Technical Note
Methods and Devices for Posterior Ventriculoperitoneal Shunt Placement Surgery: 25
Years of Iterative Refinement
Mario Zanaty, Jorge A. Roa, Anthony J. Piscopo, Michael E. Kritikos, Nahom Teferi, Matthew A. Howard, III
- BACKGROUND: The posterior ventriculoperitoneal shunt
(VPS) placement procedure is technically efficient and
cosmetically appealing. The main limitations of the posterior
approach relate to the technical challenges associated with
accurately placing the ventricular catheter. In this report, we
describe methods and simple devices used for posterior VPS
surgery that have evolved over a >25-year period to enhance
catheter placement accuracy and reduce complication rates.
- OBJECTIVE: We describe the combination of methods
and customized devices used at a single institution to
perform posterior VPS surgery. Results are presented for
the most recent 11-year epoch, along with a description of
sources of technical errors and plans for further meth-
odologic refinements.
- MATERIALS AND METHODS: The medical records and
imaging studies of 468 patients undergoing posterior VPS,
from 2007 to 2018 were reviewed. Ventricular catheter
placement accuracy data were collected and complica-
tions were identified and recorded.
- RESULTS: Optimal ventricular catheter placement was
achieved in 98.29%. Of the remaining 1.71%, one half
(0.85%) required acute revision surgery. Four patients
(0.85%) developed new neurologic deficits following sur-
gery; 2 were related to intraparenchymal hemorrhages and
2 (0.43%) as a result of a misplaced catheter. The deficits
resulting from poor catheter placement were transient. The
complication rates due to causes other than catheter
placement accuracy compared favorably with those re-
ported previously in the literature.
Key words
- Hydrocephalus
- Normal-pressure hydrocephalus
- Posterior shunt
- Ventriculoperitoneal shunt
Abbreviations and Acronyms
CG: Caroline Guide
CSF: Cerebrospinal fluid
FHT: Free-hand technique
FS: Frameless stereotactic
MRI: Magnetic resonance imaging
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- CONCLUSIONS: Using the methods and devices
described in this series, posterior VPS operations can be
performed safely with a high degree of ventricular catheter
placement accuracy.
INTRODUCTION
V entriculoperitoneal shunt (VPS) procedures can be per-
formed using either a frontal or posterior ventricular
catheter approach. In patients with sufficiently large
ventricles, the posterior approach is an attractive option due to
the technical efficiency and cosmetic appeal of making a single
scalp incision. The primary disadvantage of the posterior
approach is that it can be more challenging to accurately and
safely place a ventricular catheter into the anterior horn of the
lateral ventricle using a posterior approach compared with a
frontal approach.1 With the frontal approach, easily recognized
visual landmarks can be used to localize the appropriate frontal
burr-hole entrance site, the appropriate trajectory angle can be
determined using visual landmarks or a simple tripod guide tube,
the distance separating the entrance point and the target is short,
and the planned trajectory is not in close proximity to critical
neural structures. In contrast, it is more difficult to select a
posterior catheter burr-hole entrance location due to the absence
of nearby visual landmarks. Also, the poster catheter trajectory is
longer and passes in close proximity to key periventricular
structures. For example, a misplaced posterior catheter that
damages the corticospinal tract can cause significant contralat-
eral motor deficits.
In the early 1990s, a simple device and surgical method was
developed to address these challenges and improve the accuracy
SHSP: Single-handed soft passer
VPS: Ventriculoperitoneal shunt
Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
To whom correspondence should be addressed: Matthew A. Howard, III, M.D.
[E-mail: matthew-howard@uiowa.edu]
Supplementary digital content available online.
