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Jiang Y, Xie QS, Wu XJ, Shi XL, Huang JX, Wang SH, Zhao YQ, Hu RR, Chen W, Huang CG, Yu MK, Hou LJ. Introduction of a novel, continuous, non-invasive estimation of intracranial pressure and cerebral perfusion pressure based on tympanic membrane temperature. World Neurosurg 2022; 161:e688-e697. [DOI: 10.1016/j.wneu.2022.02.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 10/19/2022]
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Alcazar P, Casado Pellejero J. Letter to the Editor. The use of a shuntogram in the diagnosis of shunt failure. J Neurosurg Pediatr 2022; 29:234-235. [PMID: 34624837 DOI: 10.3171/2021.7.peds21364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Paula Alcazar
- 1Hospital Universitario Miguel Servet, Saragossa, Spain
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Mustroph C, Saberian S, Burch K, Parker P, Wrubel D, Sawvel M. Open Retroperitoneal Inferior Vena Cava Cannulation for Distal Ventriculoatrial Shunt Catheter Placement. Cureus 2022; 14:e21555. [PMID: 35228918 PMCID: PMC8865606 DOI: 10.7759/cureus.21555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2022] [Indexed: 11/05/2022] Open
Abstract
Multiple alternative sites for distal ventriculoperitoneal shunts have been described including pleural, atrial, ureteral, fallopian, and gallbladder placement. In medically complex patients the sites for cerebrospinal fluid (CSF) diversion can be exhausted. We present a case where open retroperitoneal inferior vena cava cannulation was used for successful atrial catheter placement in a 17-month-old female. The patient had a complex abdominal, pulmonary, and vascular history precluding placement of the distal catheter in other sites or atrial placement through more peripheral venous cannulation. The patient underwent uncomplicated open retroperitoneal exposure of her inferior vena cava (IVC) with cannulation and placement of atrial catheter under fluoroscopic guidance. At the follow-up one year after surgery, the patient did not require revision with appropriate placement of the distal atrial catheter.
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Kakadia B, Badger C, Zaher M, Kavi T. Comparison of Lumbar and Ventricular Cerebrospinal Fluid for Diagnosis and Monitoring of Meningitis. Neurohospitalist 2022; 12:151-154. [PMID: 34950405 PMCID: PMC8689542 DOI: 10.1177/19418744211008018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Severe meningitis, especially basilar meningitis, can lead to hydrocephalus requiring external ventricular drain (EVD) placement. There are differences in cerebrospinal fluid (CSF) obtained from an EVD compared to a lumbar puncture (LP). Hence, it becomes difficult to compare LP and EVD samples for diagnosis and monitoring of meningitis. Recognizing these differences is important to properly treat and discontinue antibiotics. We report a case series of 6 patients with meningitis comparing EVD and LP CSF study analysis. In all 6 patients, CSF from LP was obtained before EVD placement by 1.7 days on average. Although corrected white blood cell (WBC) counts were elevated in CSF obtained from LP and EVD, the counts were significantly higher in LP CSF. Protein concentration in LP CSF was also significantly higher than EVD CSF. Glucose and red blood cells varied in both LP and EVD samples. Even though EVD CSF was obtained later in the clinical course than LP, slower circulation of CSF in lumbar space as compared to ventricles is likely the reason for a more sterile appearance of EVD CSF for the diagnosis of meningitis. It is important to recognize these differences as EVD CSF analysis for diagnosis of meningitis may lead to a missed diagnosis and false perception of significant improvement when monitoring response to treatment. One can consider repeating LP prior to discontinuation of antibiotics to properly determine the extent of improvement given EVD CSF sample appears more sterile in comparison. Larger studies are needed to confirm the above findings.
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Affiliation(s)
- Bhavika Kakadia
- Department of Neurology, Rutgers New Jersey Medical School, Camden, NJ, USA,Bhavika Kakadia, Department of Neurology, Rutgers New Jersey Medical School, 150 Bergen Street, Newark, NJ 07103, USA
| | - Clint Badger
- Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Mazen Zaher
- Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Tapan Kavi
- Department of Neurocritical Care, OhioHealth Riverside Methodist Hospital, Columbus, OH, USA
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Almeida LCA, Costa BS, de Lima FBF. Cerebral venous sinus thrombosis as a consequence of shunt hyperdrainage: a proposal of the pathophysiological mechanism and case report. Childs Nerv Syst 2022; 38:25-32. [PMID: 34562131 DOI: 10.1007/s00381-021-05370-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/18/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND AIM Shunt dysfunction is a common event, especially in children who have this intervention performed early in life. The consequences of chronic shunt overdrainage can be multiple since the cerebral hydrodynamics is altered. A thrombotic event with consequent symptoms of intracranial hypertension is discussed in this article. MATERIAL AND METHODS We performed a detailed review of cerebral hydrodynamics and intracranial pressure compensation mechanisms and how this can alter cerebral venous circulation. Next, we report the case of a 4-year-old child with such a clinical presentation that was conducted by our team. RESULTS A child with a history of hydrocephalus treated with a ventriculo-peritoneal (VP) shunt in his early childhood presented with symptoms of intracranial hypertension, initial computed tomography (CT) demonstrating reduced-sized ventricles. Complementary investigation showed bilateral papilledema, cranial suture closure, changes compatible with Chiari type I, and venous sinus thrombosis (transverse and sigmoid, bilaterally). The case was managed conservatively with full anticoagulation with enoxaparin. Four months after the onset of symptoms, there was an improvement in the clinical and imaging status. CONCLUSION A condition of severe headache in a patient with an apparently functioning shunt and small ventricles on initial CT should open up a range of diagnostic possibilities, with pseudotumor cerebri syndrome and cerebral venous sinus thrombosis being suggested. The therapeutic approach in these cases must be individualized.
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Affiliation(s)
- L C Azevedo Almeida
- Centre for Neurology and Neurosurgery, Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil.
| | - B Silva Costa
- Centre for Neurology and Neurosurgery, Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil
| | - F B Faraj de Lima
- Centre for Neurology and Neurosurgery, Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil
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Xu J, Morchi G, Magge SN. Endovascular retrieval of a broken distal ventriculoatrial shunt catheter within the heart: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21452. [PMID: 36060425 PMCID: PMC9435548 DOI: 10.3171/case21452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/02/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Displacement of a distal catheter of a ventriculoatrial (VA) shunt is a rare complication and can lead to a challenging extraction requiring endovascular retrieval of the distal catheter. OBSERVATIONS The authors describe a patient in whom the distal catheter of the VA shunt had become displaced and traveled through the tricuspid valve into the right ventricular outflow tract. LESSONS In this case report, the authors present a multidisciplinary approach to retrieving a displaced distal catheter from a VA shunt.
