Ventriculostomy

Article Author:
Sunil Munakomi
Article Editor:
Joe M Das
Updated:
7/4/2020 11:17:26 AM
PubMed Link:
Ventriculostomy

Introduction

Ventriculostomy is one of the most common emergency based neurosurgical procedures practitioners undertake globally.[1] The first attempt was by Claude-Nicolas Le Cat, a French anatomist.[2] Ingraham later advocated the application of a closed draining system to minimize the infective complications.[3]

Anatomy and Physiology

Herophilus and Erasistratus were the first to provide the anatomical depiction of the ventricular system inside the brain. Later, Domenico Felice Antonio Cotugno described the presence of cerebrospinal fluid (CSF) within this interconnecting system.[3]

The ventricular system develops from the cavities within the developing brain vesicles. The cavity of the rhombencephalon later forms the fourth ventricle, whereas the cavity of the diencephalon forms the third ventricle, and those of the telencephalon develop into the lateral ventricles. The cavity within the mesencephalon forms the aqueduct connecting third to the fourth ventricles.[3]

Indications

A summary of indications for performing ventriculostomy are as follows[4][5]:

  1. Acute symptomatic hydrocephalus - following subarachnoid hemorrhage (SAH), strokes, meningitis
  2. Intracranial pressure (ICP) monitoring
  3. Adjunct management for malfunctioning or infected ventriculoperitoneal shunts
  4. As a panacea for brain relaxation during intraoperative brain edema
  5. Planning therapeutic interventions- thrombolytics, antibiotics, for managing vasospasms

Contraindications

The contraindications for ventriculostomy include [6]:

  1. Concurrent use of anticoagulant drugs
  2. Bleeding disorders
  3. Scalp infection
  4. Brain abscess

Equipment

Basic equipment sets should include the following [6]:

  1. Non-sterile gloves, soap, brush, hand towel, razor, and a marker pen for parts preparation and marking of the site of placement of monitor devices.
  2. For the procedure itself, face mask, sterile gown and gloves, an antiseptic solution, a drape, a local anesthetic agent, a 5-ml syringe, a 15 or 11 number surgical blade, and an ICP-monitoring kit. A drill with a drill bit, a bolt, an ICP sensor, and a transducer as per the methods utilized.  A suture material and a sterile dressing.

Personnel

A composite healthcare team comprised of [6]:

  • A neurosurgeon
  • A qualified assistant
  • An attending nurse
  • An anesthetist
  • A general duty assistant (GDA)

Preparation

The patient and next of kin/relatives should receive a thorough explanation regarding the indication for the procedure and the risks involved before the procedure, and written consent obtained.[6]

Strict adherence to aseptic guidelines is a cornerstone in preventing the risk of infection and prophylactic antibiotic needs to be administered just at the beginning of the procedure.[7]

The meticulous technique is pivotal in minimizing procedure-related complications. The patient should be well sedated, assuring patency of his airway, and local anesthetic administered at the allocated point of ventriculostomy.

Technique

The insertion of the device is aided with the placement of either a burr hole or a twist drill technique. Kocher's point is the choice for the ventriculostomy. Other points of ventricular puncture include.[3]

  1. Keen’s point: -2.5 to 3 cm posterior and 2.5 to 3 cm above the pinna of the ear.
  2. Kocher’s point: This point is 1 to 2 cm anterior to the coronal suture in the mid pupillary line, or 11 cm posterior from the glabella and 3 to 4 cm lateral from midline ipsilateral medial canthus and a line extending coronally from the ipsilateral tragus.
  3. Dandy’s point: 3 cm above and 2 cm lateral to the inion
  4. Frazier’s point: 6 cm above and 4 cm lateral to the inion
  5. Paine’s point-  the apex of an isosceles triangle, whose base is 3.5 cm and lies along the Sylvian veins, and each of the two limbs is 2.5 cm.
  6. Tubbs’ point: is a point just medial to the midpapillary point through the roof of the orbit. The trajectory aims 45 degrees from a horizontal line and 15 to 20 degrees medial to a vertical line.

 Computed tomogram based grading system has been developed to assess the accuracy of the placement of ventricular catheters.[8]

  1. Grade 1 - the tip within the ipsilateral lateral ventricle nearing foramen of Monro.
  2. Grade 2 - the medial deviation into a contralateral frontal horn or a lateral ventricle.
  3. Grade 3 - the lateral deviation through the caudate nucleus along the lateral corner and wall of the frontal horn.
  4. Grade 4 - extraventricular catheterization.