Citation: World Neurosurg. (2019).
https://doi.org/10.1016/j.wneu.2019.05.148
Journal homepage: www.journals.elsevier.com/world-neurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2019 Published by Elsevier Inc.
www.journals.elsevier.com/world-neurosurgery 1
TECHNICAL NOTE
of the posterior ventricular catheter placements.2,3 The device
(Caroline Guide [CG]) is a C-shaped instrument with a catheter
guide tube that is designed in such a way that a catheter passed
through the tube will follow a straight-line trajectory between the
burr-hole entrance site and a frontal scalp target site.2,3 In the
original 1995 report, the clinical utility and accuracy of the CG
method was described in the first 38 patients treated at the
University of Washington and University of Iowa. The CG has
now been used routinely at the University of Iowa for more than
24 years, and this experience has led to further refinements in
the CG method. In this report, we describe the current CG
method, explain the rationale for methodologic modifications,
and provide clinical utility and catheter placement accuracy data
for the patients treated using the device in the most recent
11-year epoch (2007e2018, 468 patients).
MATERIALS AND METHODS
In this section, the CG device and posterior VPS method will
be described in detail, along with a description of how the
device and method has evolved since the original report.
These modifications were carried out to reduce the risks of
Figure 1. Components of the single-handed soft passer
(SHSP) and Caroline Guide (CG) system. The
ventricular catheter stylet cylinder (A) is controlled
using a thumb ring. An external cylinder (B) fits over the
stylet cylinder and is controlled with finger rings. The
CG (C) orients a slotted guide tube so that a catheter
passed through the guide tube will follow a trajectory
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complications and technical errors observed in the course of
more than 2 decades of routine clinical use. Data describing
the catheter placement accuracy and clinical utility of the CG
system for the most recent 468 patients will be presented in
the Results section. Patients were included if preoperative
brain imaging and postoperative computed tomography scan
were available for review, if they had a follow-up of greater
than 1 year, and if the CG device was used.
Surgical Devices
CG Body. The C-shaped body of the CG is designed to orient a
catheter guide tube, so that a ventricular catheter passed
through the tube will follow a straight trajectory toward the
anterior (frontal) target point (Figure 1). The dimensions of the
CG body accommodate the cranium of all patients. A blunt-
tipped conical piece delineates the anterior target. The pos-
terior bend of the body is fashioned as a “pistol grip” that
enables the surgeon to securely position the device by
grasping the grip with the left hand. The posterior portion of
the body contains a grooved section that accommodates a
slotted guide tube. The guide tube is reversibly secured to the
that intersects the frontal target post. The posterior
bend of the body is fashioned as a “pistol grip” that
enables the surgeon to securely position the device by
grasping the grip with the left hand. The posterior
portion of the body contains a grooved section that
accommodates a slotted guide tube. (D) Fully
assembled SHSP positioned within the CG guide tube.

CG body by a thumb screw. When secured, the guide tube is
oriented such that a line passing through the center of the
guide tube lumen will intersect the anterior target marker.
CG Slotted Guide Tube. The position of the CG guide tube rela-
tive to the CG body is adjustable, with the optimal position
being one whereby the anterior opening of the guide tube is
approximately 3 cm away from the burr hole during the
catheter insertion procedure. Slots were added to the guide
tube to facilitate visualization of cerebrospinal fluid (CSF) flow
from the catheter as soon as the apertures of the catheter tip
enter the ventricle. This visual cue, along with the tactile
feedback associated with a drop in mechanical resistance,
enables the surgeon to recognize when the tip of the catheter
has entered the ventricle, at which point the surgeon transi-
tions from a “hard-pass” to a “soft-pass” technique, using
the single-handed soft passer (SHSP) described to follow.
Single-Handed Soft Pass. The original CG used a rigid stylet to
advance the ventricular catheter. With this design, the cath-
eter was constrained to the precise linear path connecting the
burr-hole entrance site and anterior target. When an incorrect
trajectory was selected, the catheter could enter the poste-
rior portion of the lateral ventricle but then advance further
into periventricular brain tissue. This complication can largely
be avoided by using a “soft-pass” technique, whereby the
stylette is withdrawn from the tip of catheter after the cath-
eter has entered the ventricle.4 When using the CG, the
surgeon uses the left hand to hold the device in the proper
position while advancing the catheter with the right hand
(Figure 2). The SHSP was designed to enable catheters to
be soft passed using only one hand to control the position
of the stylette relative to the catheter, while also advancing
the catheter. As shown in Figure 2, after the catheter has
entered the ventricle, the surgeon pulls back on the SHSP
thumb ring to retract the stylette and then continues to
advance the “soft” catheter into the final position.
