Ventricular puncture and drainage

The ventricular system consists of bilateral left and right ventricles located in the cerebral hemispheres on both sides, located in the midline of the cerebral ventricle, the third ventricle communicating with the bilateral ventricles through the interventricular septum, the midbrain aqueduct and the cerebellar hemisphere and pons in the posterior cranial fossa The fourth ventricle between the medulla. Ventricular puncture refers only to the puncture of the lateral ventricles on both sides. The lateral ventricle is in the cerebral hemisphere on both sides, forming a narrow and longitudinal fissure, divided into the following parts: Anterior angle (frontal angle): In the frontal lobe, the upper wall and the front wall are the front part of the corpus callosum, the outer wall is the caudate nucleus, and the inner wall is a transparent septum. The inner lower part has an interventricular hole (Monro hole) through which the third ventricle is communicated. Body: a horizontal fissure, in the parietal lobe. The upper wall is a corpus callosum, the inner wall is a transparent septum, and the lower wall is from the inside to the outside, namely the dome, the choroid plexus, the dorsal thalamus, the terminal ridge and the caudate nucleus. Posterior angle (occipital angle): the extension of the body to the occipital lobe, which is a longitudinal fissure. Morphological variation is large, often small, and sometimes absent. The upper outer wall is radiated by the corpus callosum, the inner wall has two ridges, and the upper part is the rear corner ball, which is formed by the scorpion tongs, and the lower part is the bird's distance, which is caused by the deep depression of the front part of the distance. Lower corner (corner angle): Located in the temporal lobe, it is a downward, anterior and inwardly curved fissure. The inner edge is the end of the terminal and caudate nucleus. The end is connected with the amygdala. The lower corner is from the inside to the outside. Side bulging. The body and the back and bottom corners are triangular. There are lateral ventricle choroid plexus in the body and lower corner, and the choroidal tissue in the third ventricle continues at the interventricular septum. The choroid plexus is in the triangle of the lateral ventricle. Treatment of diseases: increased intracranial pressure in the elderly Indication 1. Patients with severe intracranial pressure caused by hydrocephalus, when the condition is critical or even cerebral palsy or coma, first use ventricular puncture and drainage, as an emergency decompression rescue measures, to create conditions for further examination and treatment. 2. Patients with hemorrhage in the cerebral ventricle, puncture and drainage of cerebrospinal fluid can reduce ventricular reaction and prevent occlusion of the ventricular system. 3. In the process of craniotomy, in order to reduce intracranial pressure, it is beneficial to improve the exposure of the operation area, often puncture the lateral ventricle and drain the cerebrospinal fluid. Postoperatively, especially in the posterior cranial fossa, the reactive intracranial hypertension is relieved, and lateral drainage of the lateral brain is also commonly used. 4. Inject a positive contrast agent or gas into the ventricle for ventriculography. 5. Drain inflammatory cerebrospinal fluid, or inject antibiotics into the ventricle to treat ependymitis. 6. Inject 1 ml of rouge or 1 ml of phenolsulfon peptide into the ventricle to identify whether it is traffic or obstructive hydrocephalus. 7. Do cerebrospinal fluid shunt surgery and place various shunt tubes. 8. Extract ventricular fluid for biochemical and cytological examination. Contraindications 1. Patients with subdural empyema or brain abscess, ventricular puncture can spread the infection into the brain, and there is a risk that the abscess will break into the ventricles. 2. Cerebrovascular malformations, especially in patients with vascular malformations of large or high flow type or located near the lateral ventricle, ventricular puncture can cause bleeding. 