Child's Nervous System

, Volume 35, Issue 9, pp 1561–1564 | Cite as

Ventriculo-humeral shunt: a cadaveric feasibility study with application to treating hydrocephalus

  • Mohammad W. Kassem
  • Basem Ishak
  • Karishma Mehta
  • Joe Iwanaga
  • Marios Loukas
  • R. Shane TubbsEmail author
Original Article



Intraosseous vascular access is often used when vascular access is difficult. However, the use of this space for a receptacle for cerebrospinal fluid (CSF) diversion has been scantly considered.

Materials and methods

Six upper limbs of fresh frozen cadavers were used for this study. In the supine position, a small hole was drilled through the outer cortex of the proximal humerus and into the medullary cavity. A 16-gauge needle was placed into the hole in the humerus and 150 cc of saline infused. Next, the adjacent axillary vein and tributaries were dissected to observe dilation or the presence of the blue-colored saline. For part two of the study, shunt tubing was passed subcutaneously from a supraclavicular incision to the hole made in the humerus. Range of motion of the shoulder was then performed.


On all sides, all 150 cc of fluid was easily infused into the humerus. No specimen was found to have leakage from the drill hole site or into the extravascular soft tissues. With dissection of the axillary vein and its tributaries, all sides were found to have engorgement of these vessels. No tension was placed on the distal shunt tubing with full range of motion of the shoulder.


Based on our study, the humerus is another option available to the neurosurgeon for CSF diversion.


Ventricular shunts Humerus Hydrocephalus Intraosseous 


Compliance with ethical standards

As a cadaveric study, our institution does not require IRB approval. However, ethical considerations were in accord with the Declaration of Helsinki.

Conflict of interest

The authors have no conflicts of interest.


