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

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Abstract

Purpose

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.

Results

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.

Conclusion

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

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References

  1. Anson J (2014) Vascular access in resuscitation. Surv Anesthesiol 58(6):319. https://doi.org/10.1097/01.sa.0000455295.73918.19

    Article  Google Scholar 

  2. Canale D, Longo L (1990) Harvey Cushing and pediatric neurosurgery. Neurosurgery:602–610. https://doi.org/10.1097/00006123-199010000-00017

  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 https://www.ncbi.nlm.nih.gov/pubmed/10920658. Accessed 30 Apr 2019

    Article  CAS  PubMed  Google Scholar 

  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. https://doi.org/10.3171/2009.8.focus09169

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.3171/2015.4.peds15192

    Article  PubMed  Google Scholar 

  6. Kovar J, Gillum L (2010) Alternate route: the humerus bone - a viable option for IO access. JEMS 35:52–59. https://doi.org/10.1016/S0197-2510(10)70207-2

    Article  PubMed  Google Scholar 

  7. Lake C (1959) THE VENTRICULOMASTOID SHUNT. Laryngoscope 69(12):1469-1477. https://doi.org/10.1288/00005537-195912000-00001

    Article  Google Scholar 

  8. LaRocco B, Wang H (2003) Intraosseous infusion. Prehospital Emergency Care 7(2):280–285. https://doi.org/10.1080/10903120390936950

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1186/1754-9493-3-24

    Article  PubMed  PubMed Central  Google Scholar 

  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. https://doi.org/10.1016/j.resuscitation.2010.03.038

    Article  PubMed  Google Scholar 

  11. McCarthy G (2000) Does intraosseous have to mean intramedullary? Emerg Med J 17(6):432–a-432. https://doi.org/10.1136/emj.17.6.432-a

    Article  CAS  Google Scholar 

  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. https://doi.org/10.1016/s0300-9572(02)00348-9

    Article  PubMed  Google Scholar 

  13. Ming Woo P, Hung Pang P, Chan K, Ching Kwok J (2015) Ventriculosternal shunting for the management of hydrocephalus. Neurosurgery 11:371–375. https://doi.org/10.1227/neu.0000000000000861

    Article  PubMed  PubMed Central  Google Scholar 

  14. Nosik W (1950) Ventriculomastoidostomy. J Neurosurg 7(3):236–239. https://doi.org/10.3171/jns.1950.7.3.0236

    Article  Google Scholar 

  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. https://doi.org/10.1016/s0196-0644(89)80932-1

    Article  CAS  PubMed  Google Scholar 

  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. https://doi.org/10.1097/ta.0000000000000516

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1097/ta.0b013e3181b16f42

    Article  Google Scholar 

  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. https://doi.org/10.3171/ped.2007.106.2.120

    Article  Google Scholar 

  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. https://doi.org/10.7205/milmed-d-13-00484

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1016/j.resuscitation.2012.11.006

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1017/s1049023x00032374

    Article  Google Scholar 

  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 https://www.ncbi.nlm.nih.gov/pubmed/14941860. Accessed 30 Apr 2019

    CAS  PubMed  Google Scholar 

  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. https://doi.org/10.1227/neu.0b013e3181ffa21c

    Article  PubMed  Google Scholar 

  24. Tubbs R, Tubbs I, Loukas M, Cohen-Gadol A (2015) Ventriculoiliac shunt: a cadaveric feasibility study. J Neurosurg Pediatr 15(3):310–312. https://doi.org/10.3171/2014.10.peds14252

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1016/j.ajem.2007.03.024

    Article  Google Scholar 

  26. Wagner K (1985) Intraosseous infusion: an alternative route of pediatric intravascular access. J Emerg Med 3(6):496. https://doi.org/10.1016/0736-4679(85)90015-0

    Article  Google Scholar 

  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. https://doi.org/10.1016/s0196-0644(05)80199-4

    Article  CAS  PubMed  Google Scholar 

  28. Welch K (1967) The secretion of cerebrospinal fluid by lamina epithelialis. Monogr Surg Sci 4:155–192. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/4864686. Accessed 30 Apr 2019

    CAS  PubMed  Google Scholar 

  29. Whitenack S, Hausberger F (1971) Intravasation of fat from the bone marrow cavity. Am J Pathol 65:335–345. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/5134888. Accessed 30 Apr 2019

    CAS  PubMed  PubMed Central  Google Scholar 

  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):2095–2098

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Seattle Science Foundation, 550 17th Avenue, Suite 600, Seattle, WA, 98122, USA

    Mohammad W. Kassem, Basem Ishak, Joe Iwanaga & R. Shane Tubbs

  2. Department of Anatomical Sciences, St. George’s University, True Blue, Grenada

    Mohammad W. Kassem, Karishma Mehta, Marios Loukas & R. Shane Tubbs

  3. Mercy Health Neuroscience Institute, Toledo, OH, USA

    Mohammad W. Kassem

Authors
  1. Mohammad W. Kassem
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  2. Basem Ishak
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  3. Karishma Mehta
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  4. Joe Iwanaga
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  5. Marios Loukas
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  6. R. Shane Tubbs
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Correspondence to R. Shane Tubbs.

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

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The authors have no conflicts of interest.

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Kassem, M.W., Ishak, B., Mehta, K. et al. Ventriculo-humeral shunt: a cadaveric feasibility study with application to treating hydrocephalus. Childs Nerv Syst 35, 1561–1564 (2019). https://doi.org/10.1007/s00381-019-04175-3

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  • DOI: https://doi.org/10.1007/s00381-019-04175-3

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