3. Diffuse brain swelling or cerebral edema, the ventricle is compressed, the puncture is difficult, drainage is also difficult to work. 4. Severe intracranial hypertension, visual acuity less than 0.1, puncture should be cautious, due to sudden decompression and blindness. Preoperative preparation Shave all the hair. In addition to emergency, preoperative fasting should be 4 to 6 hours, intramuscular injection of phenobarbital 0.1g (children's discretion). Surgical procedure 1. Skull drilling and puncture (1) Use the gentian violet or methylene blue solution to draw a midline sagittal line on the scalp, and then draw the scalp incision line with the selected puncture point as the midpoint. The length of the incision is generally 3 cm. The skin was sterilized twice with 3% iodine and 75% ethanol or skin disinfectant, covered with a sterile surgical towel, and fixed to the scalp with a slit film or suture. (2) Local anesthesia with 0.5% procaine. The epidermis and periosteum were cut in the whole layer, separated by the periosteal stripper, and then retracted by the mastoid retractor. Do a skull drill. After the electric hard dura, the "Ten" shape is cut. (3) The cortex that has been electrocoagulated by the ventricle puncture needle or the core drainage tube is punctured into the lateral ventricle in a predetermined direction. When the needle or drainage tube passes through the wall of the ventricle, the resistance is suddenly reduced, and the core of the needle can be seen to show the flow of cerebrospinal fluid. If the catheter drainage is to be retained, the drainage tube is fixed with tweezers, and the drainage tube is ligated and fixed to the scalp with a medium thread. (4) Intermittently suture the aponeurotic aponeurosis and skin incision. The drainage tube is connected to the sterilized ventricle drainage bottle. The joints of the incision and the drainage tube are properly wrapped with sterile gauze to prevent contamination. 2. Cranial cone puncture In order to reduce surgical trauma, in recent years, a small hole cone cranial puncture has been advocated. The cone-shaped cranial tool has a common hand-drill or a specially designed cranial cone. The operation method is described by taking the sleeve cranial cone designed by Shanghai Changzheng Hospital as an example. The sleeve cranial cone consists of a three-edged cranial cone with a T-handle and scale, a 3/4 slotted sleeve and a fixed helix. (1) After marking the puncture point on the scalp, routinely disinfect, towel, and anesthetize. Use a sharp knife to puncture a small hole in the scalp. According to the thickness of the skull measured by the X-ray film, the cannula was fixed on the corresponding part of the cranial cone with a fixed spiral, and the skull and the dura mater were perforated with a cranial cone and a cannula. (2) Pull out the cranial cone and retain the cannula. The core ventricle drainage tube is inserted into the ventricle through the cannula according to the direction of puncture. After the cerebrospinal fluid flows out, the cannula is pulled out. The drainage tube is fixed on the scalp and connected to the ventricle drainage bottle. This method does not need to cut the beginning of the skin to drill the skull, which is simple and quick, and the damage is small. After the cone is removed, the cranial cone is removed to retain the cannula in the bone hole, which can prevent the soft tissue and bone hole of the scalp from being dislocated. The puncture needle or the drainage tube can smoothly penetrate into the ventricle along the cannula, avoiding the shortcomings of the general thin hole cone. 3. Piercing through the fistula It is suitable for those who have no cranial cone but need emergency puncture to release cerebrospinal fluid. After routine disinfection of the sanitary napkins, use a sharp knife to puncture a hole in the skin 0.5cm below the midpoint of the upper edge of the iliac crest. Use a small round chisel or a Sterling nail or a Kirschner wire to cut through the upper wall of the iliac crest. Or lumbar puncture, puncture into the anterior horn of the lateral ventricle in the direction of puncture. 4. Pre-puncture puncture Only for infants and young children with anterior and posterior patency. The puncture point is at the outermost end of the anterior temporal angle, and the lumbar puncture needle is used to puncture under local anesthesia without cutting the opening skin. The puncture direction is the same as the anterior angle puncture method. The anterior iliac crest is parallel to the sagittal plane. complication 1. Intraventricular, subdural or epidural hemorrhage. 2. Acute brain edema and sudden increase in intracranial pressure. 3. The vision suddenly drops or even becomes blind. 4. Local or intracranial infections.