Figure 2. Single-handed soft passer (SHSP) catheter
insertion method. When using the Caroline Guide, the
surgeon uses the left hand to hold the device in the
proper position while advancing the catheter with the
right hand. The SHSP was designed to enable catheters
to be soft passed using only one hand to control the
position of the stylette relative to the catheter, while
also advancing the catheter. Thus, the ventricular
catheter is mounted to the stylette extension of the
attached internal cylinder. The position of the stylette is
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TECHNICAL NOTE
Frontal Target Template. The original CG method involved using
manual measurement techniques to delineate the anterior
catheter trajectory target on the patient’s forehead. The
intent is to select a point that is in the midline and 2 cm su-
perior to a line connecting the left and right orbital rims. In
rare instances, the manual technique proved inaccurate. To
address this problem, a triangular-shaped template was
designed (Figure 3). The template is secured to the forehead
when the patient is in the straight prone position. Left and
right orbital tabs are positioned flush with the superior
orbital rims and the template is centered using the bridge
of the nose as an orienting visual landmark. A circle in the
template delineates the place on the scalp where a pen is
used to mark the anterior target.
Posterior Burr-Hole Localization Devices. The most technically
demanding aspect of the CG procedure, and the most common
source of procedural error, relates to selecting the location of the
posterior burr hole. Localization errors can occur in the ros-
trocaudal and mediolateral axis. Manual measurement tech-
niques using the palpated external protuberance as an orienting
landmark are associated with high error rates.1,5 To address this
problem, we first developed a headband-based device to
delineate a burr-hole site 3 cm to the right of the posterior
midline and an appropriate distance above the external occipital
protuberance.2 This device proved cumbersome to use in
practice, particularly in the setting in which significant portions
of the patient’s hair is preserved. With both the manual
measurement and headband localization methods, we
observed that the most significant source of error was in the
medial
lateral targeting dimension. To address this problem,
we designed and now use routinely a new caliper-like device
(Wishbone) that attaches reversibly to the left and right external
meatus and directs a localizing laser to the cranial midline. A
technical report describing this “Wishbone” device is currently
under review. The Wishbone was used in the most recent 40
patients in this clinical series.
controlled by means of a thumb ring. An external
cylinder, mounted over top of the internal stylette
cylinder, is controlled by the surgeon using 2 finger
rings. After the ventricular catheter enters the ventricle,
the surgeon withdraws the stylette from the tip of the
catheter by pulling back on the thumb ring. This
“softens” the tip of the catheter as it is advanced into
the final insertion position by the pushing force of the
external cylinder controlled by the surgeon’s index and
middle fingers.
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TECHNICAL NOTE
Figure 3. Schematic drawing depicting the triangular
shaped frontal-target localizer. The localizer is centered
on the midline and small lateral tabs (A) are positioned
flush with the patient’s superior orbital rim. The center
of the localizer aperture (B) delineates the midline
target site, 2 cm above a line connecting the left and
Shunt Scissors. The ventricular catheter placement portion of
the CG procedure is just one aspect of the VPS procedure,
and a range of other complications and technical errors can
occur. One such complication can occur when the surgeon
creates the subgaleal pocket for the shunt valve. If that
pocket is too small, the valve-tubing assembly can be kinked
resulting in shunt malfunction. In adult patients, the
galea
periosteum interface caudal to the posterior burr-hole
location can be particularly dense and difficult to dissect us-
ing the stand blunt dissection method. To address this
problem, we designed shunt scissors that the surgeon uses
to easily create the subgaleal pocket using a sharp dissection
technique (Figure 4).6
Surgical Method
Permission for this study was provided by University of Iowa
Hospitals and Clinics institutional review board.
