Feasibility of B-Ultrasound-Assisted Shunting for Hydrocephalus Patients with Skull Defect Versus Traditional Ventriculoperitoneal Shunting

Summary

During ventriculoperitoneal shunt surgery, the puncture and positioning of the drainage tube are critical, as they significantly affect the outcome. We assessed whether intraoperative B-ultrasound guidance improves ventricular puncture accuracy during ventriculoperitoneal shunting (VPS) in hydrocephalus patients with skull defects.

Abstract

Hydrocephalus combined with a skull defect is a common clinical condition in neurosurgery. It often occurs secondary to decompressive craniectomy after severe craniocerebral injury or cerebral hemorrhage. For such patients, due to the concurrent presence of a skull defect, the puncture and localization of conventional ventriculoperitoneal shunt surgery are somewhat difficult, and the risk of complications is relatively high. This study aimed to evaluate the efficacy of ultrasound-guided ventriculoperitoneal shunting in patients with hydrocephalus associated with skull defects. This study retrospectively analyzed the clinical data of 48 patients with hydrocephalus. Among them, 24 patients had combined skull defects. The observation group underwent ultrasound-assisted ventriculoperitoneal shunting (VPS), whereas the control group underwent traditional VPS. The study compared the success rate of a single puncture during the operation, the operation time, the clinical improvement 2 months after the operation, and the incidence of complications. The results showed that, compared with traditional ventriculoperitoneal shunting, B-ultrasound-assisted shunting provided real-time assessment. It not only causes less trauma and significantly improves puncture accuracy during the operation but also does not prolong the operation time. Moreover, it can allow real-time visualization of the catheter trajectory in patients with skull defects and postoperative hydrocephalus. The complication and efficacy rates of this method did not differ significantly between groups; the numerical differences warrant confirmation in larger prospective studies, improve the reliability of intraoperative operations, and have significant clinical promotion value in treating such patients.

Introduction

Hydrocephalus is a neurological disorder resulting from abnormal production, impaired circulation, or impaired absorption of cerebrospinal fluid. This results in cerebrospinal fluid accumulation within the ventricles and the cranial cavity, causing increased intracranial pressure^1,2. Typically, the condition involves enlarged ventricles, interstitial brain edema, compression of brain tissue, and severe clinical manifestations³. Surgical treatment is often required.

Additionally, certain individuals with hydrocephalus have undergone decompressive craniectomy^4,5. This commonly occurs after traumatic brain injury or cerebral hemorrhage, and the bone flap is removed to alleviate pressure. decompressive craniectomy effectively lowers intracranial pressure and boosts cerebral perfusion, offering vital survival chances⁴. Nevertheless, postoperative hydrocephalus demands prompt management.

As a non-invasive method, B-ultrasound is widely used in clinical practice, delivering effective results for tasks such as identifying blood vessels or guiding procedures. Nevertheless, its use for intracranial localization in neurosurgery is constrained by the skull. In the past, ultrasound technology was less frequently used in neurosurgery. This study focused on patients with hydrocephalus and skull defects, using B-ultrasound to identify ventricular structures and guide ventricular puncture. This research aimed to meticulously record and evaluate the treatment protocols, postoperative recovery, and long-term outcomes for these patients, while clarifying the effect of B-ultrasound on ventriculoperitoneal shunt procedures in this group. By assessing these cases, we aim to enhance comprehension of B-ultrasound-assisted ventriculoperitoneal shunting, refine therapeutic strategies, and ultimately improve patients’ quality of life and clinical outcomes.

Protocol

The study protocol was approved by the Ethics Committee of Nantong First People's Hospital, Southeast University (No. 2025KT029), and informed consent was obtained from all participants.

Patient characteristics
This study included 48 adult patients with hydrocephalus. Among them, 24 patients with skull defects (observation group) underwent ventriculoperitoneal shunt surgery assisted by B-ultrasound between January 2022 and December 2024. The other 24 patients with repaired skull defects (the control group) received traditional ventriculoperitoneal shunt treatment from January 2021 to December 2023.

The diagnosis and management of hydrocephalus have a long-established history. For this research, hydrocephalus was diagnosed based on prior literature, and patients were included in the study group, as referenced in^1,2.

The inclusion criteria were: (1) participants aged 25–75 years; (2) diagnosis of hydrocephalus based on clinical symptoms and imaging examinations, such as head CT or MRI; (3) undergoing initial ventriculoperitoneal shunt surgery; (4) complete absorption of intracranial hemorrhage; (5) positive outcomes from preoperative lumbar puncture or lumbocisternal drainage; (6) no preoperative infections in the abdomen or brain, or resolved infections with normal cerebrospinal fluid cell counts; (7) follow-up duration exceeding 2 months after surgery; (8) informed consent provided by the patient or guardian.

Exclusion criteria involve: (1) contraindications to surgery, such as severe cardiopulmonary dysfunction; (2) prior abdominal surgery, radiotherapy, or chemotherapy; (3) history of tumors, including brain or abdominal malignancies in any location, such as the brain or abdomen; (4) hydrocephalus resulting from infections.