Ghajar first introduced a ventricular catheter guide for optimizing trajectory during ventriculostomy. He advocated a perpendicular trajectory relative to the skull surface.[9]

However, the calvarial slope obviates this trajectory, especially in the coronal plane.[10][8] The accuracy for the ideal placement of the ventricular tip is around 86%. Furthermore, only 3.1% of the catheters were found to be nonfunctional and requiring a replacement or reposition.[11] The accuracy can undergo further improvement along with the application of ultrasonogram,[12] endoscopy, neuronavigation,[10] and adjustable Ghajar guide technique.[8]

Complications

The complications include [4]:

  1. Intracranial and tract hemorrhage (10%) However, this hemorrhage is usually insignificant and rarely needs surgical intervention.[13]
  2. Ventriculitis (20%)Infection is the most common complication of external ventricular drainage (EVD), with rates ranging from 0 to 45%. Multiple attempts to insertion of EVD is associated with an increased risk of infection. The duration of the drain was paradoxically not related to predicting increased odds for infection.[3] Antibiotic-impregnated catheters and provision of tunneling methods have shown to minimize EVD infection. There was no relation to the difference in infection rate comparing its placement either at OR or at the bedside.[1]
  3. Technical failure (failure to tap ventricle or misplacement) (5%) One study revealed that 22.4% of catheter tips were in extraventricular spaces during a freehand placement,  showing ample room for improvement.[14] There is also an association between malpositioned tips with the subsequent risk of shunt occlusion.[10] 
  4. The cost for placing an external ventricular drain (EVD) amounting to around $200 with transducers costing an extra $400 to 600.
  5. Over-drainage can lead to aneurysmal rebleed and in cases of hydrocephalus complicate the upward transtentorial herniation.
  6. Kinks and blockage by air, blood, and debris are also frequent, leading to the poor and false recording of the ICP.
  7. Inadvertent vascular injury.
  8. Pneumocephalus and pneumoventriculi.
  9. CSF leak.
  10. Accidental fracture
  11. Accidental pull
  12. Obstruction by choroid plexus, blood clot or proteinous plug. The anterior entry site lowered the risk of shunt failure compared with the posterior entry site by approximately one-third due to the chandelier effect.[15] Overdrainage can also lead to obstruction of the catheter due to the formation of ependymal bands.[16]

Clinical Significance

Ventricular catheters represent a “global” ICP with minimal chances of drift and influence from pressure gradients between parenchyma and ventricular system.

It is the most reliable method of achieving maximum accuracy at minimal expense. There are added therapeutic benefits of CSF drainage, instilling medications like antibiotics and thrombolytic agents.

The advantage of the ventricular monitoring device is the facility for egress of CSF in cases of a sustained rise in ICP (greater than or equal to 20 mm Hg for 5 minutes or longer), but the disadvantage is that simultaneous monitoring, as well as CSF drainage, is not possible. The amount of CSF to be drained can be guided as per the recommended target ICP (commonly set as 10 mm Hg) or can be aided with the visual guidance in the improvement in the ICP waveform analysis obtained from the concurrent application of intraparenchymal monitors or through clinical neurological examination. Care always needs to be taken in preventing paradoxical upward transtentorial herniation due to overzealous drainage of CSF.

EVD can be removed once the ICP is normalized with sustained or improved clinical neurology (motor score at least 5) for at least 48 to 72 hours without the use of any interventions by clamping, or more ideally gradual increment in its height (training of the EVD) is attained to watch for any clinical deterioration in the patient for at least 48 hours.[6]

Strict aseptic precautions and care also need to be implemented during its removal as well. The head end should be lowered down to prevent the risk of pneumocephalus and pneumoventriculi. The tip of the catheter can be sent for bacteriological analysis in cases of persisting fever with features of meningitis. The wound is closed in layers to minimize the risk of CSF leak and infection. The patient should receive close monitoring for any signs of clinical deterioration for at least 24 hours with all preparations made for the emergency placement of a new EVD set.[6]

Enhancing Healthcare Team Outcomes

To ensure better clinical outcome and to prioritize patient safety by minimizing complications, there need to be mandatory patient safety checklists to be implemented by the interprofessional team involved in the process. Following guidelines has to be adhered to [6]:

  1. Valid treatment order sheet which has to be signed and dated by the surgeon
  2. All reportable limits clearly specified by the clinician
  3. Nurses need to be educated in the management of patients with a ventriculostomy and understand the tracing waveform so that they can report abnormalities to the team.
  4. EVD drainage point at a prescribed level with the transducer leveled to the tragus of the ear
  5. The EVD column is oscillating
  6. Monitoring for normal ICP waveform
  7. ICP waveform is pulsatile on the monitor
  8. No soakage in the wound site or any junctions within the monitor set
  9. Judicious assessment of drained CSF volume
  10. Stringent evaluation of the neurological status of the patient
  11. Strict maintenance of an aseptic environment.

Monitoring of intracranial pressure requires an interprofessional team approach, including physicians, specialists, and specialty-trained nurses, all collaborating across disciplines to achieve optimal patient results. Obviously, surgically-trained nurses will play a significant role in the procedure, assisting and monitoring for the surgeon performing the procedure. Deviation from these standards can result in life-threatening complications. Open communication between the interprofessional team is necessary so that the procedure achieves optimal outcomes safely. [Level V]

Nursing, Allied Health, and Interprofessional Team Interventions

  • Draw CSF for culture
  • Assist the surgeon administer medications
  • Monitoring for signs of intracranial hypertension
  • Checking for CSF leak
  • Ensuring aseptic techniques when manipulating the catheter
  • Monitoring the tracing for dampening or lack of pulsation

