脑室体外引流术穿刺精确度的探讨
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摘要
目的：本文回顾性分析了患者脑室体外引流术(external ventricular drainaage, EVD)后CT(computerized tomography),在三维重建(three-dimensional Reconstruction,3D Reconstruction)模式下测量了颅骨钻孔位置,引流管穿刺长度,引流管尖端位置,分析其与理论位置的数值偏差,进而探讨影响EVD穿刺精确度的因素,寻找有效的改进措施以提高手术精准度及成功率。
方法：本文对齐鲁医院自2011年9月至2013年1月59位患者行73例次EVD(45位患者行右侧脑室额角穿刺,14位行双侧侧脑室额角穿刺)术后CT进行回顾性分析。在三维成像CT下,测量颅骨钻孔位置：测量骨窗中心在矢状面中距冠状缝,在冠状面中距矢状缝之间的距离；引流管的长度：引流管尖端距骨孔中心的距离；引流管尖端位置：位于同侧侧脑室额角、同侧及对侧侧脑室体、第三脑室、对侧侧脑室额角、脑室外腔隙、脑实质中,以及实际穿刺方向与理论方向在冠状面、矢状面的角度偏差。
结果：骨孔距冠状缝平均距离24mm (19mm-27mm),距矢状缝平均距离25mm(16mm-34mm)。在三维成像CT中,测得脑室体外引流管尖端至骨孔中心平均距离63mm(45mm-101mm),巨离在50-70mm范围内的有54例(74%)。在73例EVD病例中,引流管尖端位于同侧侧脑室额角(最理想部位)有26例(35.6%),同侧及对侧侧脑室体有15例(20.5%),第三脑室有11例(15.1%),对侧侧脑室额角有6例(8.2%),脑室外腔隙有10例(13.7%),脑实质中有5例(6.8%)。角度偏差在±5。内：矢状面29例(39.7%),冠状面31例(42.5%),在冠状面及矢状面中角度偏差均在±5。内的有20例(27.4%)。按Kakarla et al.提出的标准进行划分,仅有58例(79.5%)认为是有作用的。
结论：由于传统的EVD手术中无引导装置,凭借医生的临床经验徒手进行穿刺,造成穿刺误差的概率较高,所以研究表明EVD穿刺术仍需进一步改进且需要有效的引导装置进行指导,从而提高手术精准度及成功率。
Objective This study retrospectively analyzed the head computerized tomography(CT) from the patients who were performed external ventricular drain (EVD). Under three-dimensional (3D) model measurements were made to calculate position of the burr hole, length and position of the catheter and its sagittal and coronal angular variations. The deviation with the theoretical position was analyzed. It also discussed the factors influence the accuracy of EVD and improvement measures so that we could find the effective measures which could improve the accuracy and success of operation.
Methods Retrospective evaluation was performed on the head computed tomography (CT) scans of59patients who underwent73freehand EVDs (45patients were underwent in the right of heads,14patients were underwent in the both). Under three-dimensional model measurements were made to calculate position of the burr hole, length and position of the catheter and the sagittal and coronal angular variations.
Results Under3D model the mean distance from the catheter tip to the Monro foramen was60mm (47mm-69mm) and the distance of54cases (74%) was between5cm to7cm. The mean distance from burr hole to coronal suture was24mm (19mm-27mm), while to midline was25mm (16mm-34mm), and the intracranial catheter length was63mm (45mm-101mm)。Regarding accurate catheter tip placement, the catheter tips of26cases (35.6%) were in the ipsilateral lateral ventricle (target place),15cases (20.5%) were in lateral ventricle body,11cases (15.1%) were in the third ventricle,11cases (8.2%) were in the contralateral ventricle,10cases(13.7%) were within the inter hemispheric fissure, and5cases(6.8%) were in the interhemis pheric fissure.29cases(39.7%) of the EVDs were in the sagittal plane and31cases (42.5%) were in the coronal plane with an angular variation of±5°to the target and20cases (27.4%) were in the both planes with an angular variation of±5°the target. On the standard which was reported by Kakarla et al., this study shows that only79.5%was considered as functional,35.6%was in the target place。
Conclusion Because of the traditional EVD was usually performed without any guidance and only by surgery's experience, the deviations were made easily. So there was certainly much room for improving the EVD operation and the operation need effective guidance so that improve the accuracy and success.