4 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.05.148
right superior orbital rims. This will serve as the area
whereas a modified Bovie pad will be placed
(Lennarson technique, see Figure 7). The Bovie pad will
serve as the frontal target where the anterior part of
the CG would rest.
Patient Selection. Patients must have sufficiently large ventricles
to be candidates for the CG procedure. A cross-section image is
selected that best demonstrates the lateral ventricles. A trajec-
tory line is then traced between an anterior and posterior target
point. The anterior point is at the midline and the posterior point is
3 cm to the right of the posterior superior sagittal sinus. The
trajectory line must traverse the ventricles with a clear margin for
lateral displacement error (Figure 5). Since the ventricular
anatomy was the main criteria for posterior shunt placement,
the majority of the patients were adults with normal-pressure
hydrocephalus (>85%). Other indications were pediatric hy-
drocephalus, and adults with secondary hydrocephalus, or
adults with congenital hydrocephalus who underwent shunt
revision via the posterior approach. Since the study focuses on
technical aspects to avoid intraoperative complications, we
accepted the diverse etiology of hydrocephalus, as long as the
ventricular anatomy was suitable for posterior shunting.

Figure 4. Photographs of shunt scissors in the blades closed (A) and
blades open (B) configuration. The handle and blade are angularly offset
so that the blades are separated by 40 in the blade open position when
the handles are closed. The external surfaces of the scissor blades are
sharpened to facilitate dissection of the subgaleal plane. The shunt
scissor is used to create a large pocket without extensive bleeding.
Marking the Anterior Target and Posterior Burr-Hole Sites. The
triangular anterior target template is used to mark the target
site on the forehead scalp. The Wishbone method is used to
mark the posterior midline. A line parallel to and 3 cm to the
right of, the posterior midline is marked. The rostrocaudal
localization of the burr-hole site is determined by projecting a
line from the anterior target, back towards the posterior
target, with the trajectory passing over the superior attach-
ment of the ear by 4 cm (w2 finger breaths). The point of
intersection between this line and the 3 cm right paramedian
line is selected as the burr-hole entry site (Figure 6).
Positioning, Prepping, and Draping. The patient is positioned
supine on a horseshoe headrest, with a log roll under the right
shoulder. The head rotated leftward sufficiently to expose the
posterior midline. Drapes are folded, positioned and stapled
around the anterior skull and face in such a manner as to
leave the anterior target mark on the forehead exposed. That
area is covered with a transparent iodine sticky drape so that
the target mark can be clearly visualized at the completion of
the draping procedure. A Bovie cleaning pad (Symmetry
Surgical, Antioch, Tennessee, USA) is modified by using a 15
blade scalp to create a central w4  4 mm square aperture in
the center of the pad. The pad is then affixed to the patient’s
forehead with the aperture centered over the anterior target
mark (Figure 7).
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TECHNICAL NOTE
Figure 5. Preoperative magnetic resonance scan from a representative
patient depicting the method for determining the feasibility of using a
posterior ventricular catheter placement technique. An axial image
traversing the bodies of the lateral ventricles is selected. A planned
posterior entry point is then selected that is 3 cm to the right of the
midline. A catheter trajectory is plotted between the entry point and an
anterior midline scalp target point. In order for the patient to be a suitable
candidate for posterior ventriculoperitoneal shunt surgery, the planned
trajectory must traverse the right lateral ventricle with >5-mm clearance
of the lateral wall of the ventricle.
Scalp Incision and Burr-Hole Placement. A horseshoe scalp incision
is centered on the burr-hole site with the open end of the
horseshoe facing caudally. Shunt scissors are used to create a
subgaleal pocket to accommodate the shunt valve and tubing.
The scalp flap is secured rostrally using a 2e0 suture. A burr
hole is created in the standard fashion and the underlying dura
is widely opened, to avoid exerting deflecting forces on the
ventricular catheter as it is advanced into the brain.
