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Non-assisted versus neuro-navigated and XperCT-guided external ventricular catheter placement: a comparative cadaver study

  • Experimental research - Neurosurgery Training
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Abstract

Background and purpose

Accurate placement of an external ventricular drain (EVD) for the treatment of hydrocephalus is of paramount importance for its functionality and in order to minimize morbidity and complications. The aim of this study was to compare two different drain insertion assistance tools with the traditional free-hand anatomical landmark method, and to measure efficacy, safety and precision.

Methods

Ten cadaver heads were prepared by opening large bone windows centered on Kocher’s points on both sides. Nineteen physicians, divided in two groups (trainees and board certified neurosurgeons) performed EVD insertions. The target for the ventricular drain tip was the ipsilateral foramen of Monro. Each participant inserted the external ventricular catheter in three different ways: 1) free-hand by anatomical landmarks, 2) neuronavigation-assisted (NN), and 3) XperCT-guided (XCT). The number of ventricular hits and dangerous trajectories; time to proceed; radiation exposure of patients and physicians; distance of the catheter tip to target and size of deviations projected in the orthogonal plans were measured and compared.

Results

Insertion using XCT increased the probability of ventricular puncture from 69.2 to 90.2 % (p = 0.02). Non-assisted placements were significantly less precise (catheter tip to target distance 14.3 ± 7.4 mm versus 9.6 ± 7.2 mm, p = 0.0003). The insertion time to proceed increased from 3.04 ± 2.06 min. to 7.3 ± 3.6 min. (p < 0.001). The X-ray exposure for XCT was 32.23 mSv, but could be reduced to 13.9 mSv if patients were initially imaged in the hybrid-operating suite. No supplementary radiation exposure is needed for NN if patients are imaged according to a navigation protocol initially.

Conclusion

This ex vivo study demonstrates a significantly improved accuracy and safety using either NN or XCT-assisted methods. Therefore, efforts should be undertaken to implement these new technologies into daily clinical practice. However, the accuracy versus urgency of an EVD placement has to be balanced, as the image-guided insertion technique will implicate a longer preparation time due to a specific image acquisition and trajectory planning.

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Acknowledgments

The authors would like to thank all participating surgeons: S. Momjian, Y. El Hassani, I. Radovanovic, M. Jägersgerg, H. Becker, A. Bartoli, A. Kurzburch, M. Seek, A. Reverdin, and B. Rilliet for their valuable contribution. Special thanks also to Mr T. Gerken and Mrs L. Slegers from Brainlab and Philips for their expertise.

Conflict of interest

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Authors and Affiliations

  1. Service de Neurochirurgie, Département de Neurosciences cliniques, Faculté de Médecine, Hôpitaux Universitaires de Genève, Geneva, Switzerland

    Oliver P. Gautschi, N. R. Smoll, M. Kotowski, B. Schatlo, K. Schaller & P. Bijlenga

  2. Department of Neurosurgery, Georg-August-University of Göttingen, Göttingen, Germany

    B. Schatlo

  3. Institut de Radiophysique, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland

    M. Tosic

  4. Anatomie clinique, Départment de physiologie cellulaire et métabolisme, Faculté de Médecine, Geneva, Switzerland

    B. Stimec & J. Fasel

Authors
  1. Oliver P. Gautschi
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  2. N. R. Smoll
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  3. M. Kotowski
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Correspondence to Oliver P. Gautschi.

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Comments

Gautschi and colleagues performed an interesting study comparing traditional free-hand anatomical-landmark-based versus navigated and XperCT-guided external ventricular drainage (EVD) placement in ten Formol-fixed human cadaver heads. They found that EVC placement using neuronavigation or XperCT-guidance improved accuracy while the insertion time increased.

EVD placement is a frequently performed procedure in neurosurgery, often in emergency situations. The problem of misplacement of the drainage is well-known and analyzed in the literature. Thus, the results of the present study are not surprising. However, the authors give an exact analysis of the sites of misplacement and of the time needed for each procedure. This may help to decide, which technique could be used in a particular given situation. Apart from the limitations of the study discussed by the authors themselves, we have to consider that especially in emergency situations there is not only the time factor, but also a stress factor of the surgeon and the assisting personnel: I do not think that in such a situation the (ideal) time measurements for navigated procedures of the present cadaver study can be transferred to “real life”.

Marcus Reinges

Giessen, Germany

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Gautschi, O.P., Smoll, N.R., Kotowski, M. et al. Non-assisted versus neuro-navigated and XperCT-guided external ventricular catheter placement: a comparative cadaver study. Acta Neurochir 156, 777–785 (2014). https://doi.org/10.1007/s00701-014-2026-8

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  • DOI: https://doi.org/10.1007/s00701-014-2026-8

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