Surgical procedure
A thorough preoperative discussion was essential to devise the surgical strategy, with B-ultrasound specialists included to collaboratively shape the plan. All patients underwent general anesthesia. The patient was placed supine, with the incision line marked from the opposite side of the skull defect to the subxiphoid abdominal region, and draped with sterile surgical towels after standard disinfection, ensuring the skull defect area remains accessible for B-ultrasound monitoring and guidance. Kocher's point (the contralateral side of the decompressive craniectomy) was commonly selected for ventricular puncture (see Figure 1), situated at the anterior midline opening of the coronal suture, supported by clinical evidence of greater precision and improved outcomes. A linear 3 cm incision was then made, the soft tissue was expanded with a mastoid spreader, a 1 cm burr hole was drilled with an electric drill, and hemostasis was achieved. Then, the dura is cauterized before incision. Following this, a 4 cm curved incision was created 2–3 cm from the scalp incision to isolate and form the valve pocket. An incision is made at the midpoint of the subxiphoid process. A subcutaneous tunnel was used with a tunneling device, guiding the abdominal segment of the shunt tube to the curved scalp incision. If the tunnel has an angle, small auxiliary incisions were made, if needed, to facilitate passage and guide the abdominal segment of the shunt tube to the curved scalp incision. The shunt tube was connected to the shunt valve outlet and fixed with silk sutures. The dura is incised in a "+" shape, hemostasis was achieved with an electric coagulator, and ventricular puncture was performed using the shunt's ventricular segment.

A portable B-ultrasound unit was positioned on the skull defect (Figure 2). An appropriate small probe was employed to modify the orientation and conduct observations, thereby revealing the location of the frontal horn of the lateral ventricle. The surgical procedure should be aligned with the sagittal plane and matched with the direction of the imaginary line connecting the two external auditory canals. Under real-time B-ultrasound monitoring, the puncture was performed gradually to ensure precise placement at the frontal angle of the lateral ventricle (see Figure 3A,B).

After removing the needle core, cerebrospinal fluid outflow was observed. The catheter tip position must be monitored and adjusted to ensure proper shunt tube placement in the ventricle under B-ultrasound guidance. After determining the intraventricular catheter length, if cerebrospinal fluid outflow was observed, the catheter was secured to the skull opening with sutures. The ventricular segment's exit end is guided subcutaneously to the curved incision; part of the ventricular drainage tube is withdrawn as needed, connected to the shunt valve inlet, and fixed using silk sutures. After compressing the valve to verify patency, the abdominal portion of the shunt tube was inserted into the abdominal cavity, and the head and abdominal incisions were sutured separately. If simultaneous cranioplasty was indicated, the skull repair procedure was performed after re-disinfecting the surface.

Outcome measures
Clinical outcome definitions
Recovery: intracranial pressure was stable, symptoms such as pain, nausea, and visual impairment were absent, and quality of life returned to normal, marked improvement: Intracranial pressure remains basically stable, and the above clinical symptoms are significantly alleviated; effective: slight decrease in intracranial pressure and slight relief of symptoms; ineffective: Intracranial pressure remains unchanged compared to before treatment, and symptoms have not changed or worsened; death: death occurring within 2 months after surgery after the operation.

The total partial improvement rate was calculated as the recovery rate plus the death rate, which occurs within 2 months after surgery, and the marked improvement rate. The comparison of surgery-related indicators includes the operative duration of the two groups. Complications include shunt tube obstruction, abdominal organ injury, intracranial hematoma, and abdominal infection.

Statistical analysis
Statistical software (see Table of Materials) was used to identify differences in surgical outcomes and complications following B-ultrasound-guided ventriculoperitoneal shunt surgery. Chi-square tests were applied to assess postoperative effectiveness and complication rates. Independent samples t-tests were used to compare continuous variables between two groups. All tests were two-tailed, and P ≤ 0.05 was considered statistically significant, with a P < 0.05 indicating statistical significance.

Results

The two groups showed no statistically significant differences in sex, age, severity of preoperative hydrocephalus, or skull defect (P > 0.05; Table 1). All 24 patients in the observation group underwent successful initial punctures. Postoperative head CT scans confirmed precise shunt tube placement in the frontal angle of the lateral ventricle, on the day after surgery, with no evidence of puncture tract complications or intraventricular hemorrhage. In the control group, six patients require...

Discussion

Ventriculoperitoneal shunting (VPS) has been a routine method for treating communicating hydrocephalus^2,6. Clinically, hydrocephalus manifests through impaired consciousness, worsening of symptoms after initial improvement, or persistent worsening, specifically causing deepening of coma, dizziness, headaches, nausea, vomiting, slowed reactions, and progressive swelling at the cranial decompression site, accompanied by gradually increasing and stiffening tension i...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Codman Shunt	Johnson & Johnson, United States	82-6100
Drill	Beijing Honghu Medical Devices Co., LTD	HK-208
iodophor disinfectant	Taizhou Tiancheng Medical Supplies Co., LTD	PVI-500
Mastoid spreader	Shanghai Jinzhong Medical Devices Co., LTD	JZ-312
Portable Mindray Z50S B-ultrasound	Mindray Company, China	Z50S
Sterile gauze	Nantong Meilihe Medical Devices Co., LTD	MLH-GZ-01
Suture	Johnson & Johnson, United States	VP-922
SPSS26.0	version 26.0, IBM Corp., Armonk, NY, USA	https://www.ibm.com/support/pages/ibm-spss-statistics-26-documentation	Statistical software