Novel technique for ventriculoperitoneal shunt placement using a neurointerventional biplanar fluoroscopy suite: a technical note

Abstract

Background: Shunt dependent hydrocephalus is an increasingly common pathology in contemporary neurosurgery. While effective, ventriculoperitoneal shunt systems (VPS) carry a high rate of failure, most commonly secondary to proximal catheter failure and inaccurate placement has been cited an independent predictor of revision surgery. In this technical note, we describe a novel method of VPS placement in a hybrid operating room equipped with biplanar fluoroscopy with 3D-fluoroscopy capabilities to ensure appropriate proximal and distal catheter placements intraoperatively. Methods: A 27-year-old male with Human Immunodeficiency Virus and recently placed left parietooccipital VPS for cryptococcal meningitis presented to our facility with global cerebral edema with slit like ventricles. A right frontal VPS with intraoperative imaging in our hybrid operating room equipped with a Philips Azurion biplane unit (Philips, Amsterdam, Netherlands) was planned. Results: A standard right frontal VPS was conducted under neuronavigation with open distal catheter placement. Following ventricular catheter insertion, spontaneous cerebrospinal fluid (CSF) return slowed significantly prompting concern for malposition. 3D-fluoro was performed using the biplane machine, confirming accurate placement of the proximal catheter about the foramen of Monroe. Plain static fluoroscopic images were then acquired to confirm the placement and integrity of the distal catheter. The patient had a non-complicated post-operative course and experienced total symptom resolution. Conclusions: Proximal and distal catheter shunt failure secondary to malposition remains a significant etiology for revision in contemporary image guided neurosurgery. Biplanar fluoroscopic intraoperative confirmation may provide an efficient and effective modality in CSF diversion. Continued experience is necessary to validate our report.

Keywords

• Hydrocephalus
• Ventriculoperitoneal shunt
• Stereotaxic techniques