Whitehead William E, Riva-Cambrin Jay, Wellons John C, Kulkarni Abhaya V, Browd Samuel, Limbrick David, Rozzelle Curtis, Tamber Mandeep S, Simon Tamara D, Shannon Chevis N, Holubkov Richard, Oakes W Jerry, Luerssen Thomas G, Walker Marion L, Drake James M, Kestle John R W
Texas Children's Hospital, Houston, Baylor College of Medicine, Houston, Texas;
J Neurosurg Pediatr. 2014 Aug;14(2):173-8. doi: 10.3171/2014.5.PEDS13481. Epub 2014 Jun 13.
Shunt survival may improve when ventricular catheters are placed into the frontal horn or trigone of the lateral ventricle. However, techniques for accurate catheter placement have not been developed. The authors recently reported a prospective study designed to test the accuracy of catheter placement with the assistance of intraoperative ultrasound, but the results were poor (accurate placement in 59%). A major reason for the poor accurate placement rate was catheter movement that occurred between the time of the intraoperative ultrasound image and the first postoperative scan (33% of cases). The control group of non-ultrasound using surgeons also had a low rate of accurate placement (accurate placement in 49%). The authors conducted an exploratory post hoc analysis of patients in their ultrasound study to identify factors associated with either catheter movement or poor catheter placement so that improved surgical techniques for catheter insertion could be developed.
The authors investigated the following risk factors for catheter movement and poor catheter placement: age, ventricular size, cortical mantle thickness, surgeon experience, surgeon experience with ultrasound prior to trial, shunt entry site, shunt hardware at entry site, ventricular catheter length, and use of an ultrasound probe guide for catheter insertion. Univariate analysis followed by multivariate logistic regression models were used to determine which factors were independent risk factors for either catheter movement or inaccurate catheter location.
In the univariate analyses, only age < 6 months was associated with catheter movement (p = 0.021); cortical mantle thickness < 1 cm was near-significant (p = 0.066). In a multivariate model, age remained significant after adjusting for cortical mantle thickness (OR 8.35, exact 95% CI 1.20-infinity). Univariate analyses of factors associated with inaccurate catheter placement showed that age < 6 months (p = 0.001) and a posterior shunt entry site (p = 0.021) were both associated with poor catheter placement. In a multivariate model, both age < 6 months and a posterior shunt entry site were independent risk factors for poor catheter placement (OR 4.54, 95% CI 1.80-11.42, and OR 2.59, 95% CI 1.14-5.89, respectively).
Catheter movement and inaccurate catheter placement are both more likely to occur in young patients (< 6 months). Inaccurate catheter placement is also more likely to occur in cases involving a posterior shunt entry site than those involving an anterior shunt entry site. Future clinical studies aimed at improving shunt placement techniques must consider the effects of young age and choice of entry site on catheter location.
将脑室导管置入侧脑室额角或三角区时，分流管的留存率可能会提高。然而，尚未开发出精确导管置入技术。作者最近报告了一项前瞻性研究，旨在测试术中超声辅助下导管置入的准确性，但结果不佳（准确置入率为59%）。准确置入率低的一个主要原因是术中超声图像采集时间与术后首次扫描时间之间发生了导管移动（33%的病例）。未使用超声的外科医生对照组的准确置入率也很低（准确置入率为49%）。作者对其超声研究中的患者进行了探索性的事后分析，以确定与导管移动或导管置入不佳相关的因素，从而开发出改进的导管插入手术技术。
作者调查了以下与导管移动和导管置入不佳相关的风险因素：年龄、脑室大小、皮质层厚度、外科医生经验、试验前外科医生使用超声的经验、分流管入口部位、入口部位的分流管硬件、脑室导管长度以及使用超声探头引导进行导管插入。采用单因素分析，随后进行多因素逻辑回归模型分析，以确定哪些因素是导管移动或导管位置不准确的独立危险因素。
在单因素分析中，仅年龄<6个月与导管移动相关（p = 0.021）；皮质层厚度<1 cm接近显著相关（p = 0.066）。在多因素模型中，调整皮质层厚度后，年龄仍然具有显著性（OR 8.35，确切95% CI 1.20-无穷大）。与导管置入不准确相关因素的单因素分析表明，年龄<6个月（p = 0.001）和分流管后位入口部位（p = 0.021）均与导管置入不佳相关。在多因素模型中，年龄<6个月和分流管后位入口部位均是导管置入不佳的独立危险因素（分别为OR 4.54，95% CI 1.80-11.42和OR 2.59，95% CI 1.14-5.89）。
导管移动和导管置入不准确在年轻患者（<6个月）中更易发生。与前位分流管入口部位相比，后位分流管入口部位的病例中导管置入不准确也更易发生。未来旨在改进分流管置入技术的临床研究必须考虑年轻年龄和入口部位选择对导管位置的影响。
