No significant improvement in the rate of accurate ventricular catheter location using ultrasound-guided CSF shunt insertion: a prospective, controlled study by the Hydrocephalus Clinical Research Network

Clinical article

Restricted access

Object

Cerebrospinal fluid shunt ventricular catheters inserted into the frontal horn or trigone are associated with prolonged shunt survival. Developing surgical techniques for accurate catheter insertion could, therefore, be beneficial to patients. This study was conducted to determine if the rate of accurate catheter location with intraoperative ultrasound guidance could exceed 80%.

Methods

The authors conducted a prospective, multicenter study of children (< 18 years) requiring first-time treatment for hydrocephalus with a ventriculoperitoneal shunt. Using intraoperative ultrasound, surgeons were required to target the frontal horn or trigone for catheter tip placement. An intraoperative ultrasound image was obtained at the time of catheter insertion. Ventricular catheter location, the primary outcome measure, was determined from the first postoperative image. A control group of patients treated by nonultrasound surgeons (conventional surgeons) were enrolled using the same study criteria. Conventional shunt surgeons also agreed to target the frontal horn or trigone for all catheter insertions. Patients were triaged to participating surgeons based on call schedules at each center. A pediatric neuroradiologist blinded to method of insertion, center, and surgeon determined ventricular catheter tip location.

Results

Eleven surgeons enrolled as ultrasound surgeons and 6 as conventional surgeons. Between February 2009 and February 2010, 121 patients were enrolled at 4 Hydrocephalus Clinical Research Network centers. Experienced ultrasound surgeons (> 15 cases prior to study) operated on 67 patients; conventional surgeons operated on 52 patients. Experienced ultrasound surgeons achieved accurate catheter location in 39 (59%) of 66 patients, 95% CI (46%–71%). Intraoperative ultrasound images were compared with postoperative scans. In 32.7% of cases, the catheter tip moved from an accurate location on the intraoperative ultrasound image to an inaccurate location on the postoperative study. This was the most significant factor affecting accuracy. In comparison, conventional surgeons achieved accurate location in 24 (49.0%) of 49 cases (95% CI [34%–64%]). The shunt survival rate at 1 year was 70.8% in the experienced ultrasound group and 66.9% in the conventional group (p = 0.66). Ultrasound surgeons had more catheters surrounded by CSF (30.8% vs 6.1%, p = 0.0012) and away from the choroid plexus (72.3% vs 58.3%, p = 0.12), and fewer catheters in the brain (3% vs 22.4%, p = 0.0011) and crossing the midline (4.5% vs 34.7%, p < 0.001), but they had a higher proportion of postoperative pseudomeningocele (10.1% vs 3.8%, p = 0.30), wound dehiscence (5.8% vs 0%, p = 0.13), CSF leak (10.1% vs 1.9%, p = 0.14), and shunt infection (11.6% vs 5.8%, p = 0.35).

Conclusions

Ultrasound-guided shunt insertion as performed in this study was unable to consistently place catheters into the frontal horn or trigone. The technique is safe and achieves outcomes similar to other conventional shunt insertion techniques. Further efforts to improve accurate catheter location should focus on prevention of catheter migration that occurs between intraoperative placement and postoperative imaging. Clinical trial registration no.: NCT01007786 (ClinicalTrials.gov).

Abbreviation used in this paper:HCRN = Hydrocephalus Clinical Research Network.
Article Information

Contributor Notes

Address correspondence to: William E. Whitehead, M.D., M.P.H., Texas Children's Hospital, Clinical Care Center, 6621 Fannin St., Ste. 1230.01, Houston, TX 77030. email: wewhiteh@texaschildrenshospital.org.Please include this information when citing this paper: published online October 11, 2013; DOI: 10.3171/2013.9.PEDS1346.
Headings
References
  • 1

    Albright ALHaines SJTaylor FH: Function of parietal and frontal shunts in childhood hydrocephalus. J Neurosurg 69:8838861988

  • 2

    Becker DPNulsen FE: Control of hydrocephalus by valve-regulated venous shunt: avoidance of complications in prolonged shunt maintenance. J Neurosurg 28:2152261968