方法：本文对齐鲁医院自2011年9月至2013年1月59位患者行73例次EVD(45位患者行右侧脑室额角穿刺,14位行双侧侧脑室额角穿刺)术后CT进行回顾性分析。在三维成像CT下,测量颅骨钻孔位置：测量骨窗中心在矢状面中距冠状缝,在冠状面中距矢状缝之间的距离；引流管的长度：引流管尖端距骨孔中心的距离；引流管尖端位置：位于同侧侧脑室额角、同侧及对侧侧脑室体、第三脑室、对侧侧脑室额角、脑室外腔隙、脑实质中,以及实际穿刺方向与理论方向在冠状面、矢状面的角度偏差。
结果：骨孔距冠状缝平均距离24mm (19mm-27mm),距矢状缝平均距离25mm(16mm-34mm)。在三维成像CT中,测得脑室体外引流管尖端至骨孔中心平均距离63mm(45mm-101mm),巨离在50-70mm范围内的有54例(74%)。在73例EVD病例中,引流管尖端位于同侧侧脑室额角(最理想部位)有26例(35.6%),同侧及对侧侧脑室体有15例(20.5%),第三脑室有11例(15.1%),对侧侧脑室额角有6例(8.2%),脑室外腔隙有10例(13.7%),脑实质中有5例(6.8%)。角度偏差在±5。内：矢状面29例(39.7%),冠状面31例(42.5%),在冠状面及矢状面中角度偏差均在±5。内的有20例(27.4%)。按Kakarla et al.提出的标准进行划分,仅有58例(79.5%)认为是有作用的。
结论：由于传统的EVD手术中无引导装置,凭借医生的临床经验徒手进行穿刺,造成穿刺误差的概率较高,所以研究表明EVD穿刺术仍需进一步改进且需要有效的引导装置进行指导,从而提高手术精准度及成功率。
Objective This study retrospectively analyzed the head computerized tomography(CT) from the patients who were performed external ventricular drain (EVD). Under three-dimensional (3D) model measurements were made to calculate position of the burr hole, length and position of the catheter and its sagittal and coronal angular variations. The deviation with the theoretical position was analyzed. It also discussed the factors influence the accuracy of EVD and improvement measures so that we could find the effective measures which could improve the accuracy and success of operation.
Methods Retrospective evaluation was performed on the head computed tomography (CT) scans of59patients who underwent73freehand EVDs (45patients were underwent in the right of heads,14patients were underwent in the both). Under three-dimensional model measurements were made to calculate position of the burr hole, length and position of the catheter and the sagittal and coronal angular variations.
Results Under3D model the mean distance from the catheter tip to the Monro foramen was60mm (47mm-69mm) and the distance of54cases (74%) was between5cm to7cm. The mean distance from burr hole to coronal suture was24mm (19mm-27mm), while to midline was25mm (16mm-34mm), and the intracranial catheter length was63mm (45mm-101mm)。Regarding accurate catheter tip placement, the catheter tips of26cases (35.6%) were in the ipsilateral lateral ventricle (target place),15cases (20.5%) were in lateral ventricle body,11cases (15.1%) were in the third ventricle,11cases (8.2%) were in the contralateral ventricle,10cases(13.7%) were within the inter hemispheric fissure, and5cases(6.8%) were in the interhemis pheric fissure.29cases(39.7%) of the EVDs were in the sagittal plane and31cases (42.5%) were in the coronal plane with an angular variation of±5°to the target and20cases (27.4%) were in the both planes with an angular variation of±5°the target. On the standard which was reported by Kakarla et al., this study shows that only79.5%was considered as functional,35.6%was in the target place。
Conclusion Because of the traditional EVD was usually performed without any guidance and only by surgery's experience, the deviations were made easily. So there was certainly much room for improving the EVD operation and the operation need effective guidance so that improve the accuracy and success.
引文
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3. Greenburg MS:Operations and procedures, in Handbook of Neurosurgery. New York, Thieme,2006, p 620.
4. Mapstone TB, Ratcheson RA:Techniques of ventricular puncture, in Wilkins RH, Rengachary SS (eds):Neurosurgery. New York, McGraw-Hill, Inc.,1996, vol 1, pp 179-184.
5. Dunn IF, Fierichs K, Day A, Kim DH (2006) Ventriculostomy. In:Schmidek HH, Robert DW (eds) Schmidek and Sweet, Operative neurosurgical techniques: indications, methods, and results,5th edn. Saunders, Philadelphia, pp 35-36
6. Mohammad Ghazi Abdoh, Olivier Bekaert:Accuracy of external ventricular drainage catheter placement, Acta Neurochir 154:153-159,2012.
7. DAVID R. HUYETTE, M.D.,BENJAMIN J.TURNBOW:Accuracy of the freehand pass technique for ventriculostomycatheter placement:retrospective assessment usingcomputed tomography scans,J Neurosurg 108:88-91,2008.