Assembling the CG and SHSP. The peritoneal catheter is passed
from the cranial incision to the abdomen surgical site and
connected to the valve and reservoir before the CG and SHSP
are assembled. The slotted guide tube is secured to the body of
the CG with an orientation that allows the surgeon to clearly
visualize the slots during the catheter placement procedure.
The ventricular catheter is cut to the appropriate length
(w10e12 cm, based on computed tomography scan mea-
surements) and mounted onto the SHSP with the stylette in
the fully extended position, flush with the tip of the catheter.
Positioning the CG and Passing the Ventricular Catheter. An assis-
tant helps the surgeon optimally position the CG on the
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TECHNICAL NOTE
Figure 6. Lateral radiograph and schematic depiction of the method used
to plan the rostrocaudal location of the posterior burr hole. The surgeon
aligns a straightedge to visualize a line projecting posteriorly from the
frontal target point that passes w4 cm (2 finger breadths) above the
superior attachment point (SAP) of the external ear. The posterior
midline scalp is marked where this imaginary line intersects the posterior
boundary of the skull. This typically places the rostrocaudal planning
mark at a location that is approximately 7 cm superior to the external
occipital protuberance (dark triangle).
patient’s head. For optimal ergonomic efficiency and burr-
hole visualization, the surgeon sits on a stool during the
catheter placement procedure. The anterior target piece of
the CG is placed in the Bovie pad aperture and the body of the
CG is held in place by the surgeon using his left hand. The
position of the guide tube is adjusted so that the anterior
opening of the guide is suspended w3 cm away from the burr
hole (Supplementary Figure 4). This allows the surgeon to
clearly visualize the catheter passing through the dural
opening without bending or torqueing the catheter as it is
being advanced. The surgeon uses the right hand to
advance the catheter through the guide tube, into the brain,
using the SHSP. As soon as the ventricle is entered and
CSF egress is noted, the stylette is retracted and the
catheter is advanced into its final position. An assistant
uses smooth forceps to secure the catheter as the CG is
removed. The ventricular catheter is then attached to the
reservoir, and the complete shunt assembly is advanced
caudally so that the valve is positioned within the subgaleal
pocket (without kinking). The distal end of the catheter is
placed in the abdomen using standard VPS techniques.
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Figure 7. Intraoperative photographs demonstrating the Lennarson
technique for placing a modified Bovie pad over the anterior target site.
An Ioban drape (3M, Maplewood, Minnesota, USA) has been placed
over the exposed portion of the frontal scalp to create a transparent
sterile barrier. An ink mark delineating the anterior target on the frontal
scalp is visible through the Ioban drape. A Bovie cleaning pad is modified
by using a 15 blade scalp to create a w4  4 mm square aperture in the
center of the pad. The pad is then affixed to the patient’s forehead with
the aperture centered over the anterior target mark. The aperture serves
as a docking site for the frontal target post of the Caroline Guide.
Data Analysis
Data analysis was performed in R (3.5.1; R Foundation for
Statistical Computing, Vienna, Austria) and GraphPad Prism 7
(GraphPad Software, San Diego, California, USA). Descriptive
statistics without inference was performed (no comparative
groups). The following rates were calculated per patient, as
they were deemed immediately related to the technique:
new onset of neurologic deficits related to shunt placement
(and whether the deficit was sustained for greater than 6
weeks), postoperative hemorrhage, and errant placement of
the ventricular tip. The rate of infection and proximal and
distal malfunction were calculated based on the total number
of events (i.e., infection) divided by the total patient pop-
ulations. Thus, if a patient had 2 complications, such as
proximal revision followed by infection, this would count as 2
complications for the primary surgery, and not as 2 compli-
cations from 2 surgeries. This is intentional, to avoid the un-
derestimation of the complication rates.
