侧脑室穿刺（Lateral ventricular puncture）

侧脑室穿刺（Lateral ventricular puncture） 侧脑室穿刺(Lateral ventricular puncture) Using CT and MRI technology are observed in the normal subjects and patients with ventricle puncture outfit that should point to the direction of the double ear canal midpoint, occipital horn puncture direction should point to the ipsilateral eyebrow and the inner end of the line between. Indications: 1. ventricular decompression for acute hydrocephalus (even at bedside); 2. intracranial pressure elevation: Drainage cerebrospinal fluid, intracranial pressure detection; Infection after 3. shunt: drainage of infected cerebrospinal fluid; 4. brain tissue relaxation: it is beneficial to the deep structure; 5. aneurysmal subarachnoid hemorrhage; however, excessive drainage of cerebrospinal fluid increases the risk of rebleeding by increasing the pressure of aneurysm expansion outward; Contraindication: 1. disorders such as coagulation disorders or thrombocytopenia: immediate delivery of fresh frozen plasma and platelets; There were vascular malformations and other parenchymal lesions at the 2. catheter pathway; 3. midline deviation; extra ventricular drainage leads to more severe brain deviation; Preoperative: Preoperative preparation: 1. re read the film (CT or MRI); 2. two hole position: one on the forehead (the most common on the right Kocher); another in the occipital (Frazier hole); right ventricular drainage can minimize the damage of the dominant hemisphere, except for patients with left cerebral hemorrhage; 3.Kocher point is at the intersection of two vertical lines: (1) in the latter part of the pupil line, (2) the upper part of the external auditory canal and lateral canthus point line; Note: (1) simple positioning: midline 3-4cm (along the middle pupil line), 1cm before coronal suture (if the coronal suture can be touched) (2) the advantage of Kocher point is that it is located before the cerebral cortex motor area, the incision is in the hairline of the forehead, and in the superior sagittal sinus and its large frontal vein bridge; 4. posterior horn puncture external ventricular drainage using Frazier hole: 6-7cm above the occipital protuberance, 3-4cm beside the midline; the hole is located on the herringbone suture 1cm, so that the catheter into the lateral ventricle body distance is the shortest; The final location of the 5. catheter depends on three geometric variables: the position of the catheter on the sagittal plane, the position on the horizontal or coronal plane, and the depth of the catheter inserted; Note: (1) for pediatric patients, the depth of catheter insertion can be estimated from CT; (2) for adult patients, the depth of catheter insertion (from the skull surface) generally does not exceed 6cm, and this depth can reach the cerebrospinal fluid. Anesthesia and antibiotics: 1.1%lidocaine 2. short term induction of anesthesia (midazolam or inhalation of propofol within the tube) 3. avoid muscle paralysis as much as possible, so that the effect of external ventricular drainage can be determined by physical examination 4. broad-spectrum antibiotics preoperative, intraoperative and postoperative routine use (oxacillin 2G q6h or 10mg/kg q6h, cefazolin) Apparatus: 1. standard external ventricular drainage devices include: (1) blades (two) (2) marker pen; (3) sterile swab (4) aseptic surgical towel, gauze, plastic film (5) No. 25 needle and No. 22 needle (6) sterile physiological saline (7) scalpel; (8) hand skull drill (9) 3 nylon thread and silk thread (10) needle holder, forceps, scissors 2. standard external ventricular drainage tube 3. drainage bag for cerebrospinal fluid 4. sterile gloves Operation: Frontal approach: Posture: 1. patients supine position, bedside elevation 20 degrees, neck relaxation The 2. side of the surgery for catheter through the head skin subgaleal 3. the scalp is marked with a pen at the drill hole 4. skin disinfection for five minutes for the sterile area area 5., with plastic film, carefully determine the midline 6. incisions were subcutaneously injected with 1%lidocaine 7. the length of the drill bit penetrates the inside and outside of the skull At the 8. mark site, the scalp is 1cm long incision, which can reduce the bleeding as far as possible through the drill bit, and the incision is deep to the bone surface 9. hand perpendicular to the skull drilling a hole, drill can pierce the dura, but do not fall into the brain parenchyma 10., if necessary, rushed to the skull fragments 11. bit wrench or lumbar puncture needle embed hole, determine the opening through the catheter to the dura Note: (1) insertion of a catheter or metal probe if the dura mater is not broken, Epidural hematoma is caused by dural detachment (2) and, if the dura opening is too small, the catheter will be epidural and grabbed the metal probe poke head into the brain parenchyma and catheter 12. of the ventricular catheter with probe vertically into the surface of the brain was 6cm; in order to probe to remove the cerebrospinal fluid outflow reached 6cm; if the depth of previous cerebrospinal fluid outflow, should also let alone forward extraction of probe catheter to a predetermined depth, in order to reduce the damage caused by the probe 13. if you reach the depth of 6cm, cerebrospinal fluid has not drained out, can not easily continue to insert: (1) remove catheters and rinse with saline water (2) reposition (3) insert the catheter with the probe again (4) it is safe and effective to insert catheter evenly and gently 14. for the "sagittal frontal approach" method for catheter must be aligned glabella, higher than the same side tragus is about 2cm; this ensures that the catheter tip in the anterior horn of lateral ventricle, catheter head near the foramen of Monro 15. connect the drainage tube with the distal end of the catheter, hold the catheter, drain the drainage tube at least 5cm away from the incision, and clear the drainage when the catheter is pulled out 16. the end of the catheter is connected to the pressure converter and the drainage system through the interface, and the stable drainage level outside the ear canal is used as the reference point 17. the interface connected with the catheter was fixed with 3 silk thread; the incision was sutured and the catheter was fixed to at least three positions of the scalp with 3 nylon thread 18. aseptic dressing Occipital approach: Posture: 1. of the patients were in supine position, the same shoulder was closed, and the head was completely turned to the contralateral shoulder. The head of the bed was raised 15-20 degrees, or prone position (such as suboccipital skull resection) The 2. approach: 6-7cm or 3cm on the outer occipital protuberance and 3cm beside the midline Location: 1. the sagittal plane is still in the forehead or brow midpoint as the goal, this approach naturally crossed the midline in the horizontal plane, and therefore must be in alignment with the lateral canthus The 2. ventricle catheter was inserted vertically into the skull and aligned to the middle of the forehead, reaching 6cm deep 3 if there is cerebrospinal fluid outflow, don't pull out the probe, the catheter goes to the depth of 8-12cm (the tip must be more than Monro hole) Complication: Infected: 1. there is no prospective study of clinical infection (such as intraventricular inflammation or meningitis); the reported bacterial infection rate is 0-40%, with an average of 10-17% 2. cerebrospinal fluid needs routine examination and culture of protein, sugar and cell count. Fever, leukocytosis and lymphocyte increase are not significant, and cell culture is valuable 3. risk factors: (1) intracranial hemorrhage and enlargement of ventricles of brain (2) intracranial pressure is greater than 20mmHg (3) monitoring time is greater than 5 days (4) other department of neurosurgery operations are required (5) ventricular perfusion Bleed: The incidence was 1.1% in 1., and 0.5% in hematoma requiring surgery 2. if the neurological signs worsen or epilepsy, CT examination should be performed immediately 3. the vast majority of bleeding can be resolved immediately Catheter translocation: 3% requiring surgical treatment Blockage or failure: the incidence is about 6% Ruptured aneurysm