Arq Neuropsiquiat r 2002;60(4):932-934
THIRD VENTRICULOSTOM Y THROUGH THE LAM INA
TERM INALIS FOR INTRACRANIAL PRESSURE
M ONITORING AFTER ANEURYSM SURGERY
Technical not e
Jorge L. Kraemer
1, Pedro L. Gobbat o
2, Yuri M . Andrade-Souza
3ABSTRACT - Objective: A new vent riculost omy t echnique t hrough t he lamina t erminalis is described. This t echnique is applied mainly during aneurysm surgery at t he acut e st age. Method: Thirt een pat ient s w ere operat ed on int racranial aneurysms and, during t he procedure, had t he lamina t erminalis fenest rat ed. A vent ricular cat het er w as insert ed int o t he t hird vent ricule, left in place and connect ed t o an ext ernal drainage syst em for furt her int racranial pressure (ICP) monit oring and/or cerebrospinal fluid (CSF) drainage. Results: ICP readings and CSF drainage w ere obt ained in all cases. No complicat ion w as recorded. Conclusion: Third vent riculost omy t hrough t he lamina t erminalis is a simple and easy t echnique t hat can be used as an alt ernat ive t o convent ional vent riculost omy. This procedure can be indicat ed in cases w here t he vent ricule is not reached by means of anot her t echnique, and w hen t he decision t o perform vent riculost omy is made at t he end of aneurysm surgery.
KEY WORDS: cerebral aneurysm, ventricular drainage, third ventricle, intracranial pressure, operative technique.
Terceiroventriculostomia via lamina terminalis para monitorização de pressão intracraniana após cirurgia
de aneurisma: nota técnica
RESUM O - Objetivo: Uma nova técnica de ventriculostomia através da lamina terminalis é descrita para utilização durant e cirurgia de aneurisma na fase aguda. Método: Treze pacient es foram operados de aneurisma cerebral e, durant e o procediment o, t iveram a lamina terminalis fenest rada. Um cat ét er vent ricular foi inserido no terceiro ventrículo e conectado a um sistema de drenagem externa para monitorização da pressão intracraniana (PIC) e/ou drenagem de líquor (LCR). Resultados: A leit ura da PIC e a drenagem do LCR foram obt idas em t odos os casos. Não se evidenciaram complicações. Conclusão: A t erceirovent riculost omia at ravés da lamina t erminalis é uma t écnica simples e f ácil, que pode ser usada como uma alt ernat iva à vent riculost omia convencional. Esse procediment o pode ser indicado em casos em que as t écnicas convencionais falham, ou quando a decisão de realizar a vent riculost omia é t omada ao final da cirurgia de aneurisma.
PALAVRAS-CHAVE: aneurisma cerebral, drenagem ventricular, terceiro ventrículo, pressão intracraniana, técnica operat ória.
Hospit al São José, Irmandade da Sant a Casa de M isericórdia de Port o Alegre, Port o Alegre RS, Brasil: 1Dout or em Neurocirurgia, 2M édico
Neurocirurgião, 3M édico Resident e em Neurocirurgia.
Received 18 M arch 2002, received in final form 20 June 2002. Accept ed 9 July 2002.
Dr. Jo r g e Lu i z Kr aem er - Ru a Pad r e Ch ag as 4 1 5 / 7 0 2 - 9 0 5 7 0 -0 8 0 Po r t o A l eg r e RS - Br asi l . FA X: 5 5 5 1 3 3 3 3 -2 0 7 6 . E-mail: jkraemer@doct or.com
Early surgery for t reat ment of rupt ured int racra-nial aneurysms is w ell established1,2. Intracranial
pres-sure (ICP), monit oring, by means of a vent riculos-t omy, may improve riculos-t he ouriculos-t come as iriculos-t decreases riculos-t he incidence of ischaem ic com plicat ions and hydro-cephalus3-5. How ever, ventricular puncture in patients
w it h acut e Subarachinoide Hem orrhage (SAH) is neit her at raumat ic6 nor easy t o be performed.
Fur-t hermore, opening Fur-t he lamina Fur-t erminalis influences a b et t er o u t co m e i n p at i en t s w i t h r u p t u r ed int racranial aneurysms7,8.
Arq Neuropsiquiat r 2002;60(4) 933
M ETHOD
Thirt een consecut ive pat ient s harboring int racranial aneurysms w ere operat ed on in t he acut e st age of SAH.