RESULTS
We identified 468 CG VPS operations in a retrospective review of
the University of Iowa Electronic Medical Record system from

2007 to 2018. The procedures were performed by multiple
neurosurgical attendings in patients with a broad range of hy-
drocephalus etiologies (age range: 11e90 years). The age distri-
bution was the following: 412 (88.03%) patients were older than
60 years; 47 (10.04%) patients were between 18 and 60 years;
and 9 (1.92%) patients were younger than 18 years of age. All the
patients had significantly large ventricles with large posterior
horns. The majority of our patients had normal-pressure hydro-
cephalus (>85%).
Postoperative imaging showed that in 98.29% of cases (n ¼ 460)
the tip of the ventricular catheter was positioned within either the
anterior horn of the ipsilateral (n ¼ 393) or contralateral (n ¼ 67)
lateral ventricle. Thus, optimal position (ipsilateral) was achieved
in 85.43% and suboptimal (contralateral) in 14.31% of the cases.
In 8 cases (1.71%), the catheter tip was positioned in either
periventricular white matter, or the atrium or inferior horn of the
lateral ventricle. Four of these patients (0.85%) underwent im-
mediate revision of the poorly placed ventricular catheter. In this
series, 4 patients (0.85%) sustained new neurologic deficits as a
result of the shunt placement procedure due to intraparenchymal
hemorrhage (n ¼ 2) or errant placement of the ventricular cath-
eter (n ¼ 2). In the 2 cases in which a misplaced ventricular
catheter caused neurologically injury, patients recovered fully
within 6 months of surgery based on the results of neurologic
exams performed in the outpatient clinic.
Other delayed complications included shunt system disconnec-
tion at the level of the valve (1.07%), shunt infection (2.56%),
proximal failure (8.97%), distal obstruction (4.91%), and back-out
of the peritoneal catheter (1.50%). The proportion of patients
who subsequently required shunt ligation due to acute or chronic
refractory symptomatic subdural hematoma was 1.71%. A pro-
grammable valve was used in all cases. Our overall incidence of
shunt revision during the entire follow-up period was 21.34%.
With minimal training and experience, the CG method for ven-
tricular catheter placement becomes a simple, efficient and safe
surgical technique. Compared with a free-hand technique (FHT),
use of the CG method adds less than 5 minutes to the total
operative time for a posterior VPS operation. The posterior burr-
hole localization procedure took less than 3 minutes with the
Wishbone device.
DISCUSSION
The posterior VPS operation is an appealing shunt surgery option
because of its technical efficiency and minimal cosmetic impact
on the patient. The primary limitation of the procedure, and the
consideration that causes many surgeons to select the frontal
VPS method instead, relates to the technical challenges of
accurately and safely placing a posterior ventricular catheter. In
this report, we describe a system of devices and methods that
have been used in an evolving fashion to improve the accuracy of
posterior catheter placement over the last 25 years. The occipital
approach is known to have the smallest margin of errors due to
the small range of possible angles for successful ventricular
cannulation, as Lind et al.1 demonstrated. This, combined with
the lack of a clear anatomical landmark for localizing the
posterior burr-hole site, makes this a more technically chal-
lenging VPS procedure and stresses the need for instrumentation
that assists with burr-hole localization and catheter trajectory
determination. The CG method was developed to address this
challenge and is effective at insuring that a ventricular catheter
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TECHNICAL NOTE
follows the straight line trajectory from a posterior burr hole to an
anterior target site.2 However, the CG alone does not address
errors in burr-hole localization. Other devices and methods,
including most recently a caliper-based system, have been
designed and tested to address the burr-hole localization chal-
lenge. The present series shows that using these devices and
methods the tip of the ventricular catheter was placed in the
anterior horn of the ipsilateral or contralateral lateral ventricle in
98.3% of patients. This compares favorably with the reports of
catheter placement accuracy and revision rates using the FHT
and shows similar results to the frameless stereotactic (FS)
methods.5,7 Jung and Kim5 compared FS with FHT in posterior
VPS. They reported a 28% rate of suboptimal positioning using
the FHT compared with 7% using FS. In the Jung and Kim
series of 72 patients, the rate of revision from proximal
obstruction was 31.11% and 11% for FHT and FS,
respectively, where 4% of the FHT cases had to be revised
due to catheter malposition. In our series, 0.9% had to be
revised due to catheter malposition, and the cumulative rate of
proximal obstruction during the period of follow-up was 9.0%.
