Ventricular Access Device

The placement of a ventricular access device (VAD) is not an emergency procedure and in older children and adults this is performed in the operating room. However, for neonates, and especially premature neonates, these devices can be easily implanted at the bedside, avoiding unnecessary patient movement. They are accessed very easily and, as they are entirely subcutaneous, have less risk of infection than the ventriculostomy.

Indications

Used almost exclusively in neonates following intraventricular hemorrhage as a temporizing measure until the child is large enough to receive a permanent VP shunt.

Procedure

The device is placed in the lateral corner of the anterior fontanelle and this region is prepped and draped in a sterile fashion. For this procedure, a 'cut- down' tray from the operating room is very helpful.

A curvilinear incision is made and the scalp flap is retracted laterally, as with a ventriculostomy. A small subgaleal pocket is fashioned over the parietal bone just posterior and lateral to the incision. The dura in the corner of the fontanelle is dissected free of the inner surface of the skull and a small opening is made with a hand held cautery or #11 scalpel. The VAD, which has been flushed with saline, is then inserted into the pocket with the flat side towards the skull, and the small catheter is slipped through the durotomy into the lateral ventricle aiming perpendicular to the brain surface. A 25-gauge needle on a syringe is used to access the reservoir and ensure flow of CSF. The wound is closed with absorbable skin sutures.

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