Shtaya Anan, Roach Joy, Sadek Ahmed-Ramadan, Gaastra Benjamin, Hempenstall Jonathan, Bulters Diederik
1Wessex Neurological Centre, University Hospital Southampton, Southampton; and.
2Neurosciences Research Centre, St. George's, University of London, United Kingdom.
J Neurosurg. 2018 May 11;130(4):1268-1273. doi: 10.3171/2017.11.JNS171892. Print 2019 Apr 1.
External ventricular drain (EVD) insertion is one of the most common emergency neurosurgical procedures. EVDs are traditionally inserted freehand (FH) in an emergency setting, but often result in suboptimal positioning. Image-guided surgery (IGS) is selectively used to assist placement. However, the accuracy and practicality of IGS use is yet to be reported. In this study, the authors set out to assess if IGS is practical and improves the accuracy of EVD placement.
Case notes and images obtained in patients who underwent frontal EVD placement were retrospectively reviewed. Ventriculomegaly was determined by the measurement of the Evans index. EVD location was classified as optimal (ipsilateral frontal horn) or suboptimal (any other location). Propensity score matching of the two groups (IGS vs FH) for the Evans index was performed. Data were analyzed for patient age, diagnosis, number of EVDs, and complications. Those without postoperative CT scans were excluded.
A total of 607 patients with 760 EVDs placed were identified; 331 met inclusion criteria. Of these, 287 were inserted FH, and 44 were placed with IGS; 60.6% of all unmatched FH EVDs were optimal compared with 75% of the IGS group (p = 0.067). The IGS group had a significantly smaller Evans index (p < 0.0001). Propensity score matching demonstrated improved optimal position in the IGS group when compared with the matched FH group (75% vs 43.2%, OR 4.6 [1.5-14.6]; p = 0.002). Patients with an Evans index of ≥ 0.36 derived less benefit (75% in IGS vs 66% in FH, p = 0.5), and those with an Evans index < 0.36 derived more benefit (75% in IGS vs 53% in FH, p = 0.024). The overall EVD complication rate was 36% in the FH group versus 18% in the IGS group (p = 0.056). Revision rates were higher in the FH group (p = 0.035), and the operative times were similar (p = 0.69). Long intracranial EVD catheters were associated with tip malposition irrespective of the group.
Image guidance is practical and improves the accuracy of EVD placement in patients with small ventricles; thus, it should be considered for these patients.
脑室外引流（EVD）置入是最常见的神经外科急诊手术之一。传统上，在急诊情况下EVD是徒手置入的，但常常导致定位欠佳。影像引导手术（IGS）被选择性地用于辅助放置。然而，IGS使用的准确性和实用性尚未见报道。在本研究中，作者旨在评估IGS是否实用以及能否提高EVD放置的准确性。
回顾性分析接受额部EVD置入患者的病历和影像资料。通过测量Evans指数来确定脑室扩大情况。EVD位置分为最佳位置（同侧额角）或欠佳位置（其他任何位置）。对两组（IGS组与徒手组）的Evans指数进行倾向评分匹配。分析患者年龄、诊断、EVD数量及并发症等数据。排除未进行术后CT扫描的患者。
共确定607例患者置入760根EVD；331例符合纳入标准。其中，287根为徒手置入，44根为IGS辅助置入；所有未匹配的徒手置入EVD中60.6%位置最佳，而IGS组为75%（p = 0.067）。IGS组的Evans指数显著更小（p < 0.0001）。倾向评分匹配显示，与匹配的徒手组相比，IGS组最佳位置有所改善（75% 对 43.2%，OR 4.6 [1.5 - 14.6]；p = 0.002）。Evans指数≥0.36的患者获益较少（IGS组为75%，徒手组为66%，p = 0.5），而Evans指数< 0.36的患者获益更多（IGS组为75%，徒手组为53%，p = 0.024）。徒手组的总体EVD并发症发生率为36%，而IGS组为18%（p = 0.056）。徒手组的翻修率更高（p = 0.035），手术时间相似（p = 0.69）。无论哪组，长颅内EVD导管均与尖端位置不当有关。
影像引导是实用的，可提高小脑室患者EVD放置的准确性；因此，对于这些患者应考虑采用。