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Affiliation(s)
- Jordan Xu
- Department of Neurosurgery, University of California, Irvine Medical Center, Orange, California
| | - Gira Morchi
- Division of Cardiology, CHOC Children’s Specialists, Children’s Hospital of Orange County, Orange, California; and
| | - Suresh N. Magge
- Department of Neurosurgery, University of California, Irvine Medical Center, Orange, California
- Division of Neurosurgery, CHOC Children’s Specialists, Children’s Hospital of Orange County, Orange, California
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Licci M, Zaed I, Beuriat PA, Szathmari A, Guibaud L, Mottolese C, Di Rocco F. CSF shunting in myelomeningocele-related hydrocephalus and the role of prenatal imaging. Childs Nerv Syst 2021; 37:3417-3428. [PMID: 34076708 DOI: 10.1007/s00381-021-05217-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/13/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Hydrocephalus is commonly associated with myelomeningocele (MMC). Indication and timing of cerebrospinal fluid (CSF) shunting are still a topic of discussion. The aim of this study was to investigate whether the analysis of prenatal cerebral imaging studies could provide information that is predictive of the necessity of CSF shunting in the postnatal period. MATERIAL AND METHODS Among 73 infants operated on because of MMC between January 2003 and June 2020, 50 had undergone prenatal and postnatal MRI studies and were considered for analysis. For each patient, frontal horn width, atrial ventricle diameter, third ventricle diameter, and subarachnoid spaces (sinocortical width, craniocortical width, and the interhemispheric width) have been measured on prenatal, postnatal, and a follow-up MRI study. The need of CSF shunting device placement in relation to prenatal and early postnatal MRI data was investigated. RESULTS Of the 50 infants, 31 (62%) developed a progressive hydrocephalus. Of these, 30 needed a CSF shunt and the majority of them (n=29) was operated on within 28 days after birth. One patient needed CSF shunt implantation at 45 days after birth and one child developed a late progressive hydrocephalus, successfully treated by ETV alone, at 14.2 months of age. All patients with an atrial ventricle diameter greater than 1.9 cm and a 3rd ventricle diameter larger than 0.3 cm on antenatal third trimester imaging have undergone CSF shunting within 1 month after birth. Conversely, all the children that did not undergo a CSF shunt placement showed an atrial cerebral ventricle diameter inferior to 1.2 cm and a 3rd ventricle width < 0.3 cm on antenatal imaging. Frontal horn width and subarachnoid CSF spaces' evolution did not seem to play a role. CONCLUSION The prenatal MRI assessment of the associated prenatal ventriculomegaly in MMC provides parameters that have a predictive value heralding the probability of a CSF diversion procedure after birth. In the same way, the analysis of intrauterine MRI studies may identify those subjects that are less at risk of developing a progressive hydrocephalus after birth, therefore encouraging a more cautious attitude towards the early implantation of CSF shunting devices in the current clinical practice.
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Affiliation(s)
- Maria Licci
- "Centre de compétence" MAVEM, Department of Pediatric Neurosurgery, Hôpital Femme Mère-Enfant, Hospices Civils de Lyon, 69003, Lyon, France
| | - Ismail Zaed
- "Centre de compétence" MAVEM, Department of Pediatric Neurosurgery, Hôpital Femme Mère-Enfant, Hospices Civils de Lyon, 69003, Lyon, France
| | - Pierre-Aurélien Beuriat
- "Centre de compétence" MAVEM, Department of Pediatric Neurosurgery, Hôpital Femme Mère-Enfant, Hospices Civils de Lyon, 69003, Lyon, France
| | - Alexandru Szathmari
- "Centre de compétence" MAVEM, Department of Pediatric Neurosurgery, Hôpital Femme Mère-Enfant, Hospices Civils de Lyon, 69003, Lyon, France.,Department of Pediatric Radiology, Hôpital Femme Mère-Enfant, Hospices civils de Lyon, 69003, Lyon, France
| | - Laurent Guibaud
- Department of Pediatric Radiology, Hôpital Femme Mère-Enfant, Hospices civils de Lyon, 69003, Lyon, France
| | - Carmine Mottolese
- "Centre de compétence" MAVEM, Department of Pediatric Neurosurgery, Hôpital Femme Mère-Enfant, Hospices Civils de Lyon, 69003, Lyon, France.,Department of Pediatric Radiology, Hôpital Femme Mère-Enfant, Hospices civils de Lyon, 69003, Lyon, France
| | - Federico Di Rocco
- "Centre de compétence" MAVEM, Department of Pediatric Neurosurgery, Hôpital Femme Mère-Enfant, Hospices Civils de Lyon, 69003, Lyon, France.
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Wubie AB, Teshome GS, Ayele WE, Abebe F, Nigussie TM, Alemu YB, Mekonnen MS. Survival status and predictors of mortality among children who underwent ventriculoperitoneal shunt surgery at public hospitals in Addis Ababa, Ethiopia. Int J Neurosci 2021:1-9. [PMID: 34643151 DOI: 10.1080/00207454.2021.1986492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: Despite the increase in ventriculoperitoneal shunt surgeries performed for children with hydrocephalus, the potential complications and survival of patients after the procedure remains the major challenge for both clinical and public health aspects. This study intends to assess the survival status and scrutinize the predictive factors of mortality among children after a ventriculoperitoneal shunt.Methods: A retrospective cohort study was employed by reviewing charts of 337 systematically selected children who have undergone a ventriculoperitoneal shunt from 2016 to 2018 in Addis Ababa. The extraction tool was used for data collection, Epi-data version 4.4.2 for data entry, and Stata version-14 for cleaning and analysis. Kaplan-Meier curve, log-rank test, and life table were used to describe the data. Cox proportional hazard regression model was used for analysis. Any variable at p < 0.25 in the bi-variable analysis was fitted to multivariate analysis, and significance was declared at p ≤ 0.05. Then, AHR with 95% CI was used to report the association and test the statistical significance. Finally, texts and tables were used to present the results.Results and Conclusion: The incidence rate of mortality was 58.4 per 1000 child-months of observation with a median survival time of 12 months (95%CI: 9.04-14.96). Communicative hydrocephalus (AHR: 1.99, 95% CI: 1.18-3.36), post-traumatic brain injury (AHR: 7.43, 95% CI: 3.21-16.88), emergency surgery (AHR: 1.86, 95% CI: 1.17-3.13) as well as revised shunt procedure (AHR: 8.01, 95% CI: 6.12-13.43) were independent predictors of death. Besides, sunset eye (ARH: 2.01; 95% CI: 1.17-3.47), rapidly increased head size (ARH: 2.05, 95% CI: 1.14-3.37), prolonged antibiotics treatment (AHR: 2.46, 95% CI: 1.82-7.37), and gram-negative infections (AHR: 1.95, 95% CI: 1.60-12.64) were also significantly associated. Hence, health professionals ought to give special attention to patients with identified predictors.
