External landmarks should be adapted from patient to patient to improve EVD placement accuracy
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External ventricular drain (EVD) placement is mandatory for several pathologies. The misplacement rate of the EVD varies widely in literature, ranging from 12.3 to 60%. The purpose of this simulation study is to provide preliminary data about the possibility of increasing the safety of one of the most common life-saving procedures in neurosurgery by testing a new device for EVD placement.We used a novel guide for positioning the ventricular catheter (patent RM2014A000376). The trajectory was assessed using 25 anonymized head CT scans. The data sets were used to conduct three-dimensional computer-based and combined navigation and augmented reality-based simulations using plaster models. The data set inclusion criteria were volumetric head CT scan, without midline shift, of patients older than 18. Evans' index was used to quantify the ventricle's size. We excluded patients with slit ventricles, midline shift, skull fractures, or complex skull malformations. The proximal end of the device was tested on the cadaver.The cadaveric tests proved that a surgeon could use the device without any external help. The multimodal simulation showed Kakarla grade 1 in all cases but one (grade 2) on both sides, after right and left EVD placement. The mean Evans' index was 0.28. The geometric principles that explain the device's efficacy can be summarized by studying the properties of circumference and chord. The contact occurs, for each section considered, at the extreme points of the chord. Its axis, perpendicular to the plane tangent to the spherical surface at the entry point, corresponds to the direction of entry of the catheter guided by the instrument.According to our multimodal simulation on cadavers, 3D computer-based simulation, 3D plaster modeling, 3D neuronavigation, and augmented reality, the device promises to offer safer and effective EVD placement. Further validation in future clinical studies is recommended.
External ventricular drain
Cadaveric spasm
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Abstract Background Currently, the trajectory for insertion of an external ventricular drain (EVD) is mainly determined using anatomical landmarks. However, non-assisted implantations frequently require multiple attempts and are associated with EVD malpositioning and complications. The authors evaluated the feasibility and accuracy of a novel smartphone-guided, angle-adjusted technique for assisted implantations of an EVD (sEVD) in both a human artificial head model and a cadaveric head. Methods After computed tomography (CT), optimal insertion angles and lengths of intracranial trajectories of the EVDs were determined. A smartphone was calibrated to the mid-cranial sagittal line. Twenty EVDs were placed using both the premeasured data and smartphone-adjusted insertion angles, targeting the center of the ipsilateral ventricular frontal horn. The EVD positions were verified with post-interventional CT. Results All 20 sEVDs (head model, 8/20; cadaveric head, 12/20) showed accurate placement in the ipsilateral ventricle. The sEVD tip locations showed a mean target deviation of 1.73° corresponding to 12 mm in the plastic head model, and 3.45° corresponding to 33 mm in the cadaveric head. The mean duration of preoperative measurements on CT data was 3 min, whereas sterile packing, smartphone calibration, drilling, and implantation required 9 min on average. Conclusions By implementation of an innovative navigation technique, a conventional smartphone was used as a protractor for the insertion of EVDs. Our ex vivo data suggest that smartphone-guided EVD placement offers a precise, rapidly applicable, and patient-individualized freehand technique based on a standard procedure with a simple, cheap, and widely available multifunctional device.
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External ventricular drain
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A ventriculostomy is often performed to relieve symptoms of emergent hydrocephalus. This involves the placement of an external ventricular drain (EVD) into the cerebral ventricles to remove excess cerebrospinal fluid. Free-handed EVD cannulation results in high rates of misplacement (~50%), leading to an increased risk of iatrogenic complications. Extant technical approaches to improve ventriculostomy guidance are either too complex or inaccurate. We have investigated the possibility of a novel device to guide EVD placement using transcranial ultrasound. The device uses three specifically aligned transducers delivering pulse-echo 0.5-MHz ultrasound through the skull bone to detect and localize the targeted ventricle. It also incorporates a cannula guide that is registered with the ultrasound FOV to integrate guidance with surgery. Results from the design, fabrication, and testing of the prototype device with ex vivo human skulls and brain phantoms will be presented.
