Manual occipital ventricular puncture for cerebrospinal fluid shunt surgery: can aiming be standardized?

The manual occipital ventricular puncture is a standard surgical procedure, but specific targeting has not received sufficient attention despite the experience of anatomical disorientation. This study tried to identify an exact site for the ideal trajectory with this method, especially in the sagittal plane, which avoids contact with the choroid plexus that may be the major source of complications. A total of 44 consecutive adult cases undergoing cerebrospinal fluid shunting through the occipital route for hydrocephalus were retrospectively reviewed for the following: correlations between burr hole site, direction of puncture, and location of the ventricular catheter based on postsurgical radiological studies; calculation of the ideal trajectory to place the catheter tip in the anterior horn of the lateral ventricle without contact with the choroid plexus through the standard occipital burr hole. In addition, the relationships between the location of the ventricular structure, the cranial base line connecting the nasion and inion, and the size of the ventricle were evaluated. Incorrect catheter emplacement was found in five cases, which suggested that this procedure using the standard burr hole site and aim point might result in incorrect catheter placement. The ideal external aim points were widely distributed because of the variable heights of ventricular structures from the cranial baseline. No correlation between the locations of the anatomical points and ventricular size was found. The present study could not define a standard external aim point. Tailored preoperative planning of the trajectory is recommended.