Predominance of ventricular catheter misplacement with anterior approach in neonates and infants

Background: Ventricular puncture is crucial in hydrocephalus management, especially in shunt surgery, where accurate catheter placement is essential for shunt survival. Despite the high malposition rate associated with freehand insertion, image-guided techniques remain underutilized. The anterior approach predominates globally, though debate continues over the merits of anterior versus posterior routes. Methods: We retrospectively analyzed 106 anterior approach catheter insertions in hydrocephalus patients: neonates/infants (<1 year), children (1–15 years), and adults (60–65 years). Using postoperative computed tomography scans, we assessed catheter placement accuracy, cranial inclination at the puncture site, and trajectory deviation. Proper placement was defined as catheter tips located in the ipsilateral frontal horn or third ventricle. Results: Accurate placement was achieved in 76.4% of cases. Misplacement rates were highest in neonates/ infants (39.3%), significantly exceeding those in children (7.7%) and adults (4.2%) ( p < 0.01). Logistic regression identified younger age and greater cranial inclination (>37.2°) as key predictors of misplacement. Deviations from the ideal trajectory exceeding 12.9° (particularly coronal deviations >12.1°) were associated with increased misplacement and reduced shunt survival. Conclusion: Misplacement rates are significantly higher in neonates/infants, primarily due to anatomical differences. Image-guided techniques are recommended to improve catheter placement and shunt outcomes, particularly in younger patients.