8. Young-Gil Park, M.D.,1 Hyun-Jin Woo:Accuracy and Safety of Bedside External Ventricular Drain Placement at Two Different Cranial Sites:Kochers Point versus Forehead,J Korean Neurosurg Soc 50:317-321,2011.
9.王强：侧脑室额角穿刺方向的探讨,J Postgrad Med, November 2005, Vol 28, No.11B.
10. Ahmed K. Toma, F.R.C.S.,(N.S.):external ventricular drain insertion accuracy:is there a need for change in practice,Neurosurgery 65:1197-1201,2009
11. Jamshid BG, Ghajar MD:A guide for ventricular catheter placement. J Neurosurg 63:985-986,1985.
12. Udaya K. Kakarla,Louis J. Kim,Steven W. Chang:safety and accuracy of bedside external ventricular drain placement,Neurosurgery 63[ONS Suppl 1]:ONS 164-ONS169,2008
13. Krotz M, Linsenmaier U. Kanz KG, Pfeifer KJ, Mutschler W. Reiser M:Evaluation of minimally invasive percutaneous CT-controlled ventriculostomy in patients with severe head trauma. Eur Radiol 14:227-233,2004.
14.王满,胡亚兰,王捷：侧脑室额角穿刺方法改进介绍,中华全科医学,9A期,2009,12.
15. Anderson RC, Kan P, Klimo P, Brockmeyer DL,Walker ML, Kestle JR (2004) Complications of intracranial pressure monitoring in children with head trauma. J Neurosurg 101:53-58
16. Bogdahn U, Lau W, Hassel W, Gunreben G, Mertens HG, Brawanski A (1992) Continuous-pressure controlled external ventricular drainage for treatment of acute hydrocephalus:evaluation of risk factors. Neurosurgery 31:898-904
17. Scheithauer S. Burgel U. Ryang Y-M. Koch S. Schiefer J. Hafner H, Haase G. Lemmen S (2009) Prospective surveillance of drainassociated meningitis/ventriculitis in a neurosurgery and a neurologic intensive care unit. J Neurol Neurosurg Psychiatry
18. Daniel D. Binz L. Gerard T. Jonathan A, Friedman (2009) Hemorrhagic complications of ventriculostomy placement:a meta-analysis. Neurocrit Care 10(2):253-256
19. Ehtisham A, Taylor S. Bayless L. Klein M, Janzen J (2009) Placement of external ventricular drains and intracranial pressure monitors by neurointensivists. Neurocrit Care 10(2):241-247
20. Huyette DR. Turnbow BJ, Kaufman C, Vaslow D, Whiting B.Michael Y (2008) Accuracy of the freehand pass technique for ventriculostomy catheter placement: retrospective assessment using computed tomography scans. J Neurosurg 108(1):88-91
21. Kakarla K, Chang W. Theodore N, Spetzler F, Kim J (2008) Safety and accuracy of bedside external ventricular drain placement. Neurosurgery 63(1 Suppl 1):ONS162-ONS167
22. Krotz M, Linsenmaier U. Kanz KG, Pfeifer KJ, Mutschler W.Reiser M (2004) Evaluation of minimally invasive percutaneous CT-controlled ventriculostomy in patients with severe head trauma. Eur Radiol 14:227-233
23. O'Leary ST, Kole MK,Hoover DA. Hysell SE,Thomas A, Shaffrey CI (2000) Efficacy of the Ghajar Guide revisited. J Neurosurg 92:801-803
24. Saladino A, Bradley W. Eelco F, Wijdicks M. Giuseppe L (2009) Malplacement of ventricular catheters by neurosurgeons. Neurocrit Care 10(2):155-156
25.程令刚,何文,李慧展：术中超声在脑外伤后脑室穿刺中的应用,中国介入影像与治疗学,2012年第9卷第12期Chin j interv imaging Ther,2012, Vol.9, No.12:859.
26.金鑫,陈娜,王洪等.侧脑室穿刺外引流在颅脑损伤术后大面积脑梗死中的应用.中国医药指南,2011,9(8)：95-96.
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2. Ghajar JB:A guide for ventricular catheter placement. Technical note. J Neurosurg 63:985-986,1985.
3. Greenburg MS:Operations and procedures, in Handbook of Neurosurgery. New York, Thieme,2006, p 620.
4. Mapstone TB, Ratcheson RA:Techniques of ventricular puncture, in Wilkins RH, Rengachary SS (eds):Neurosurgery. New York, McGraw-Hill, Inc.,1996, vol 1, pp 179-184.