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Affiliation(s)
- Azene Bantie Wubie
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
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Rennert RC, Brandel MG, Srinivas S, Prajapati D, Al Jammal OM, Brown NJ, Diaz-Aguilar LD, Elster J, Gonda DD, Crawford JR, Levy ML. Palliative endoscopic third ventriculostomy for pediatric primary brain tumors: a single-institution case series. J Neurosurg Pediatr 2021; 28:387-394. [PMID: 34359046 DOI: 10.3171/2021.3.peds20952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/29/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Children with nonoperative brain tumors, such as diffuse intrinsic pontine gliomas (DIPGs), often have life-threatening hydrocephalus. Palliative shunting is common in such cases but can be complicated by hardware infection and mechanical failure. Endoscopic third ventriculostomy (ETV) is a minimally invasive alternative to treat hydrocephalus without implanted hardware. Herein, the authors report their institutional experience with palliative ETV for primary pediatric brain tumors. METHODS The authors conducted a retrospective review of consecutive patients who had undergone palliative ETV for hydrocephalus secondary to nonresectable primary brain tumors over a 10-year period at Rady Children's Hospital. Collected variables included age, sex, tumor type, tumor location, presence of leptomeningeal spread, use of a robot for ETV, complications, ETV Success Score (ETVSS), functional status, length of survival, and follow-up time. A successful outcome was defined as an ETV performed without clinically significant perioperative complications or secondary requirement for a new shunt. RESULTS Fifteen patients met the study inclusion criteria (11 males, 4 females; average age 7.9 years, range 0.8-21 years). Thirteen patients underwent manual ETV, and 2 patients underwent robotic ETV. Preoperative symptoms included gaze palsy, nausea/vomiting, headache, lethargy, hemiparesis, and seizures. Tumor types included DIPG (3), intraventricular/thalamic glioblastoma (2), and leptomeningeal spread of medulloblastoma (2), anaplastic oligo-/astrocytoma (2), rhabdoid tumor (2), primitive neuroectodermal tumor (1), ganglioglioma (1), pineoblastoma (1), and embryonal carcinoma (1). The mean preoperative ETVSS was 79 ± 8.8. There was 1 perioperative complication, a wound breakdown consistent with refractory hydrocephalus. The mean follow-up was 4.9 ± 5.5 months overall, and mean survival for the patients who died was 3.2 ± 3.6 months. Two patients remained alive at a mean follow-up of 15.7 months. Palliative ETV was successful in 7 patients (47%) and unsuccessful in 8 (53%). While patients with successful ETV were significantly older (11.9 ± 5.6 vs 4.4 ± 4.1 years, p = 0.010), there were no significant differences in preoperative ETVSS (p = 0.796) or postoperative survival (p = 0.476) between the successful and unsuccessful groups. Overall, functional outcomes were similar between the two groups; there was no significant difference in posttreatment Karnofsky Performance Status scores (68.6 ± 19.5 vs 61.3 ± 16.3, p = 0.454), suggesting that including ETV in the treatment algorithm did not worsen outcomes. CONCLUSIONS Palliative ETV is a safe and potentially efficacious treatment option in selected pediatric patients with hydrocephalus from nonoperative brain tumors. Close follow-up, especially in younger children, is required to ensure that patients with refractory symptoms receive appropriate secondary CSF diversion.
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Affiliation(s)
| | | | | | | | | | | | | | - Jennifer Elster
- 3Pediatrics, University of California San Diego, La Jolla; and
- 4Rady Children's Hospital, San Diego, California
| | - David D Gonda
- Departments of1Neurological Surgery and
- 2Neurosciences, and
| | - John R Crawford
- 2Neurosciences, and
- 3Pediatrics, University of California San Diego, La Jolla; and
| | - Michael L Levy
- Departments of1Neurological Surgery and
- 2Neurosciences, and
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Rothrock RJ, Lu VM, Levi AD. Syrinx shunts for syringomyelia: a systematic review and meta-analysis of syringosubarachnoid, syringoperitoneal, and syringopleural shunting. J Neurosurg Spine 2021; 35:535-545. [PMID: 34330095 DOI: 10.3171/2020.12.spine201826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Syringomyelia is a debilitating, progressive disease process that can lead to loss of neurological function in patients already experiencing significant compromise. Syringosubarachnoid, syringoperitoneal, and syringopleural shunts are accepted treatment options for patients with persistent syringomyelia, but direct comparisons have been lacking to date. The authors conducted a systematic review of the literature and meta-analysis to compare clinical outcomes between these three syrinx shunt modalities. METHODS Utilizing PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for systematic reviews, Ovid Embase, PubMed, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, American College of Physicians Journal Club, and Database of Abstracts of Review of Effectiveness were searched to identify all potentially relevant studies published from inception until July 2020. Data were extracted and analyzed using meta-analysis of proportions. The primary study outcome was the rate of reoperation based on the initial shunt modality. Secondary outcomes included clinical improvement, clinical deterioration, and complications following shunt placement. RESULTS A total of 22 articles describing 27 distinct treatment cohorts published between 1984 and 2019 satisfied the inclusion criteria. This captured 473 syrinx shunt procedures, 193 (41%) by syringosubarachnoid shunt, 153 (32%) by syringoperitoneal shunt, and 127 (27%) by syringopleural shunt, with an overall median clinical follow-up of 44 months. The pooled incidences of revision surgery were estimated as 13% for syringosubarachnoid, 28% for syringoperitoneal, and 10% for syringopleural shunts, respectively (p-interaction = 0.27). The rate of clinical improvement was estimated as 61% for syringosubarachnoid, 64% for syringoperitoneal, and 71% for syringopleural shunts. The rate of clinical deterioration following placement was estimated as 13% for syringosubarachnoid, 13% for syringoperitoneal, and 10% for syringopleural shunts. CONCLUSIONS The preferred modality of syrinx shunting remains a controversial topic for symptomatic syringomyelia. This study suggests that while all three modalities offer similar rates of clinical improvement and deterioration after placement, syringoperitoneal shunts have a greater rate of malfunction requiring surgical revision. These data also suggest that syringopleural shunts may offer the best rate of clinical improvement with the lowest rate of reoperation.