  1. 1.
    Anson J (2014) Vascular access in resuscitation. Surv Anesthesiol 58(6):319. CrossRefGoogle Scholar
  2. 2.
    Canale D, Longo L (1990) Harvey Cushing and pediatric neurosurgery. Neurosurgery:602–610.
  3. 3.
    Dubick M, Holcomb J (2000) A review of intraosseous vascular access: current status and military application. Mil Med 165(7):552–559. Retrieved from Accessed 30 Apr 2019CrossRefGoogle Scholar
  4. 4.
    García-González U, Cavalcanti D, Agrawal A, Gonzalez L, Wallace R, Spetzler R, Preul M (2009) The diploic venous system: surgical anatomy and neurosurgical implications. Neurosurg Focus 27(5):E2. CrossRefGoogle Scholar
  5. 5.
    Goldstein H, Feldstein N, Anderson R (2015) Letter to the editor: ventriculoiliac shunt: a single case experience. J Neurosurg Pediatr 16(4):477–478. CrossRefGoogle Scholar
  6. 6.
    Kovar J, Gillum L (2010) Alternate route: the humerus bone - a viable option for IO access. JEMS 35:52–59. Google Scholar
  7. 7.
    Lake C (1959) THE VENTRICULOMASTOID SHUNT. Laryngoscope 69(12):1469-1477. CrossRefGoogle Scholar
  8. 8.
    LaRocco B, Wang H (2003) Intraosseous infusion. Prehospital Emergency Care 7(2):280–285. CrossRefGoogle Scholar
  9. 9.
    Leidel B, Kirchhoff C, Bogner V, Stegmaier J, Mutschler W, Kanz K, Braunstein V (2009) Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Saf Surg 3(1):24. CrossRefGoogle Scholar
  10. 10.
    Leidel B, Kirchhoff C, Braunstein V, Bogner V, Biberthaler P, Kanz K (2010) Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: a prospective, randomized study. Resuscitation 81(8):994–999. CrossRefGoogle Scholar
  11. 11.
    McCarthy G (2000) Does intraosseous have to mean intramedullary? Emerg Med J 17(6):432–a-432. CrossRefGoogle Scholar
  12. 12.
    McCarthy G, O'Donnell C, O'Brien M (2003) Successful intraosseous infusion in the critically ill patient does not require a medullary cavity. Resuscitation 56(2):183–186. CrossRefGoogle Scholar
  13. 13.
    Ming Woo P, Hung Pang P, Chan K, Ching Kwok J (2015) Ventriculosternal shunting for the management of hydrocephalus. Neurosurgery 11:371–375. CrossRefGoogle Scholar
  14. 14.
    Nosik W (1950) Ventriculomastoidostomy. J Neurosurg 7(3):236–239. CrossRefGoogle Scholar
  15. 15.
    Orlowski J, Julius C, Petras R, Porembka D, Gallagher J (1989) The safety of intraosseous infusions: risks of fat and bone marrow emboli to the lungs. Ann Emerg Med 18(10):1062–1067. CrossRefGoogle Scholar
  16. 16.
    Pasley J, Miller C, DuBose J, Shackelford S, Fang R, Boswell K et al (2015) Intraosseous infusion rates under high pressure. J Trauma Acute Care Surg 78(2):295–299. CrossRefGoogle Scholar
  17. 17.
    Paxton J, Knuth T, Klausner H (2009) Proximal humerus intraosseous infusion: a preferred emergency venous access. J Trauma: Injury, Infection, And Critical Care 67(3):606–611. CrossRefGoogle Scholar
  18. 18.
    Pugh J, Tyler J, Churchill T, Fox R, Aronyk K (2007) Intraosseous infusion into the skull: potential application for the management of hydrocephalus. J Neurosurg Pediatr 106(2):120–125. CrossRefGoogle Scholar
  19. 19.
    Rush S, D'Amore J, Boccio E (2014) A review of the evolution of intraosseous access in tactical settings and a feasibility study of a human cadaver model for a humeral head approach. Mil Med 179(8S):24–28. CrossRefGoogle Scholar
  20. 20.
    Santos D, Carron P, Yersin B, Pasquier M (2013) EZ-IO® intraosseous device implementation in a pre-hospital emergency service: a prospective study and review of the literature. Resuscitation 84(4):440–445. CrossRefGoogle Scholar
  21. 21.
    Susak L, Macnab A, Christenson J, Peng J, Horwood B, Johnson D et al (2000) Early report on emergency sternal intraosseous infusion in adults. Prehospital Disaster Med 15(S2):S106. CrossRefGoogle Scholar
  22. 22.
    Svien H, Dodge H, Lake C (1952) Ventriculomastoid shunt in the management of obstruction to the aqueduct of sylvius in the adult: report of case. Proc Staff Meet Mayo Clin 27:215–218. Retrieved from Accessed 30 Apr 2019Google Scholar
  23. 23.
    Tubbs R, Bauer D, Chambers M, Loukas M, Shoja M, Cohen-Gadol A (2011) A novel method for cerebrospinal fluid diversion. Neurosurgery 68(2):491–495. CrossRefGoogle Scholar
  24. 24.
    Tubbs R, Tubbs I, Loukas M, Cohen-Gadol A (2015) Ventriculoiliac shunt: a cadaveric feasibility study. J Neurosurg Pediatr 15(3):310–312. CrossRefGoogle Scholar
  25. 25.
    Von Hoff D, Kuhn J, Burris H, Miller L (2008) Does intraosseous equal intravenous? A pharmacokinetic study. Am J Emerg Med 26(1):31–38. CrossRefGoogle Scholar
  26. 26.
    Wagner K (1985) Intraosseous infusion: an alternative route of pediatric intravascular access. J Emerg Med 3(6):496. CrossRefGoogle Scholar
  27. 27.
    Warren D, Kissoon N, Sommerauer J, Rieder M (1993) Comparison of fluid infusion rates among peripheral intravenous and humerus, femur, malleolus, and tibial intraosseous sites in normovolemic and hypovolemic piglets. Ann Emerg Med 22(2):183–186. CrossRefGoogle Scholar
  28. 28.
    Welch K (1967) The secretion of cerebrospinal fluid by lamina epithelialis. Monogr Surg Sci 4:155–192. Retrieved from Accessed 30 Apr 2019Google Scholar
  29. 29.
    Whitenack S, Hausberger F (1971) Intravasation of fat from the bone marrow cavity. Am J Pathol 65:335–345. Retrieved from Accessed 30 Apr 2019Google Scholar
  30. 30.
    Kassem MW, Chern J, Loukas M, Tubbs RS (2017 Dec) Intramedullary placement of ventricular shunts: a review of using bone as a distal cerebrospinal absorption site in treating hydrocephalus. Childs Nerv Syst 33(12):2095–2098CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Mohammad W. Kassem
    • 1
    • 2
    • 3
  • Basem Ishak
    • 1
  • Karishma Mehta
    • 2
  • Joe Iwanaga
    • 1
  • Marios Loukas
    • 2
  • R. Shane Tubbs
    • 1
    • 2
    Email author
  1. 1.Seattle Science FoundationSeattleUSA
  2. 2.Department of Anatomical SciencesSt. George’s UniversityTrue BlueGrenada
  3. 3.Mercy Health Neuroscience InstituteToledoUSA

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