A pt erional approach w as performed in all cases and t he cist erns opened w idely. Aft er having clipped t he aneu-rysm, a fenest rat ion of t he lamina t erminalis w as perfor-med by using bipolar forceps. A ventricular catheter (Radio-paque silicone vent ricular cat het er. Codman Ext ernal Drai-nage Syst em II, Johnson & Johnson Professional, Raynham, M A, USA) w as insert ed int o t he t hird vent ricle for approxi-mat ely 20 mm (t he fenest rat ed t ip of t he cat het er w as insert ed) (Fig 1). The vent ricular cat het er w as t hen con-nect ed t o t he ext ernal drainage syst em.
The drainage w as accomplished cont inuously keeping t he drip chamber at 20 cm height . ICP w as measured every hour and recorded. Vent riculost omy w as removed t he day aft er ICP had st abilized.
RESULTS
The result s are summarized on Table 1. There w as no com plicat ion t hat could be at t ribut ed t o t he vent riculost omy.
DISCUSSION
In pat ient s w it h SAH, vent riculost omy is useful for 1) ICP monit oring; 2) cerebrospinal fluid (CSF) drainage and 3) m anaging hydrocephalus2,3,5,9-11.
Alt hough t he risk of aneurysmal rebleeding increa-ses4, it is out w eighed by t he benefit s5.
The most popular technique of ventriculostomy is to perform catheterization of the frontal horn of the lateral ventricle through an ipsilateral frontal drill ho-le12, at the operating theatre or bedside13. Although
Table 1. Result s.
Case Gender Age HH Sit e ICP(mean) Time GOS
(years) mmHg (days)
1 f 23 2 A1 6.8 5 5
2 f 48 1 ACoA 6.7 3 5
3 f 51 1 PCoA 6.5 6 4
4 f 42 1 PCoA 2.7 3 5
5 f 47 2 M 2 5.6 4 4
6 f 51 1 ACoA/M 2 1.9 4 4
7 f 31 1 ACoA 1.6 2 5
8 f 65 3 ACoA 4.0 6 3
9 m 37 1 ACoA 5.5 5 5
10 f 71 1 M 1 8.4 4 4
11 f 57 2 ACoA 12.6 4 5
12 f 44 2 basilar t ip 6.5 5 2
13 f 41 1 ACoA/PCoA/M 2/M 3 9.1 5 4
HH, Hunt &Hess; ICP, int racranial pressure; GOS, Glasgow Out com e Scale; A1, ant erior cerebral art ery; ACoA, ant erior communicat ing art ery; PCoA, post erior communicat ing art ery; M 1,M 2,M 3, middle cerebral art ery; m, male; f, female.
934 Arq Neuropsiquiat r 2002;60(4)
this is generally considered a straightforward procedure, it may add time and trauma to aneurysm surgery6.
Alt ernat ively, Paine et al.14 described an int
raope-rat ive vent ricular punct ure. This approach is very use-ful in most cases but t he vent ricle is not alw ays rea-ched t hrough t he first pass.
Lamina t erminalis fenest rat ion is indicat ed as an adjunct t o aneurysm repair7,8 and has been a rout ine
procedure in our clinic in t he last years w it hout not iceable complicat ion. Previous experience w it h a shunt syst em using t he t hird vent ricle15 proved t hat
cat het erizat ion is w ell t olerat ed. In t he present st udy, w e describe a simple w ay t o get a reliable vent ricu-lost omy for CSF drainage and ICP monit oring. The cat het er placement is done under direct vision t o ascert ain t hat t he w hole fenest rat ed cat het er t ip is act ually in t he vent ricle. Bot h ICP readings and pres-sure curve are ext remely sensit ive, and CSF drainage is very easy. Due t o simult aneous CSF drainage, t he pressure values recorded in our cases may be low er t h an t h e act u al o n es16, b u t t h is f act d o es n o t
undermine t he efficacy of t he procedure. The midline vent ricular posit ion of t he cat het er w arrant s t he best ICP reference (Fig 2). The disadvantage of the method is t hat t he surgeon has t o dissect t he cist erns before
Fig 2. Postoperative CT scan showing catheter placed in the third ventricle.
he or she obt ains CSF vent ricular drainage. Alt hough t his procedure is sim ple and saf e, it needs m ore clinical experience; yet , it may become an alt ernat ive t o vent ricular diversion during an aneurysm surgery.
CONCLUSIONS
Third vent riculost om y t hrough t he lam ina t er-minalis is a simple and easy t echnique for t he skilled neurosurgeon. Preliminary experience suggest s t hat it can be used as an alt ernat ive t o convent ional vent riculost omy. This procedure can be indicat ed in cases w hich t he vent ricle is not reached by means of anot her t echnique, and t he decision t o perf orm vent riculost om y is m ade at t he end of aneurysm surgery. No complicat ions direct ly at t ribut able t o t his approach w ere observed in our cases. How ever, it deserves furt her st udy.
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