5. Dunn IF, Fierichs K, Day A, Kim DH (2006) Ventriculostomy. In:Schmidek HH, Robert DW (eds) Schmidek and Sweet, Operative neurosurgical techniques: indications, methods, and results,5th edn. Saunders, Philadelphia, pp 35-36
6. Mohammad Ghazi Abdoh, Olivier Bekaert:Accuracy of external ventricular drainage catheter placement, Acta Neurochir 154:153-159,2012.
7. DAVID R. HUYETTE, M.D.,BENJAMIN J.TURNBOW:Accuracy of the freehand pass technique for ventriculostomycatheter placement:retrospective assessment usingcomputed tomography scans,J Neurosurg 108:88-91,2008.
8. Young-Gil Park, M.D.,1 Hyun-Jin Woo:Accuracy and Safety of Bedside External Ventricular Drain Placement at Two Different Cranial Sites:Kochers Point versus Forehead,J Korean Neurosurg Soc 50:317-321,2011.
9.王强：侧脑室额角穿刺方向的探讨,J Postgrad Med, November 2005, Vol 28, No.11B.
10. Ahmed K. Toma, F.R.C.S.,(N.S.):external ventricular drain insertion accuracy:is there a need for change in practice,Neurosurgery 65:1197-1201,2009
11. Jamshid BG, Ghajar MD:A guide for ventricular catheter placement. J Neurosurg 63:985-986,1985.
12. Udaya K. Kakarla,Louis J. Kim,Steven W. Chang:safety and accuracy of bedside external ventricular drain placement,Neurosurgery 63[ONS Suppl 1]:ONS 164-ONS169,2008
13. Krotz M, Linsenmaier U. Kanz KG, Pfeifer KJ, Mutschler W. Reiser M:Evaluation of minimally invasive percutaneous CT-controlled ventriculostomy in patients with severe head trauma. Eur Radiol 14:227-233,2004.
14.王满,胡亚兰,王捷：侧脑室额角穿刺方法改进介绍,中华全科医学,9A期,2009,12.
15. Anderson RC, Kan P, Klimo P, Brockmeyer DL,Walker ML, Kestle JR (2004) Complications of intracranial pressure monitoring in children with head trauma. J Neurosurg 101:53-58
16. Bogdahn U, Lau W, Hassel W, Gunreben G, Mertens HG, Brawanski A (1992) Continuous-pressure controlled external ventricular drainage for treatment of acute hydrocephalus:evaluation of risk factors. Neurosurgery 31:898-904
17. Scheithauer S. Burgel U. Ryang Y-M. Koch S. Schiefer J. Hafner H, Haase G. Lemmen S (2009) Prospective surveillance of drainassociated meningitis/ventriculitis in a neurosurgery and a neurologic intensive care unit. J Neurol Neurosurg Psychiatry
18. Daniel D. Binz L. Gerard T. Jonathan A, Friedman (2009) Hemorrhagic complications of ventriculostomy placement:a meta-analysis. Neurocrit Care 10(2):253-256
19. Ehtisham A, Taylor S. Bayless L. Klein M, Janzen J (2009) Placement of external ventricular drains and intracranial pressure monitors by neurointensivists. Neurocrit Care 10(2):241-247
20. Huyette DR. Turnbow BJ, Kaufman C, Vaslow D, Whiting B.Michael Y (2008) Accuracy of the freehand pass technique for ventriculostomy catheter placement: retrospective assessment using computed tomography scans. J Neurosurg 108(1):88-91
21. Kakarla K, Chang W. Theodore N, Spetzler F, Kim J (2008) Safety and accuracy of bedside external ventricular drain placement. Neurosurgery 63(1 Suppl 1):ONS162-ONS167
22. Krotz M, Linsenmaier U. Kanz KG, Pfeifer KJ, Mutschler W.Reiser M (2004) Evaluation of minimally invasive percutaneous CT-controlled ventriculostomy in patients with severe head trauma. Eur Radiol 14:227-233
23. O'Leary ST, Kole MK,Hoover DA. Hysell SE,Thomas A, Shaffrey CI (2000) Efficacy of the Ghajar Guide revisited. J Neurosurg 92:801-803
24. Saladino A, Bradley W. Eelco F, Wijdicks M. Giuseppe L (2009) Malplacement of ventricular catheters by neurosurgeons. Neurocrit Care 10(2):155-156
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26.金鑫,陈娜,王洪等.侧脑室穿刺外引流在颅脑损伤术后大面积脑梗死中的应用.中国医药指南,2011,9(8)：95-96.
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