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Christian EA, Quezada JJ, Melamed EF, Lai C, McComb JG. Ventriculopleural shunts in a pediatric population: a review of 170 consecutive patients. J Neurosurg Pediatr 2021; 28:450-457. [PMID: 34388722 DOI: 10.3171/2021.3.peds2176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/24/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to determine the outcome of using the pleural space as the terminus for ventricular CSF-diverting shunts in a pediatric population. METHODS All ventriculopleural (VPl) shunt insertions or revisions done between 1978 and 2018 in patients at Children's Hospital Los Angeles were identified. Data recorded for analysis were age, sex, weight, etiology of hydrocephalus, previous shunt history, reason for VPl shunt insertion or conversion from a ventriculoperitoneal (VP) or ventriculoatrial (VA) shunt, valve type, nature of malfunction, presence of shunt infection or pleural effusion, and conversion to a different distal site. RESULTS A total of 170 patients (mean age 14 ± 4 years) with a VPl shunt who were followed up for a mean of 57 ± 53 months were identified. The reasons for conversion to a VPl shunt for 167 patients were previous shunt infection in 57 (34%), multiple abdominal procedures in 44 (26%), inadequate absorption of CSF in 34 (20%), abdominal pseudocyst in 25 (15%), and obesity in 7 (4%). No VPl revisions were required in 97 (57%) patients. Of the 73 (43%) patients who did require revision, the most common reason was proximal obstruction in 32 (44%). The next most frequent complication was pleural effusion in 22 (30%) and included 3 patients with shunt infection. All 22 patients with a clinically significant pleural effusion required changing the distal end of the shunt from the pleural space. Pleural effusion was more likely to occur in VPl shunts without an antisiphon valve. Of the 29 children < 10 years old, 7 (24%) developed a pleural effusion requiring a revision of the distal catheter to outside the pleural space compared with 15 (11%) who were older (p = 0.049). There were 14 shunt infections with a rate of 4.2% per procedure and 8.2% per patient. CONCLUSIONS VPl shunts in children younger than 10 years of age have a significantly higher rate of symptomatic pleural effusion, requiring revision of the shunt's terminus to a different location. VPl shunt complication rates are similar to those of VP shunts. The technical difficulty of inserting a VPl shunt is comparable to that of a VP shunt. In a patient older than 10 years, all else being equal, the authors recommend that the distal end of a shunt be placed into the pleural space rather than the right atrium if the peritoneal cavity is not suitable.
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Affiliation(s)
- Eisha A Christian
- 1Department of Neurological Surgery, Kaiser Permanente Medical Center, Los Angeles
| | | | | | - Carolyn Lai
- 2Division of Neurosurgery, Children's Hospital Los Angeles; and
| | - J Gordon McComb
- 2Division of Neurosurgery, Children's Hospital Los Angeles; and
- 3Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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The surface topography of silicone breast implants mediates the foreign body response in mice, rabbits and humans. Nat Biomed Eng 2021; 5:1115-1130. [PMID: 34155355 DOI: 10.1038/s41551-021-00739-4] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 04/28/2021] [Indexed: 02/07/2023]
Abstract
Silicone is widely used in chronic implants and is generally perceived to be safe. However, textured breast implants have been associated with immune-related complications, including malignancies. Here, by examining for up to one year the foreign body response and capsular fibrosis triggered by miniaturized or full-scale clinically approved breast implants with different surface topography (average roughness, 0-90 μm) placed in the mammary fat pads of mice or rabbits, respectively, we show that surface topography mediates immune responses to the implants. We also show that the surface surrounding human breast implants collected during revision surgeries also differentially alters the individual's immune responses to the implant. Moreover, miniaturized implants with an average roughness of 4 μm can largely suppress the foreign body response and fibrosis (but not in T-cell-deficient mice), and that tissue surrounding these implants displayed higher levels of immunosuppressive FOXP3+ regulatory T cells. Our findings suggest that, amongst the topographies investigated, implants with an average roughness of 4 μm provoke the least amount of inflammation and foreign body response.
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Hudson TQ, Baldwin A, Samiei A, Lee P, McComb JG, Meng E. A portable multi-sensor module for monitoring external ventricular drains. Biomed Microdevices 2021; 23:45. [PMID: 34542705 DOI: 10.1007/s10544-021-00579-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2021] [Indexed: 11/30/2022]
Abstract
External ventricular drains (EVDs) are used clinically to relieve excess fluid pressure in the brain. However, EVD outflow rate is highly variable and typical clinical flow tracking methods are manual and low resolution. To address this problem, we present an integrated multi-sensor module (IMSM) containing flow, temperature, and electrode/substrate integrity sensors to monitor the flow dynamics of cerebrospinal fluid (CSF) drainage through an EVD. The impedimetric sensors were microfabricated out of biocompatible polymer thin films, enabling seamless integration with the fluid drainage path due to their low profile. A custom measurement circuit enabled automated and portable sensor operation and data collection in the clinic. System performance was verified using real human CSF in a benchtop EVD model. Impedimetric flow sensors tracked flow rate through ambient temperature variation and biomimetic pulsatile flow, reducing error compared with previous work by a factor of 6.6. Detection of sensor breakdown using novel substrate and electrode integrity sensors was verified through soak testing and immersion in bovine serum albumin (BSA). Finally, the IMSM and measurement circuit were tested for 53 days with an RMS error of 61.4 μL/min.
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Affiliation(s)
- Trevor Q Hudson
- Department of Biomedical Engineering, University of Southern California, 1042 Downey Way, Los Angeles, CA, 90089, USA
| | - Alex Baldwin
- Department of Biomedical Engineering, University of Southern California, 1042 Downey Way, Los Angeles, CA, 90089, USA
| | - Aria Samiei
- Ming Hsieh Department of Electrical and Computer Engineering, University of Southern California, 3740 McClintock Avenue, Los Angeles, CA, 90089, USA
| | - Priya Lee
- Department of Biomedical Engineering, University of Southern California, 1042 Downey Way, Los Angeles, CA, 90089, USA
| | - J Gordon McComb
- Division of Neurosurgery, Children's Hospital Los Angeles, 1300 N. Vermont Ave. Suite 1006, Los Angeles, CA, 90027, USA
| | - Ellis Meng
- Department of Biomedical Engineering, University of Southern California, 1042 Downey Way, Los Angeles, CA, 90089, USA. .,Ming Hsieh Department of Electrical and Computer Engineering, University of Southern California, 3740 McClintock Avenue, Los Angeles, CA, 90089, USA.
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Azzam M, Wathoni RTZ, Suryaningtyas W, Parenrengi MA. Pediatric shunt revision analysis within the first year of shunt placement: A single center experience. Surg Neurol Int 2021; 12:419. [PMID: 34513183 PMCID: PMC8422432 DOI: 10.25259/sni_283_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/30/2021] [Indexed: 11/04/2022] Open
Abstract
Background Hydrocephalus is a common problem in neurosurgery with shunt placement remains the mainstay of the management. However, shunt placement generally requires following surgical procedures, including shunt revision. Despite the recent developments, the incidence of shunt failure remains high, approximately 30-51% in the 1st year following the shunt placement. Methods An observational retrospective study of pediatric neurosurgery patients whom underwent CSF shunting procedure, both primary and repeated VPS, VAS, CPS, and subdural-peritoneal shunt procedures between January 2018 and May 2019. The patients were observed for 12 months for potential complication requiring shunt revision following the shunt placement. Results A total of 142 patients underwent shunt placement. The shunt revision within 12 months was found in 26 patients (18.3%), 25 cases were VPS (96.2%) and one case was CPS (3.8%). The mean period of time between shunt placement to shunt revision was 3.96 months. Age of under 6 months old during the shunt placement showed significantly higher risk for shunt revision (RR 2.32 CI 1.13-4.74, P = 0.018). The most common diagnosis requiring shunt revision was congenital anomaly (16 cases, 61.5%). The most common cause of revision was shunt malfunction, with 21 cases (80.8%) followed by infected shunt with 5 cases (19.2%). Conclusion The 1st year observation showed relatively high rate for shunt revision. The patient underwent shunt procedure should be regularly followed up in long period for better evaluation of the outcome. The application of shunt registry in some countries appears to be efficient and beneficial for sustainable follow-up in patients underwent shunt placement.