Ventriculostomy
Transcranial Doppler
External ventricular drain
Echoencephalography
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Neuronavigation
External ventricular drain
Foramen
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Despite the widespread use of external ventricular drainage, revision rates, and associated complications are reported between 10 and 40%. Current available image-guided techniques using stereotaxy, endoscopy, or ultrasound for catheter placements remain time-consuming techniques. Also, brain targeting procedures in emergency setting are challenging. The development of an easy-to-use, portable, image-guided system could reduce the need for multiple passes and improve the rate of accurate catheter placement and other brain targeting interventions in emergency setting. This study aims to design a novel smartphone assisted device for external ventricular drainage (EVD) placement and neuronavigation.In this study, authors have designed a novel 3D system composed of 3D software based on Android operating system and 3D design of a device in Autodesk 3D max using simple cranial measurements by DICOM PACS software for data input from Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). We plan to utilize this software as a guide and as a replacement for far more advanced neuronavigation systems. We have designed and launched the pilot version of this software and tested and compared it by DICOM PACS and also in an artificial skull for accuracy assessment. Our evaluation confirmed high accuracy performance of this smartphone application compared with DICOM PACS software for initial surgical approach to candidates for EVD placement or other emergency setting procedures which require neurotargeting interventions. Also, our neurotargeting device's accuracy was tested using provided angles by the application, which results in acceptable performance.This smartphone application coupled with targeting device can be used in various settings such as EVD placement in hydrocephalus and in other brain targeting candidates in emergency settings. Also, it may be used in any emergency or neurosurgery department centers with no access to advanced neuro-imaging facilities, only using patient's simple cranial measures to achieve acceptable and highly accurate brain targeting compared with conventional, time consuming and costly techniques. We plan to expand this study to clinical trials for further evaluation.
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Neuronavigation
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Abstract BACKGROUND External ventricular drain (EVD) placement is one of the most commonly performed procedures in neurosurgery, frequently by the junior neurosurgery resident. Simulators for EVD placement are often costly, time-intensive to create, and complicated to set up. OBJECTIVE To describe creation of a simulator that is inexpensive, time-efficient, and simple to set up. METHODS This simulator involves printing a hollow head using a desktop 3-dimensional (3D) printer. This head is registered to a commercially available image-guidance system. A total of 11 participants volunteered for this simulation module. EVD placement was assessed at baseline, after verbal teaching, and after live 3D view instruction. RESULTS Accurate placement of an EVD on the right side at the foramen of Monro or the frontal horn of the lateral ventricle increased from 44% to 98% with training. Similarly, accurate placement on the left increased from 42% to 85% with training. CONCLUSION During participation in the simulation, accurate placement of EVDs increased significantly. All participants believed that they had a better understanding of ventricular anatomy and that this module would be useful as a teaching tool for neurosurgery interns.
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Ventriculostomy
Foramen
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External ventricular drain
Foramen
Neuronavigation
Interventional radiology
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The freehand technique for insertion of an external ventricular drain (EVD) is based on fixed anatomical landmarks and does not take individual variations into consideration. A patient-tailored approach based on augmented-reality techniques using devices such as smartphones can address this shortcoming. The Sina neurosurgical assist (Sina) is an Android mobile device application (app) that was designed and developed to be used as a simple intraoperative neurosurgical planning aid. It overlaps the patient's images from previously performed CT or MRI studies on the image seen through the device camera. The device is held by an assistant who aligns the images and provides information about the relative position of the target and EVD to the surgeon who is performing EVD insertion. This app can be used to provide guidance and continuous monitoring during EVD placement. The author describes the technique of Sina-assisted EVD insertion into the frontal horn of the lateral ventricle and reports on its clinical application in 5 cases as well as the results of ex vivo studies of ease of use and precision. The technique has potential for further development and use with other augmented-reality devices.
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The goal of this study was to explore the feasibility and accuracy of using a wearable mixed-reality holographic computer to guide external ventricular drain (EVD) insertion and thus improve on the accuracy of the classic freehand insertion method for EVD insertion. The authors also sought to provide a clinically applicable workflow demonstration.
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