    • Search Google Scholar
    • Export Citation
  • 3

    Dickerman RDMcConathy WJMorgan JStevens QEJolley JTSchneider S: Failure rate of frontal versus parietal approaches for proximal catheter placement in ventriculoperitoneal shunts: revisited. J Clin Neurosci 12:7817832005

    • Search Google Scholar
    • Export Citation
  • 4

    Drake JMKestle J: Rationale and methodology of the multicenter pediatric cerebrospinal fluid shunt design trial. Childs Nerv Syst 12:4344471996

    • Search Google Scholar
    • Export Citation
  • 5

    Kestle JRDrake JMCochrane DDMilner RWalker MLAbbott R III: Lack of benefit of endoscopic ventriculoperitoneal shunt insertion: a randomized controlled trial. J Neurosurg 98:2842902003

    • Search Google Scholar
    • Export Citation
  • 6

    Kim YBLee JWLee KSLee KC: Image-guided placement of ventricular shunt catheter. J Clin Neurosci 13:50542006

  • 7

    Lind CRTsai AMLind CJLaw AJ: Ventricular catheter placement accuracy in non-stereotactic shunt surgery for hydrocephalus. J Clin Neurosci 16:9189202009

    • Search Google Scholar
    • Export Citation
  • 8

    Missori PArtizzu SSalvati M: Immediate postoperative CT to assess the correct positioning of a ventricular catheter. Br J Neurosurg 14:44452000

    • Search Google Scholar
    • Export Citation
  • 9

    O'Hayon BBDrake JMOssip MGTuli SClarke M: Frontal and occipital horn ratio: a linear estimate of ventricular size for multiple imaging modalities in pediatric hydrocephalus. Peditr Neurosurg 29:2452492000

    • Search Google Scholar
    • Export Citation
  • 10

    Pang DGrabb PA: Accurate placement of coronal ventricular catheter using stereotactic coordinate-guided free-hand passage. Technical note. J Neurosurg 80:7507551994

    • Search Google Scholar
    • Export Citation
  • 11

    Sainte-Rose CPiatt JHRenier DPierre-Kahn AHirsch JFHoffman HJ: Mechanical complications in shunts. Pediatr Neurosurg 17:291992

    • Search Google Scholar
    • Export Citation
  • 12

    Sekhar LNMoossy JGuthkelch AN: Malfunctioning ventriculoperitoneal shunts. Clinical and pathological features. J Neurosurg 56:4114161982

    • Search Google Scholar
    • Export Citation
  • 13

    Shkolnik AMcLone DG: Intraoperative real-time ultrasonic guidance of ventricular shunt placement in infants. Radiology 141:5155171981

    • Search Google Scholar
    • Export Citation
  • 14

    Strowitzki MKomenda YEymann RSteudel WI: Accuracy of ultrasound-guided puncture of the ventricular system. Childs Nerv Syst 24:65692008

    • Search Google Scholar
    • Export Citation
  • 15

    Theodosopoulos PVAbosch AMcDermott MW: Intraoperative fiber-optic endoscopy for ventricular catheter insertion. Can J Neurol Sci 28:56602001

    • Search Google Scholar
    • Export Citation
  • 16

    Tuli SO'Hayon BDrake JClarke MKestle J: Change in ventricular size and effect of ventricular catheter placement in pediatric patients with shunted hydrocephalus. Neurosurgery 45:132913351999

    • Search Google Scholar
    • Export Citation
  • 17

    Wan KRToy JAWolfe RDanks A: Factors affecting the accuracy of ventricular catheter placement. J Clin Neurosci 18:4854882011

  • 18

    Whitehead WEJea AVachhrajani SKulkarni ADrake JM: Accurate placement of cerebrospinal fluid shunt ventricular catheters with real-time ultrasound guidance in older children without patent fontanelles. Technical note. J Neurosurg 107:5 Suppl4064102007

    • Search Google Scholar
    • Export Citation
TrendMD
Cited By
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 306 187 17
Full Text Views 161 30 5
PDF Downloads 138 27 6
EPUB Downloads 0 0 0
PubMed
Google Scholar