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Affiliation(s)
- Muhammad Azzam
- Department of Neurosurgery, Dr. Soetomo General Academic Hospital, Surabaya, East Java, Indonesia
| | | | - Wihasto Suryaningtyas
- Department of Neurosurgery, Universitas Airlangga - Faculty of Medicine, Dr. Soetomo Academic General Hospital, Surabaya, East Java, Indonesia
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Aghayev K, Iqbal SM, Asghar W, Shahmurzada B, Vrionis FD. Advances in CSF shunt devices and their assessment for the treatment of hydrocephalus. Expert Rev Med Devices 2021; 18:865-873. [PMID: 34319823 DOI: 10.1080/17434440.2021.1962289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Hydrocephalus is a neurological disorder caused by excessive accumulation of the cerebrospinal fluid (CSF) in the ventricles of the brain. It can be treated by diverting the extra fluid to different parts of the body using a device called a shunt. This paper reviews different shunt devices that are used for this purpose. AREAS COVERED Shunts have high failure rates either due to infection or mechanical failure, therefore there is still ongoing work to address these two main handicaps. They require additional devices for performance assessment. Here, the paper also reviews different approaches for assessing shunt limitations. Moreover, future prospects are also discussed. EXPERT OPINION This study shows that shunt devices still remain an important treatment option for hydrocephalus. However, further efforts are required to design more advanced shunts, to eliminate high failure rates in clinical use. Sophisticated sensor systems that can accurately detect and regulate changes in CSF drainage to optimize drainage for individual needs. Moreover, shunt infection problem is still present despite recent improvements such as antibiotic impregnated catheters.
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Affiliation(s)
- Kamran Aghayev
- Department of Neurosurgery, Esencan Hospital, Esenyurt, Turkey
| | - Sheikh Ma Iqbal
- Department of Computer & Electrical Engineering and Computer Science, Florida Atlantic University, Boca Raton, FL, USA.,Asghar-Lab, Micro and Nanotechnology in Medicine, College of Engineering and Computer Science, Boca Raton, FL, USA
| | - Waseem Asghar
- Department of Computer & Electrical Engineering and Computer Science, Florida Atlantic University, Boca Raton, FL, USA.,Asghar-Lab, Micro and Nanotechnology in Medicine, College of Engineering and Computer Science, Boca Raton, FL, USA.,Department of Biological Sciences (Courtesy Appointment), Florida Atlantic University, Boca Raton, FL, USA
| | | | - Frank D Vrionis
- Department of Neurosurgery, Marcus Neuroscience Institute, Boca Raton Regional Hospital, Boca Raton, FL, USA
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Wong T, Gold J, Houser R, Herschman Y, Jani R, Goldstein I. Ventriculopleural shunt: Review of literature and novel ways to improve ventriculopleural shunt tolerance. J Neurol Sci 2021; 428:117564. [PMID: 34242833 DOI: 10.1016/j.jns.2021.117564] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 05/21/2021] [Accepted: 06/30/2021] [Indexed: 11/19/2022]
Abstract
Cerebrospinal fluid (CSF) diversion is among the most commonneurosurgical procedures that are performed worldwide. It is estimated thatapproximately 30,000 ventriculostomies are performed annually in the United States.Ventriculoperitoneal (VP) shunt malfunction rate within the first year of initialimplantation has been reported to be as high as 11-25%. In patients with abdominaladhesions, infections or multiple failed VP shunts, another bodily compartment shouldbe utilized as a substitute for the peritoneal cavity for distal shunt catheter placement.Ventriculopleural (VPL) shunting for hydrocephalus was first introduced by Heile in1914. Since the inception of this idea, VPL shunts have been utilized in select patientswith varying degrees of success. There have been a number of case reports andseries documenting unique complications with VPL shunting, with pleural effusion andpneumothorax being the most common complications. In our review article, we soughtto review the development of VPL shunting, pleuropulmonary physiology, insertiontechniques for VPL shunt, complications associated with VPL shunts, and uniquestrategies to improve VPL shunt tolerance.
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Affiliation(s)
- Timothy Wong
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark NJ, Doctor's Office Center 90 Bergen Street, Newark, NJ 07101-1709, United States of America
| | - Justin Gold
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark NJ, Doctor's Office Center 90 Bergen Street, Newark, NJ 07101-1709, United States of America.
| | - Ryan Houser
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark NJ, Doctor's Office Center 90 Bergen Street, Newark, NJ 07101-1709, United States of America
| | - Yehuda Herschman
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark NJ, Doctor's Office Center 90 Bergen Street, Newark, NJ 07101-1709, United States of America
| | - Raja Jani
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark NJ, Doctor's Office Center 90 Bergen Street, Newark, NJ 07101-1709, United States of America
| | - Ira Goldstein
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark NJ, Doctor's Office Center 90 Bergen Street, Newark, NJ 07101-1709, United States of America
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Ryan DJ, Kavanagh RG, Joyce S, O'Callaghan Maher M, Moore N, McMahon A, Hussey D, O'Sullivan MGJ, Wyse G, Fanning N, O'Connor OJ, Maher MM. Development and implementation of an ultralow-dose CT protocol for the assessment of cerebrospinal shunts in adult hydrocephalus. Eur Radiol Exp 2021; 5:26. [PMID: 34180040 PMCID: PMC8236421 DOI: 10.1186/s41747-021-00222-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/17/2021] [Indexed: 11/17/2022] Open
Abstract
Background Cerebrospinal fluid shunts in the treatment of hydrocephalus, although associated with clinical benefit, have a high failure rate with repeat computed tomography (CT) imaging resulting in a substantial cumulative radiation dose. Therefore, we sought to develop a whole-body ultralow-dose (ULD) CT protocol for the investigation of shunt malfunction and compare it with the reference standard, plain radiographic shunt series (PRSS). Methods Following ethical approval, using an anthropomorphic phantom and a human cadaveric ventriculoperitoneal shunt model, a whole-body ULD-CT protocol incorporating two iterative reconstruction (IR) algorithms, pure IR and hybrid IR, including 60% filtered back projection and 40% IR was evaluated in 18 adult patients post new shunt implantation or where shunt malfunction was suspected. Effective dose (ED) and image quality were analysed. Results ULD-CT permitted a 36% radiation dose reduction (median ED 0.16 mSv, range 0.07–0.17, versus 0.25 mSv (0.06–1.69 mSv) for PRSS (p = 0.002). Shunt visualisation in the thoracoabdominal cavities was improved with ULD-CT with pure IR (p = 0.004 and p = 0.031, respectively) and, in contrast to PRSS, permitted visualisation of the entire shunt course (p < 0.001), the distal shunt entry point and location of the shunt tip in all cases. For shunt complications, ULD-CT had a perfect specificity. False positives (3/22, 13.6%) were observed with PRSS. Conclusions At a significantly reduced radiation dose, whole body ULD-CT with pure IR demonstrated diagnostic superiority over PRSS in the evaluation of cerebrospinal fluid shunt malfunction. Supplementary Information The online version contains supplementary material available at 10.1186/s41747-021-00222-4.
