrocephalus. Despite advances in both operative technique and technology, shunt failure remains a significant problem. As a result, image guidance technology has been utilized in hopes of improving catheter placement and decreasing failure rates. The objective of this study was to determine if the use of image guidance technology decreases the need for revision surgery in CSF shunting at our institution.

    Methods: A retrospective review of patients who underwent placement of a ventricular catheter for permanent CSF shunting between July 2008 and July 2011 was undertaken. Data on age, sex, diagnosis, operative procedure, complications, failure, and type of failure were collected. Appropriate statistical methods were used to ascertain rates of malfunction and compare the influence of diagnosis or shunt location (occipital vs. frontal).

    Results: 459 patients were included. Summary statistics are seen in table 1. 124/459 (27%) of patients underwent placement of ventricular catheters via image guidance. The overall failure rate in the study period was 24.6% (113/459). The failure rate for catheters placed with the use of image guidance was 22.6% (28/124) versus 25.4% (85/335) for catheters placed free hand (Table 2) There was no statistical difference between the image guidance and freehand group overall (p= 0.61) (Table 3), or comparing individual diagnoses or failure type (proximal vs. distal) (Table 4).

    Conclusions: Shunt failure remains a significant problem for patients, surgeons and the healthcare system at large. Our single center, retrospective study concludes that image guidance does not decrease the need for revision shunt surgery, either in total revisions, or in proximal shunt complications. Larger, prospective studies are needed to better clarify indications for the use of image guidance technology in the placement of ventricular catheters in shunt surgery.

    Patient Care: Ventricular catheter (for ventriculoperitoneal or ventriculoatrial shunt) placement for the relief of hydrocephalus continues to be one of the most important and commonly performed operations in the Neurosurgeon’s repertoire. Despite the frequency in which these surgeries are performed, an estimated 30-50% of shunts fail within 1 year often leading to readmission, reoperation and higher risk for future revisions. It has been shown that optimal placement of the ventricular catheter is one of the most important factors effecting shunt failure rates and thus image-guidance technology has been applied to the placement of ventricular catheters in hope that more accurate placement of catheters will lead to lower revision rates and thus better patient outcomes. My research shows that at least at our institution, use of image-guidance technology did not alter the revision rate and thus may be over utilized in many instances adding time to anesthesia and unnecessary costs to the patient and healthcare system.

    Learning Objectives: 1) Describe the importance of cerebrospinal fluid (CSF) shunting. 2) Indicate whether the use of image guidance decreases the need for revision surgery at our institution 3) Describe the need for larger studies to assess the optimal use of image-guided technology in shunt surgery

    References: 1. Lind, Christopher, Amy Tsai, Christina Lind, and Andrew Law. "Ventricular catheter placement accuracy in non-stereotactic shunt surgery for hydrocephalus." Journal of Clinical Neuroscience 16 (2009): 918-920. Print. 2. Lind, Christopher, Amy Tsai, Andrew Law, Hui Lau, and Kavitha Muthiah. "Ventricular catheter trajectories from traditional shunt approaches: a morphometric study in adults with hydrocephalus." Journal of Neurosurgery 108 (2008): 930-933. Print. 3. Strowitzki, M., Y. Komenda, R. Eymann, and W.I. Steudel. "Accuracy of ultrasound-guided puncture of the ventricular system." Childs Nervous System 24 (2008): 65-69. Print. 4. Whitehead, William E., Andrew Jea, Shobhan Vachhrajani, Abhaya V. Kulkarni, and James M. Drake. "Accurate placement of cerebrospinal fluid shunt ventricular catheters with real-time ultrasound guidance in older children without patent fontanelles." Journal of Neurosurgery (5 Suppl Pediatrics) 107 (2007): 406-410. Print. 5. Villavicencio, Alan T. , Jean-Christophe Leveque, Matthew J. McGirt, John S. Hopkins, Herbert E. Fuchs, and Timothy M. George. "Comparison of Revision Rates Following Endoscopically versus Nonendoscopically Placed Ventricular Shunt Catheters." Surgical Neurology 59 (2003): 375-380. Print. 6. Wan, Kai Rui, Jennifer Ah Toy, Rory Wolfe, and Andrew Danks. "Factors affecting the accuracy of ventricular catheter placement." Journal of Clinical Neuroscience 18 (2011): 485-488. Print. 7. Tuli S, O’Hayon B, Drake J, et al. Change in ventricular size and effect of ventricular catheter placement in pediatric patients with shuntedhydrocephalus. Neurosurgery 1999;45:1329. 8. Strowitzki, M., Y. Komenda, R. Eymann, and W.I. Steudel. "Accuracy of ultrasound-guided puncture of the ventricular system." Childs Nervous System 24 (2008): 65-69. Print. 9. Levitt, Michael R. , Brent R. O'Neill, Gisele E. Ishak, Paritosh C. Khanna, and Samuel R. Browd. "Image-guided cerebral spinal fluid shunting in children: catheter accuracy and shunt survival." Journal of Neurosurgery Pediatrics 10.2 (2012): 112-117. Print. 10. Korinek, Anne-Marie, Laurence Fulla-Oller, Anne-Laure Boch, and Louis Puybasset. "Morbidity of Ventricular Cerebrospinal Fluid Shunt Surgery in Adults: An 8-year Study." Neurosurgery 68.985 (2011): 995. Print. 11. Sampath, R, R Wadhawa, T Tawfik, A Nanda, and B Guthikonda. "Stereotactic placement of ventricular catheters: does it affect proximal malfunction rates?." Stereotactic and functional neurosurgery 90.2 (2012): 97-103. Print. 12. Hayhurst, Caroline, Tjemme Beems, Michael Jenkinson, Patricia Byrne, D.S. Nandoe Tewarie, and Conor L. Mallucci. "Effect of electromagnetic-navigated shunt placement on failure rates: a prospective multicenter study." Journal Neurosurgery 113.6 (2010): 1273-1278. Print. 13. Wilson, Thomas J. , William R. Stetler Jr., Wajd N. Al-Holou, and Stephen E. Sullivan. "Comparison of the accuracy of ventricular catheter placement using freehand placement, ultrasonic guidance, and stereotactic neuronavigation." Journal Neurosurgery online January 18, 2013; DOI: 10.3171/2012.11.JNS111384 (2013): 1-5. Print.

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