두개골 내부를 구성하는 것은 혈액과 뇌 실질(Brain matter), 그리고 CSF(뇌척수액)입니다.
CSF flow
이중에서 뇌척수액은 뇌실간을 이동하면서 뇌의 쿠션역할을 하기도하고, 뇌내에서 기본적인 면역학적, 구조적 보호역할을 담당하는 액체입니다
EVD는 뇌실외배액술이며, 뇌실(cerebral ventricle)에 튜브를 넣어 고인 혈액이나 뇌척수액을 몸 밖으로 배출하는 치료법이다.
기본적인 point
* Entry : Kocher`s point
Trajectory: 좌우: medial canthus를 향해서
위아래: tragus를 향해서
Navigation 사용시: foramen of Monro를 향해서
(Kocher’s point를 entry point로 하여 foramen of Monro를 통과해서 floor of third ventricle로 가는 가상의 선을 그음. -> 가상의 선 위에서 foramen of Monro보다 약간 윗쪽을 entry point로 함. 성인에서 대게 skull outer table에서 6cm 정도)
skull의 표면에 대해 normal (수직) 하게 넣으면 들어갈 가능성이 높음.
4~5cm 넣었을 때 대게 puncture가 되고 CSF가 나오면 stylet을 잡은 상태로 1~2cm 더 catheter만 밀어넣는다. 7cm보다 더 깊게 넣으면 위험하므로 금기!
Morone PJ, Dewan MC, Zuckerman SL, Tubbs RS, Singer RJ. Craniometrics and Ventricular Access: A Review of Kocher's, Kaufman's, Paine's, Menovksy's, Tubbs', Keen's, Frazier's, Dandy's, and Sanchez's Points. Oper Neurosurg (Hagerstown). 2020 May 1;18(5):461-469. doi: 10.1093/ons/opz194. PMID: 31420653.
Kocher’s point
Ventricular access via Kocher’s point. The burr hole should be placed 11 cm superior and posterior to the nasion and 3 cm lateral to the midline. Next, the ventricular catheter should be aimed at an angle that is perpendicular to the intersection of lines drawn from the ipsilateral medial canthus and the ipsilateral external auditory meatus (EAM). The catheter should be passed to a depth of approximately 6 cm or until the frontal horn of the ipsilateral lateral ventricle is reached.
Kaufman’s point
Ventricular access via Kaufman’s point. The burr should be placed 5 cm superior to the nasion and 3 cm lateral to midline. Next, the ventricular catheter should be aimed toward the midline and inferiorly to a point that is 3 cm superior to the inion. The catheter should be passed to a depth of approximately 7 cm or until the frontal horn of the ipsilateral lateral ventricle is reached.
Paine’s, Hyun’s, and Park’s points
Ventricular access via Paine’s, Hyun’s, and Park’s points. Ventricular access should only be attempted after completion of a frontotemporal craniotomy. For Paine’s point, the ventricular catheter should enter the brain at a location that is 2.5 cm above the floor of the anterior cranial fossa and 2.5 cm anterior to the sylvian fissure. The catheter should be passed perpendicular to the convexity of the brain surface and advanced to a depth of approximately 4 to 5 cm or until the frontal horn of the ipsilateral lateral ventricle is reached. For Hyun’s point, the ventricular catheter should enter the brain at a location that extends 2 cm from the anterior limb of Paine’s triangle (4.5 cm above the floor of the anterior cranial fossa). The catheter should be passed perpendicular to the convexity of the brain surface and advanced to a depth of approximately 5 to 6.5 cm or until the frontal horn of the ipsilateral lateral ventricle is reached. For Park’s point, the ventricular catheter should enter the brain at a location that extends 2 cm from the posterior limb of Paine’s triangle (4.5 cm anterior to the sylvian fissure). The catheter should be passed perpendicular to the convexity of the brain surface and advanced to a depth of approximately 5 to 6 cm or until the frontal horn of the ipsilateral lateral ventricle is reached.
Menovsky’s point
Ventricular access via Menovsky’s point. After drilling the keyhole burr hole through the bone during a supraorbital craniotomy and incising the dura, the ventricular catheter should be passed at an angle that is 45◦ toward the midline and 20◦ superior to the orbitomeatal line. The catheter should be passed to a depth of approximately 5 to 6.5 cm or until the frontal horn of the ipsilateral lateral ventricle is reached
Tubbs’ point
Ventricular access via Tubbs’ point. The spinal needle should be placed under the upper eyelid medial to the midpupillary line and advanced at a trajectory that is 45◦ superior to the orbitomeatal line and 20◦ toward the midline. As the needle is advanced, the orbital roof should be encountered and penetrated. The needle should be passed to a depth of approximately 8 cm or until the frontal horn of the ipsilateral lateral ventricle is reached
Keen’s point
Ventricular access via Keen’s point. After a burr hole is placed 2.5 cm superior and posterior to the pinna of the ear, the catheter should be placed perpendicular to the cortex and aimed in a slight cephalic direction. The catheter should be advanced 4 to 5 cm or until the trigone of the ipsilateral lateral ventricle is reached
Frazier’s point
Ventricular access via Frazier’s point. From a parietal approach, the burr hole should be positioned slightly above and lateral to the lambdoid suture at a location that is 6 cm superior to the inion and 3 to 4 cm lateral to the midline. The catheter is directed to a point that lies 4 cm above the contralateral medial canthus and passed 5 cm or until CSF is encountered. The catheter stylet is then removed, and the catheter is soft-passed an additional 5 cm, placing it within the body of the ipsilateral lateral ventricle
Dandy’s point
Ventricular access via Dandy’s point. From an occipital approach, a burr hole is created 3 cm above the inion and 2 cm lateral to the midline. The catheter is directed toward a point 2 cm above the glabella and passed 4 to 5 cm or until the body of the ipsilateral lateral ventricle is reached.
Sanchez’s point
Ventricular access via Sanchez’s point. A burr hole is placed 5.6 cm above the inion and 2.7 cm lateral to midline. The catheter is angled 5◦ lateral to the parasagittal plane and 30◦ inferior toward the orbitomeatal plane. The catheter is then advanced 9 to 10 cm to be positioned within the temporal horn of the ipsilateral lateral ventricle.