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Affiliation(s)
- David J Ryan
- Department of Radiology, Cork University Hospital, Wilton, Cork city, T12 DC4A, Ireland.
| | - Richard G Kavanagh
- Department of Radiology, Cork University Hospital, Wilton, Cork city, T12 DC4A, Ireland
| | - Stella Joyce
- Department of Radiology, Cork University Hospital, Wilton, Cork city, T12 DC4A, Ireland
| | | | - Niamh Moore
- Department of Radiography, School of Medicine, Brookfield Health Sciences Complex, University College Cork, Cork, T12 AK54, Ireland
| | - Aisling McMahon
- Department of Medical Physics, Cork University Hospital, Wilton, Cork city, T12 DC4A, Ireland
| | - Deirdre Hussey
- Department of Neurosurgery, Cork University Hospital, Wilton, Cork city, T12 DC4A, Ireland
| | - Michael G J O'Sullivan
- Department of Neurosurgery, Cork University Hospital, Wilton, Cork city, T12 DC4A, Ireland
| | - Gerald Wyse
- Department of Radiology, Cork University Hospital, Wilton, Cork city, T12 DC4A, Ireland
| | - Noel Fanning
- Department of Radiology, Cork University Hospital, Wilton, Cork city, T12 DC4A, Ireland
| | - Owen J O'Connor
- Department of Radiology, Cork University Hospital, Wilton, Cork city, T12 DC4A, Ireland.,School of Medicine, University College Cork, Cork, Ireland
| | - Michael M Maher
- Department of Radiology, Cork University Hospital, Wilton, Cork city, T12 DC4A, Ireland.,School of Medicine, University College Cork, Cork, Ireland
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Determination of ventriculoperitoneal shunt dysfunction using optic nerve sheath diameter measurement on CT scan in pediatric patients with hydrocephalus. Childs Nerv Syst 2021; 37:1895-1900. [PMID: 33694128 DOI: 10.1007/s00381-021-05097-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 02/18/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE We aimed to evaluate whether optic nerve sheath diameter (ONSD) measurement by computed tomography (CT) can be a diagnostic criteria for the detection of ventriculoperitoneal shunt dysfunction among children whose fontanels are still open. METHODS Patients with a ventriculoperitoneal shunt who were currently showing clinical and radiological signs of acute hydrocephalus depending on the shunt dysfunction were included in this study. The study was designed to compare the preoperative and postoperative ONSDs of three groups of patients divided according to their ages: group 1, patients aged < 4 months; group 2, patients aged 4-18 months; and group 3, patients aged > 18 months. RESULTS We included 138 patients (mean age, 35.18 ± 51.01 months). Among the patients, 46.4% were females and 53.6% were males. ONSD measurements in the preoperative period were < 2.86 ± 0.59 in group 1, 3.93 ± 0.82 in group 2, and 5.40 ± 0.81 in group 3 and those in the postoperative period were 2.02 ± 0.38 in group 1, 2.72 ± 0.62 in group 2, and 3.64 ± 0.81 in group 3. Right, left, and mean ONSDs increased significantly in the three groups and were found to be statistically significant. CONCLUSION ONSD measurement in CT has been evaluated as an appropriate finding that can be used especially in acute hydrocephalus, when clinical and radiological findings are not diagnostic.
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Alarfaj A, Sankar T, Bhargava R, Tyler J, Walji A, Fox R, Sagga A, Ishaque A, Aronyk K. Magnetic resonance imaging analysis of human skull diploic venous anatomy. Surg Neurol Int 2021; 12:249. [PMID: 34221580 PMCID: PMC8247719 DOI: 10.25259/sni_532_2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/30/2020] [Indexed: 02/04/2023] Open
Abstract
Background: The skull diploic venous space (DVS) represents a potential route for cerebrospinal fluid (CSF) diversion and absorption in the treatment of hydrocephalus. The goal of this study was to carry out a detailed characterization of the drainage pattern of the DVS of the skull using high-resolution MRI, especially the diploic veins draining to the lacunae laterales (LLs) since the LLs constitute an important channel for the CSF to access the superior sagittal sinus and subsequently the systemic circulation. The objective was to identify those skull regions optimally suited for an intraosseous CSF diversion system. Methods: High-resolution, T1-weighted MRI scans from 20 adult and 16 pediatric subjects were selected for analysis. Skulls were divided into four regions, that is, frontal, parietal, temporal, and occipital. On each scan, a trained observer counted all diploic veins in every skull region. Each diploic vein was also followed to determine its final drainage pathway (i.e., dural venous sinus, dural vein, LL, or indeterminate). Results: In the adult age group, the frontal and occipital skull regions showed the highest number of diploic veins. However, the highest number of draining diploic veins connecting to the lacunae lateralis was found in the frontal and parietal skull region, just anterior and just posterior to the coronal suture. In the pediatric age group, the parietal skull region, just posterior to the coronal suture, showed the highest overall number of diploic veins and also the highest number of draining diploic veins connecting to the LL. Conclusion: This study suggested that diploic venous density across the skull varies with age, with more parietal diploic veins in the pediatric age range, and more occipital and frontal diploic veins in adults. If the DVS is ultimately used for CSF diversion, our anatomical data point to optimal sites for the insertion of specially designed intraosseous infusion devices for the treatment of hydrocephalus. Likely the optimal sites for CSF diversion would be the parietal region just posterior to the coronal suture in children, and in adults, frontal and/or parietal just anterior or just posterior to the coronal suture.