Our overall incidence of shunt revision was 21.7%, which is
similar to rates reported in the literature (15%
38.5%).8-11
Similarly, our postoperative infection rate compares favorably
with those reported in the literature (2.5% vs. 2%
10%).9,11,12
A recent meta-analysis of 11 studies (adult and pediatric patients)
showed an overall shunt functional survival rate of 55.8% to
84.1% for the FHT and from 67.2% to 97.1% for shunts placed
using image guidance.13 The rate of accurate catheter placement
using image guidance was generally greater in case series
(range, 95.2%
100%) than in cohort studies (range, 55.3%

100%). The authors concluded that use of intraoperative
navigation will reduce the risk of proximal malfunction due to
catheter malposition but may increase the infection rate.13 This
meta-analysis, however, did not describe or delineate whether
posterior or frontal surgical approaches were used to place the
ventricular catheter.
Compared with the FS technique, the CG device and method are
less expense and more time-efficient. FS systems are more
complicated to use because they require skillful implementation
of image registration and related tasks.14 However, even though
the CG method is less complex, the surgeon must still pay
meticulous attention to every technical detail of the procedure
to achieve optimal results. Common sources of technical error
are briefly discussed to follow.
The most common and clinically significant technical error that
occurs is linked to poor localization of the posterior burr-hole site
due to an inaccurate localization of the posterior midline. When
the burr hole is placed too medial, the catheter trajectory may
traverse sulci of medial hemisphere cortex, rupture sulcal ves-
sels, and cause an intraparenchymal hemorrhage (2 patients in
this series, 0.43%; Supplementary Figure 1). Medial burr-hole
placement can also increase the probability of contralateral can-
nulation of the ventricle, particularly if the SHSP device is not
deployed properly. A laterally placed burr hole can lead to errant
placement of the ventricular catheter into periventricular tissue
and potentially damage the corticospinal tract (Supplementary
Figure 2). Since the Wishbone device was invented to localize
the midline, we only had 2 posterior burr holes that were not
accurately placed but did not result in any malposition of the
ventricular catheter requiring revision. We only used the
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TECHNICAL NOTE

midline localizing device on 40 patients thus far, so we do not Limitations

have a significant number to perform a meaningful analysis. A
low burr-hole placement can result in a catheter position in the
temporal horn, temporal lobe, basal cisterns, thalamus, or
midbrain (Supplementary Figure 3).
The SHSP is designed to reduce the risk of complications when a
suboptimal catheter trajectory is selected, but it must be used
properly to be effective. In the absence of a rigid stylette, the
malleable catheter tip will typically stay within the ventricular
system after the cavity has been entered. The SHSP is designed
to achieve this objective, but our experience has shown that
effective use of the device requires careful attention to every
detail of its implementation. In some instances an inexperienced
surgeon will fail to recognize the signs of the catheter’s initial
entry into the ventricle (i.e., drop in mechanical resistance and
flash of CSF observed in the slotted guide tube) and fail to
withdraw the stylette as the catheter is advanced. In that
circumstance, if an improper trajectory has been selected, the
rigid catheter will traverse the ventricle and then enter periven-
tricular brain tissue. The surgeon typically recognizes this error
when a significant proportion of the catheter total length has
been introduced into the brain but there is no CSF egress from
the lumen. This pitfall can be avoided when the surgeon acquires
the ability to recognize the signs of ventricular entry and use the
SHSP properly.
