title: The relative efficacy of 3 different freehand frontal ventriculostomy trajectories: a prospective neuronavigation-assisted simulation study.
abstract: OBJECTIVE Ventriculostomy is a relatively common neurosurgical procedure, often performed in the setting of acute hydrocephalus. Accurate positioning of the catheter is vital to minimize morbidity and mortality, and several anatomical landmarks are currently used. The aim of this study was to prospectively evaluate the relative performance of 3 recognized trajectories for frontal ventriculostomy using imaging-derived metrics: perpendicular to skull (PTS), contralateral medial canthus/external auditory meatus (CMC/EAM), and ipsilateral medial canthus/external auditory meatus (IMC/EAM). METHODS Participants completed 9 simulated ventriculostomy attempts (3 of each trajectory) on a model head with Medtronic StealthStation coregistered imaging. Performance measures were distance of the ventricular catheter tip to the foramen of Monro (FoM) and presence of the catheter tip in a lateral ventricle. RESULTS Thirty-one individuals of varying seniority and prior ventriculostomy experience performed a total of 279 simulated freehand frontal ventriculostomies. The PTS and CMC/EAM trajectories were found to be significantly more likely to result in both the catheter tip being closer to the FoM and in a lateral ventricle compared with the IMC/EAM trajectory. These findings were not influenced by the prior ventriculostomy experience of the participant, corroborating the significance of these results. CONCLUSIONS The PTS and CMC/EAM trajectories were superior to the IMC/EAM trajectories during freehand frontal ventriculostomy in this study, and further data from studies incorporating varying ventricular sizes and bur hole locations are required to facilitate a change in clinical practice. In addition, neuronavigation and other guidance techniques for ventriculostomy are becoming increasingly popular and may be superior to freehand techniques, necessitating further prospective data evaluating their safety, efficacy, and feasibility for routine clinical use.
authors.affiliation: Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London.|Department of Surgery and Cancer, Imperial College London, St Mary's Campus, London; and.
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Kirkman
authors.affiliation: Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London.
authors.forename: William
authors.initials: W
authors.lastname: Muirhead
authors.affiliation: Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom.
authors.forename: Nick
authors.initials: N
authors.lastname: Sevdalis
mesh_terms: D002983:Clinical Competence; D003198:Computer Simulation; D005260:Female; D006801:Humans; D008297:Male; D008953:Models, Anatomic; D038361:Neuronavigation; D011361:Professional Competence; D011446:Prospective Studies; D016896:Treatment Outcome; D014696:Ventriculostomy / Q000295:instrumentation / Q000379:methods*
keywords: CMC = contralateral medial canthus; EAM = external auditory meatus; EVD = external ventricular drain; FoM = foramen of Monro; IMC = ipsilateral medial canthus; PTS = perpendicular to skull; external ventricular drain; hydrocephalus; neurosurgical simulation; surgical technique; trajectory; ventriculostomy