gms | German Medical Science

Objective: Accurate targeting is pivotal in functional stereatactic neurosurgery. But not just hitting the target is essential, also the trajectory to the target needs consideration. Using a transventricular approach has been thought to bear a higher risk of intracerebral haemorrhage by several surgeons, although this has debated by others. Here we investigate the comparative occurence of haemorrhage with or without transventricular apporaches in a large series of patients operated over two decades.

Methods: In 550 patients out of a total of 585 patients, who underwent DBS electrode implantation or radiofrequency lesioning, it could be determined retrospectively whether or not the trajectory transversed the ventricles. Patient were operated over a period of 20 years in three different centers, performed or supervised by the senior neurosurgeon using the same technique. Targets were determined by CT-stereotactic surgery supplemented by MR imaging according to standardised approach which did not consider to avoid a transventricular trajectory. Postoperative CT scans obtained within 24 hours after surgery were searched for confirmation of a transventricular tajectory and for haemorrhage of any size at any site.

Results: Patients were operated for movement disorders (478), pain syndromes (48) or psychiatric disorders (24). 25% of the leads placed in the globus pallidus internus (GPi) passed the ventricles, 91% of the leads in the nucleus ventralis intermedius (Vim) passed the ventricles and 90% of the leads in the subthalamic nucleus (STN). Out of 357 patients with a transventricular lead placement, 13 patients had an intracranial haemorrhage (3,64%). In the other 193 patients, where the electrodes did not pass the ventricle, 6 patients had an intracranial haemorrhage (3,11%). In the transventricular group haemorrhage manifested as a small haemorrhage at the target site (6), subdural haematoma (2) or intraventricular haematoma (5). In the non-transventricular group haemorrhage manifested as haematoma at the target site (5) or subdural haematoma (1). Haemorrhage was asymptomatic in all patients except in 1 patient in the transventricular group, who had a persistent mild hemiparesis on the right side.

Conclusion: In this large cohort of patients we could show that there is no significantly increased risk for an intracranial haemorrhage by choosing a transventricular approach for DBS lead placement.