Our study is limited by the lack of a control group for direct
comparison. This is due to the CG being the standard of care for
posterior VPS in our institution. The functional outcomes
(whether surgery was helpful in symptom control) were also not
evaluated, given the heterogenous population. The follow-up
period is also heterogenous, as patients with complications
were followed for a longer duration than patients who did not
have any complications. However, we cannot rule out that these
patients that were lost to follow-up had undergone surgeries in
other institutions. However, the aim of the paper is to describe
the techniques that lead to a reduced intraoperative risk of the
procedure. Finally, We did not perform the Evans ratio, since the
posterior shunt was performed only when the posterior ventri-
cles were dilated, there was a short distance from the occipital
surface to the ventricles, and the trajectory line must traverse the
ventricles with a clear margin for lateral displacement error, as
detailed in the Indications section.
CONCLUSIONS
The Iowa posterior shunt placement method is a simple, multi-
step technique for safely and accurately placing a VPS. Iterative
methodologic and device refinements over the last 3 decades
have steady improved ventricular catheter placement accuracy
and reduced complication rates.

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Conflict of interest statement: Dr. Howard and Dr. Zanaty
are listed as inventors on a provisional patent application
filed at the University of Iowa for the “Wishbone” device
used in this manuscript. The “Wishbone” is the only
component of the system to which the patent applies. All
the other patents have expired. All of the devices
described in this report were fabricated in the University
of Iowa Medical Instruments Shop. Surgeons at other
institutions have fabricated Caroline Guide devices at their
own hospitals or used devices that were manufactured at
the University of Iowa and shipped to their institutions in
support of collaborative device development research
projects. None of the devices are protected by issued U.S.
patents. A provisional patent has been filed by the
University of Iowa for the Wishbone midline localizer.
Work is underway to enable hospitals to purchase
Caroline Guide systems through a non-profit, university-
based medical device company (MADE) that is part of the
University of Iowa.
Received 16 April 2019; accepted 16 May 2019
Citation: World Neurosurg. (2019).
https://doi.org/10.1016/j.wneu.2019.05.148
Journal homepage: www.journals.elsevier.com/world-
neurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2019 Published by
Elsevier Inc.

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Supplementary Figure 1. Computed tomography (CT)
images from a patient who sustained a complication
related to placing the posterior burr hole too medially. The
CT scan on the left shows the center of the burr hole is
w16 mm lateral to the center of the posterior superior
Supplementary Figure 2. Computed tomography images from a patient
who sustained a transient neurologic deficit due to poor catheter
placement resulting from placement of the posterior burr hole too
laterally. In this case the center of the burr hole was placed 4.5 cm to
WORLD NEUROSURGERY -: ---, MONTH 2019
TECHNICAL NOTE
sagittal sinus, instead of the planned 3 cm. The too-medial
trajectory resulted in the catheter traversing medial
hemisphere sulci and causing an intracerebral hemorrhage
resulting in visual field loss.
the right of the midline. The catheter traverses brain tissue lateral to the
lateral ventricle in close proximity to the corticospinal tract. Proximal
shunt revision surgery was required.
www.journals.elsevier.com/world-neurosurgery 8.e1
TECHNICAL NOTE

Supplementary Figure 3. Computed tomography images from a patient error, and the failure of the surgeon to properly deploy the single-
with a burr-hole localization error in the rostrocaudal dimension. In this handed soft passer when the catheter entered the ventricle, the tip of
case the burr hole was positioned too low (caudal); 4 cm above the the ventricular catheter was positioned in periventricular brain tissue
external occipital protuberance instead of 7. Due to this localization adjacent to the third ventricle.

8.e2 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.05.148

 TECHNICAL NOTE

Supplementary Figure 4. An intraoperative figure of the the center of the guide tube lumen will intersect the
surgeon using the Caroline Guide. The front part is on the anterior target marker. The surgeon is using the single-
frontal template and the posterior part is at the burr hole. handed soft passer technique.
The guide tube is oriented such that a line passing through

WORLD NEUROSURGERY -: ---, MONTH 2019 www.journals.elsevier.com/world-neurosurgery 8.e3