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Affiliation(s)
- Abdullah Alarfaj
- Department of Neurosurgery, University of Alberta, Alberta, Canada.,Departments of Neurosurgery, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Tejas Sankar
- Department of Neurosurgery, University of Alberta, Alberta, Canada
| | - Ravi Bhargava
- Department of Radiology, University of Alberta, Alberta, Canada
| | - Jonathan Tyler
- Department of Tyler Research Corporation, Alberta, Canada
| | - Anil Walji
- Department of Anatomy and Cell Biology, University of Alberta, Alberta, Canada
| | - Richard Fox
- Department of Neurosurgery, University of Alberta, Alberta, Canada
| | - Aziz Sagga
- Department of Neurosurgery, University of Alberta, Alberta, Canada.,Departments of Neurosurgery, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdullah Ishaque
- Department of Neurosurgery, University of Alberta, Alberta, Canada
| | - Keith Aronyk
- Department of Neurosurgery, University of Alberta, Alberta, Canada
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Gerges C, Wijesekera O, Herring E, Adesina A, Wright CH, Woodard J, Stout A, Rothstein B, Selden N, Wright J. Evaluation of Risk of Gastrostomy and Ventriculoperitoneal Shunt Placement in Pediatric Patients: A Systematic Review of the Literature. World Neurosurg 2021; 152:180-188.e1. [PMID: 34033958 DOI: 10.1016/j.wneu.2021.05.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 11/30/2022]
Abstract
A subset of patients with neurologic deficits require ventriculoperitoneal shunt (VPS) placement in addition to gastrostomy tubes (GTs). At present, the literature is inconsistent with respect to the sequence and time period between procedures that yields the lowest risk profile for GT and VPS placement. The purpose of this systematic literature review was to determine if time elapsed between VPS and GT placement was associated with infection (peritoneal and/or CSF). A systematic literature review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 guidelines. PubMEd/MEDLINE, Scopus, Ovid, Cochrane, and EMBASE databases were queried. Precise search terminology is available in the body of the manuscript. The initial database query yielded 88 unique articles. After abstract screening, 28 articles were identified and 6 met criteria for inclusion in the final analysis. The included studies were all retrospective analyses and reported data for 217 patients between the years of 1988 and 2016. Across all included studies, the infection rate after VPS and GT placement during the studies' surveillance period was 15.2% (n = 33/217). The cumulative rate of all reported complications in patients with both VPS and GT was 24.0% (n = 52/217). These studies suggest that placement of GT in patients with preexisting VPS does not significantly contribute to increased shunt or intraperitoneal infection. Future studies should determine the optimal time interval between VPS and GT placement and to identify the most appropriate prophylactic antibiotic regimen.
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Affiliation(s)
- Christina Gerges
- Case Western Reserve University, School of Medicine, Cleveland, Ohio, USA
| | - Olindi Wijesekera
- Case Western Reserve University, School of Medicine, Cleveland, Ohio, USA; Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Eric Herring
- Case Western Reserve University, School of Medicine, Cleveland, Ohio, USA; Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Adeleso Adesina
- Case Western Reserve University, School of Medicine, Cleveland, Ohio, USA
| | - Christina Huang Wright
- Case Western Reserve University, School of Medicine, Cleveland, Ohio, USA; Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jos'lyn Woodard
- Division of Pediatric Neurosurgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Amber Stout
- Core Library, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Brian Rothstein
- Case Western Reserve University, School of Medicine, Cleveland, Ohio, USA; Department of Neurosurgery, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Nathan Selden
- Division of Pediatric Neurosurgery, Oregon Health & Science University, Portland, Oregon, USA
| | - James Wright
- Case Western Reserve University, School of Medicine, Cleveland, Ohio, USA; Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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Copley PC, Emelifeonwu J, Gallo P, Sokol D, Kandasamy J, Wallace H, Kaliaperumal C. Guideline for the management of long tunnelled external ventricular drains in chronic hydrocephalus. ACTA ACUST UNITED AC 2021; 30:416-421. [PMID: 33830799 DOI: 10.12968/bjon.2021.30.7.416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article reports on the journey of a child with an inoperable hypothalamic-origin pilocytic astrocytoma causing hydrocephalus, which was refractory to treatment with shunts, and required a new approach. With multidisciplinary support, excellent nursing care and parental education, the child's hydrocephalus was managed long term in the community with bilateral long-tunnelled external ventricular drains (LTEVDs). This article describes the patient's journey and highlights the treatment protocols that were created to achieve this feat. Despite the difficulties in initially setting up these protocols, they proved successful and thus the team managing the patient proposed that LTEVDs are a viable treatment option for children with hydrocephalus in the context of inoperable tumours to help maximise quality of life.
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Affiliation(s)
- Phillip Correia Copley
- Neurosurgery Registrar, Department of Paediatric Neurosurgery, Royal Hospital For Sick Children, Edinburgh
| | - John Emelifeonwu
- Neurosurgery Registrar, Department of Paediatric Neurosurgery, Royal Hospital For Sick Children, Edinburgh
| | - Pasquale Gallo
- Neurosurgery Consultant, Department of Paediatric Neurosurgery, Royal Hospital For Sick Children, Edinburgh
| | - Drahoslav Sokol
- Neurosurgery Consultant, Department of Paediatric Neurosurgery, Royal Hospital For Sick Children, Edinburgh
| | - Jothy Kandasamy
- Neurosurgery Consultant, Department of Paediatric Neurosurgery, Royal Hospital For Sick Children, Edinburgh
| | - Hamish Wallace
- Paediatric Oncology Consultant, Department of Paediatric Oncology, Royal Hospital For Sick Children, Edinburgh
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The role of intraventricular antibiotic therapy in the treatment of ventriculo-peritoneal shunt infection in children. Childs Nerv Syst 2021; 37:1605-1612. [PMID: 33733692 DOI: 10.1007/s00381-021-05116-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND In this study, the effectiveness of intraventricular (IVT) antibiotic administration was evaluated in the treatment of ventriculo-peritoneal (VP) shunt infection by comparing patients who received only systemic antibiotic treatment with patients who received antibiotics added to systemic therapy by IVT route. METHODS From July 2009 to July 2019, 78 shunt infection episodes of 74 pediatric patients with bacterial growth in cerebrospinal fluid (CSF) culture who were treated with the diagnosis of VP shunt infection were retrospectively analyzed. The demographic data, clinical and laboratory parameters, antimicrobial management, and treatment outcomes of patients with VP shunt infections were recorded. RESULTS Thirty-eight of 78 shunt episodes received only systemic antibiotic treatment, and 40 had received IV plus IVT treatment. The mean age of the entire patient group was 16.7±21.3 months (range, 1 to 95 months). There was no significant difference between the two treatment groups in terms of mean age. The most common microorganism grown in CSF culture was coagulase-negative Staphylococcus. However, in the group that received IV plus IVT treatment, gram-negative bacteria were predominant (42.1% versus 20%), and this group had carbapenem-resistant and ESBL positive gram-negative bacteria growth. In the duration of CSF sterilization, hospital stay was statistically significantly shorter in the group receiving IV plus IVT treatment (p=0.000, p=0.000, respectively). CONCLUSION Our study shows that IVT administration of antibiotics shortens the duration of CSF sterilization, duration of antibiotic use, and the duration of hospital stay. For the treatment of VP shunt infection, the usage of IVT treatment in a particular group of a pediatric age is promising. However, further efforts should be done for supporting the current results by randomized controlled studies.
