Intraventricular or Intracisternal Drug Delivery

Intraventricular or intracisternal drug delivery is primarily used in patients with head and neck pain (such as refractory cluster headaches or trigeminal neuralgia) who have not had success with conservative measures, or for treatment of certain neoplastic processes (abnormal tissue growth).

The ventricles and cisterns are small fluid-filled spaces with interconnected channels in the subarachnoid space near the base of the brain. Drug delivery to one of these areas bypasses the blood-brain barrier. (1) Direct drug administration also requires less medication, and causes fewer side effects than oral dosing.

The medicine is delivered through an implanted catheter connected to a pump, which contains a reservoir of medication and controls the rate of delivery. The reservoir system may be programmable, and either implanted or external.

In this mode of drug delivery, the medication is released into the cerebrospinal fluid (CSF) of the cisterna magna. The catheter can either be introduced between the first and second cervical vertebrae (C1-C2 interspace) or into the intracranial ventricles. Either route allows the medication delivered through the catheter to flow to the cisterna magna. In this area, cerebrospinal fluid pools, and blood vessels or nerves may pass through.

Evaluation
A comprehensive preoperative evaluation will determine if a patient is a good candidate for intraventricular or intracisternal drug delivery. Preoperative scans, such as computed tomography (CT) and magnetic resonance imaging (MRI), are obtained.

This type of drug delivery often involves a trial process prior to implantation of the drug delivery system. Trials should take place in an intensive care unit. During a trial, patients will be monitored for adverse events such as mental clouding, visual hallucinations, seizures, somnolence, respiratory depression, or coma. Patients should be monitored during the trial in the intensive care unit until an optimal dose of medication is achieved. (2)

If the intraventricular or intracisternal drug delivery device will be fully implanted, the procedure should take place about 3-4 weeks after the trial period. At that time, the drug reservoir is implanted under the skin, usually in the abdomen, in a “pocket” between skin and muscle tissue. Ongoing treatment may involve multiple dose adjustments over time.

Future considerations for research about this drug delivery method include studying administration of non-opioid medications, and development of long-term data on safety and efficacy.

References:

1. Cook AM, Mieure KD, Owen RD, Pesaturo AB, Hatton J. Intracerebroventricular administration of drugs. Pharmacotherapy. 2009 Jul;29(7):832-45. doi: 10.1592/phco.29.7.832. Review. PubMed PMID: 19558257.

2. Lee DJ, Gurkoff GG, et al. Intracerebroventricular opiate infusion for refractory head and facial pain. World J Clin Cases. 2014 Aug 16; 2(8): 351-356.

3. Roguski M, Rughani A, et al. Survival following Ommaya reservoir placement for neoplastic meningitis. J Clin Neurosci. 2015 Sep; 22(9): 1467-72.


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Direct delivery of agents intracisternally or intraventricularly bypasses the first pass effect of agents that are delivered orally and diffuse into the substance of the spinal cord/ and or brain . . .


Submitted Nov. 2, 2016
Samir Sheth, MD
Member, International Neuromodulation Society Public Education Committee, 2016
Assistant Professor, Pain Medicine
Director of Neuromodulation
University of California, Davis Health System
Sacramento, California, USA

Last Updated on Tuesday, April 25, 2017 11:59 AM