Nursing, Allied Health, and Interprofessional Team Monitoring

The nurses involved in patient care should monitor the following: [4]

  • Monitor hourly CSF drainage
  • Ensure CSF oscillation inside the tubes
  • Confer no soakage of the wound
  • Ensure the correct height of EVD
  • Zeroing of the EVD height at the level of the foramen of Monro or tragus of the ear
  • Stringent neurological monitoring of the patient
  • Monitor hourly ICP

There needs to be a strict provision of following checklists.[4]

Maintaining a sterile environment, and stringent monitoring for foreseeing and timely troubleshooting of complications are the cornerstones in the care bundle approach in managing these patients.[17]  


References

[1] Kohli G,Singh R,Herschman Y,Mammis A, Infection Incidence Associated with External Ventriculostomy Placement: A Comparison of Outcomes in the Emergency Department, Intensive Care Unit, and Operating Room. World neurosurgery. 2018 Feb;     [PubMed PMID: 29097331]
[2] Missori P,Paolini S,Domenicucci M, The origin of the cannula for ventriculostomy in pediatric hydrocephalus. Journal of neurosurgery. Pediatrics. 2011 Mar     [PubMed PMID: 21361770]
[3] Mortazavi MM,Adeeb N,Griessenauer CJ,Sheikh H,Shahidi S,Tubbs RI,Tubbs RS, The ventricular system of the brain: a comprehensive review of its history, anatomy, histology, embryology, and surgical considerations. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery. 2014 Jan;     [PubMed PMID: 24240520]
[4] Lele AV,Hoefnagel AL,Schloemerkemper N,Wyler DA,Chaikittisilpa N,Vavilala MS,Naik BI,Williams JH,Venkat Raghavan L,Koerner IP, Perioperative Management of Adult Patients With External Ventricular and Lumbar Drains: Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. Journal of neurosurgical anesthesiology. 2017 Jul;     [PubMed PMID: 28169966]
[5] M Das J,Zito PM, Nimodipine . 2019 Jan     [PubMed PMID: 30521291]
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[7] Tse Ts,Cheng K,Wong K,Pang K,Wong C, Ventriculostomy and Infection: A 4-year-review in a local hospital. Surgical neurology international. 2010 Sep 9;     [PubMed PMID: 20975968]
[8] Yoon SY,Kwak Y,Park J, Adjustable Ghajar Guide Technique for Accurate Placement of Ventricular Catheters: A Pilot Study. Journal of Korean Neurosurgical Society. 2017 Sep;     [PubMed PMID: 28881125]
[9] Ghajar JB, A guide for ventricular catheter placement. Technical note. Journal of neurosurgery. 1985 Dec;     [PubMed PMID: 4056916]
[10] Thomale UW,Schaumann A,Stockhammer F,Giese H,Schuster D,Kästner S,Ahmadi AS,Polemikos M,Bock HC,Gölz L,Lemcke J,Hermann E,Schuhmann MU,Beez T,Fritsch M,Orakcioglu B,Vajkoczy P,Rohde V,Bohner G, GAVCA Study: Randomized, Multicenter Trial to Evaluate the Quality of Ventricular Catheter Placement with a Mobile Health Assisted Guidance Technique. Neurosurgery. 2018 Aug 1;     [PubMed PMID: 28973670]
[11] Hsieh CT,Chen GJ,Ma HI,Chang CF,Cheng CM,Su YH,Ju DT,Hsia CC,Chen YH,Wu HY,Liu MY, The misplacement of external ventricular drain by freehand method in emergent neurosurgery. Acta neurologica Belgica. 2011 Mar;     [PubMed PMID: 21510229]
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[13] Gardner PA,Engh J,Atteberry D,Moossy JJ, Hemorrhage rates after external ventricular drain placement. Journal of neurosurgery. 2009 May;     [PubMed PMID: 19199471]
[14] Huyette DR,Turnbow BJ,Kaufman C,Vaslow DF,Whiting BB,Oh MY, Accuracy of the freehand pass technique for ventriculostomy catheter placement: retrospective assessment using computed tomography scans. Journal of neurosurgery. 2008 Jan;     [PubMed PMID: 18173315]
[15] Whitehead WE,Riva-Cambrin J,Kulkarni AV,Wellons JC 3rd,Rozzelle CJ,Tamber MS,Limbrick DD Jr,Browd SR,Naftel RP,Shannon CN,Simon TD,Holubkov R,Illner A,Cochrane DD,Drake JM,Luerssen TG,Oakes WJ,Kestle JR, Ventricular catheter entry site and not catheter tip location predicts shunt survival: a secondary analysis of 3 large pediatric hydrocephalus studies. Journal of neurosurgery. Pediatrics. 2017 Feb;     [PubMed PMID: 27813457]
[16] Kraemer MR,Koueik J,Rebsamen S,Hsu DA,Salamat MS,Luo S,Saleh S,Bragg TM,Iskandar BJ, Overdrainage-related ependymal bands: a postulated cause of proximal shunt obstruction. Journal of neurosurgery. Pediatrics. 2018 Nov 1;     [PubMed PMID: 30117791]
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