J Korean Neurosurg Soc.  2017 Sep;60(5):604-609. 10.3340/jkns.2016.1011.004.

Adjustable Ghajar Guide Technique for Accurate Placement of Ventricular Catheters: A Pilot Study

• Yoon SY
• Kwak Y
• Park J

• KMID: 2457969
• DOI: http://doi.org/10.3340/jkns.2016.1011.004

Abstract

OBJECTIVE
An adjustable Ghajar guide is presented to improve the accuracy of the original Ghajar guide technique. The accuracy of the adjustable Ghajar guide technique is also investigated.
METHODS
The coronal adjustment angle from the orthogonal catheter trajectory at Kocher's point is determined based on coronal head images using an electronic picture archiving and communication system. For the adjustable Ghajar guide, a protractor is mounted on a C-shaped basal plate that is placed in contact with the margin of a burrhole, keeping the central 0° line of the protractor orthogonal to the calvarial surface. A catheter guide, which is moved along the protractor and fixed at the pre-determined adjustment angle, is then used to guide the ventricular catheter into the frontal horn adjacent to the foramen of Monro. The adjustable Ghajar guide technique was applied to 20 patients, while a freehand technique based on the surface anatomy of the head was applied to another 47 patients. The accuracy of the ventricular catheter placement was then evaluated using postoperative computed tomography scans.
RESULTS
For the adjustable Ghajar guide technique (AGT) patients, the bicaudate index ranged from 0.23 to 0.33 (mean±standard deviation [SD]: 0.27±0.03) and the adjustment angle ranged from 0° to 10° (mean±SD: 5.2°±3.2°). All the AGT patients experienced successful cerebrospinal fluid diversion with only one pass of the catheter. Optimal placement of the ventricular catheter in the ipsilateral frontal horn approximating the foramen of Monro (grade 1) was achieved in 19 patients (95.0%), while a suboptimal trajectory into a lateral corner of the frontal horn passing along a lateral wall of the frontal horn (grade 3) occurred in 1 patient (5.0%). Thus, the AGT patients experienced a significantly higher incidence of optimal catheter placement than the freehand catheterized patients (95.0% vs. 68.3%, p=0.024). Moreover, none of the AGT patients experienced any tract hemorrhages along the catheter or procedure-related complications.
CONCLUSION
The proposed adjustable Ghajar guide technique, using angular adjustment in the coronal plane from the orthogonal trajectory at Kocher's point, facilitates accurate freehand placement of a ventricular catheter for hydrocephalic patients.

Keyword

Catheterization; Cerebral ventricles; Hydrocephalus; Ventriculoperitoneal shunt

MeSH Terms

Animals
Catheterization
Catheters*
Cerebral Ventricles
Cerebrospinal Fluid
Head
Hemorrhage
Horns
Humans
Hydrocephalus
Incidence
Pilot Projects*
Ventriculoperitoneal Shunt

Figure

• 

  Fig. 1 Illustration of the adjustable Ghajar guide.

• 

  Fig. 2 Coronal computed tomography images showing the radiographic simulation of the catheter trajectories to determine the adjustment angle for the adjustable Ghajar guide technique. A: A burrhole site (arrow) is marked at a point 3 cm lateral to the midline of the skull. B: An approximately 3 cm-long chord (red line) is drawn with both ends equidistant from the burrhole site on the circular line outlining the calvarial surface. C: A perpendicular line starting at the middle of the chord is drawn to the ventricular system. D: The ideal catheter trajectory toward the foramen of Monro is drawn from the middle of the chord. The adjustment angle, the difference between the catheter trajectory (90°) perpendicular to the calvarial surface and the ideal catheter trajectory (95°), is 5°.

• 

  Fig 3 Intraoperative photograph showing the adjustable Ghajar guide used for the ventriculoperitoneal shunt.

Reference

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