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Reisner A, Smith AD, Wrubel DM, Buster BE, Sawvel MS, Blackwell LS, Laxpati NG, Brahma B, Chern JJ. Utility of ventriculogallbladder shunts in complex cases of hydrocephalus related to extreme prematurity. J Neurosurg Pediatr 2021; 27:511-517. [PMID: 33636696 DOI: 10.3171/2020.9.peds20522] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 09/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The management of hydrocephalus resulting from intraventricular hemorrhage related to extreme prematurity remains demanding. Given the complexities of controlling hydrocephalus in this population, less commonly used procedures may be required. The authors examined the utility of ventriculogallbladder (VGB) shunts in a series of such children. METHODS The authors retrospectively reviewed the medical records of all children who underwent surgery for hydrocephalus in the period from 2011 through 2019 at Children's Healthcare of Atlanta. Six patients who underwent VGB shunt placement were identified among a larger cohort of 609 patients who had either a new shunt or a newly changed distal terminus site. The authors present an analysis of this series, including a case of laparoscopy-assisted distal VGB shunt revision. RESULTS The mean age at initial shunt placement was 5.1 months (range 3.0-9.4 months), with patients undergoing a mean of 11.8 shunt procedures (range 5-17) prior to the initial VGB shunt placement at a mean age of 5.3 years (range 7.9 months-12.8 years). All 6 patients with VGB shunt placement had hydrocephalus related to extreme prematurity (gestational age < 28 weeks). At the time of VGB shunt placement, all had complex medical and surgical histories, including poor venous access due to congenital or iatrogenic thrombosis or thrombophlebitis and a peritoneum hostile to distal shunt placement related to severe necrotizing enterocolitis. VGB complications included 1 case of shunt infection, identified at postoperative day 6, and 2 cases of distal shunt failure due to retraction of the distal end of the VGB shunt. In all, there were 3 conversions back to ventriculoperitoneal or ventriculoatrial shunts due to the 2 previously mentioned complications, plus 1 patient who outgrew their initial VGB shunt. Three of 6 patients remain with a VGB shunt, including 1 who underwent laparoscopy-assisted distal shunt revision 110.5 months after initial VGB shunt insertion. CONCLUSIONS Placement of VGB shunts should be considered in the armamentarium of procedures that may be used in the particularly difficult cohort of children with hydrocephalus related to extreme prematurity. VGB shunts show utility as both a definitive treatment and as a "bridge" procedure until the patient is larger and comorbid abdominal and/or vascular issues have resolved sufficiently to allow conversion back to ventriculoperitoneal or ventriculoatrial shunts, if needed.
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Affiliation(s)
- Andrew Reisner
- Departments of1Pediatrics
- 2Neurosurgery, and
- Departments of4Neurosurgery and
| | - Alexis D Smith
- 3Surgery, Emory University School of Medicine, Atlanta; and
- Departments of4Neurosurgery and
| | | | | | | | | | | | | | - Joshua J Chern
- Departments of1Pediatrics
- 2Neurosurgery, and
- Departments of4Neurosurgery and
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Altwejri IS, AlRaddadi KK, Alsager GA, Abobotain AH, Al Abdulsalam HK, AlQazlan SM, Almujaiwel NA. Patterns and prognosis of ventriculoperitoneal shunt malfunction among pediatrics in Saudi Arabia. ACTA ACUST UNITED AC 2021; 25:356-361. [PMID: 33459283 PMCID: PMC8015599 DOI: 10.17712/nsj.2020.5.20200038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives: To examine the predictors of pediatric ventriculoperitoneal (VP) shunt malfunction in a university hospital. Methods: A retrospective cohort was conducted. Patients under 18 years old who underwent VP shunt revision at least once between 2016 and 2019 were included. Data were stratified based on age, gender, diagnosis, type of valve, valve position, cause of revision, and part revised. Results: A total of 45 patients (64% males and 36% females) were included in this study. Eighty-two revision surgeries were identified. The most common revised part was the entire shunt system. The most common type of valve which required revision was the low-pressure valve (15.5%). Since a p-value of less than 0.05 was considered significant, no significant differences among the 4 groups for different points. Conclusions: Younger age at initial VP shunt insertion is associated with a higher rate of shunt malfunction. Valve mechanical failures followed by infections are the most common causes for the first 3 revisions. A prospective multi-center study to confirm the current findings is recommended.
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Affiliation(s)
- Ikhlass S Altwejri
- Division of Neurosurgery, Department of Surgery, King Saud University, College of Medicine and King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. E-mail:
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Udayakumaran S, Kumar S. Should not we be using aspirin in patients with a ventriculoatrial shunt? Borrowing a leaf from other specialities: a case for surrogate evidence. Childs Nerv Syst 2021; 37:1137-1142. [PMID: 33033899 DOI: 10.1007/s00381-020-04925-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Ventriculoatrial (VA) shunts are life-saving in circumstances where ventriculoperitoneal shunts (VP) have failed. They are at risk for different complications, and more specific of them are cardiopulmonary complications. Currently, there are no standard recommendations concerning screening for risk factors, prophylaxis, or anticoagulation treatment in patients after VA shunt placement. Our study aims to prospectively study the possible role and efficacy of the use of aspirin to increase the survival of shunts in children with VA shunt and avoid secondary morbidity. In this article, the authors describe the interim results of an ongoing prospective study which supports the use of aspirin for VA shunt. MATERIALS AND METHODS The study design is prospective. The duration of the study is 2011 onwards and is ongoing. Hospital ethics board clearance and consent from the family were taken before inclusion in the study. All patients who had VA shunt were given a once-a-day low-antiplatelet dose of aspirin 5 mg/kg, from the first postoperative day onwards. Primary endpoints of the study are as follows: (1) major distal end malfunction documented on echocardiography or (2) any cardiac complications associated with the VA shunt catheter. RESULTS We have 6 patient since march 2011, who are being followed up. None of the shunts had malfunctioned until the reporting. None of the patients had any cardiac issues reported. The patients are to be followed continually. The present follow-up ranges from 2.5 to 10 years. The patient follow-up is being continued. CONCLUSIONS Aspirin is a drug with well-accepted safety profile, and its use and our preliminary observation and outcome of the use of aspirin in VA shunt are promising.
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Affiliation(s)
- Suhas Udayakumaran
- Division of Paediatric Neurosurgery, Amrita Institute of Medical Sciences and Research Centre, Kochi, India. .,Department of Neurosurgery, Amrita Institute of Medical Sciences and Research Centre, Kochi, India.
| | - Shine Kumar
- Department of Neurosurgery, Amrita Institute of Medical Sciences and Research Centre, Kochi, India.,Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Kochi, India
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76
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Chia WL, Zaben M, Leach P. Is cerebrospinal fluid sampling necessary at the time of first ventriculo-peritoneal shunt insertion in paediatric patients? Clin Neurol Neurosurg 2021; 204:106608. [PMID: 33813372 DOI: 10.1016/j.clineuro.2021.106608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/27/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We aim to evaluate whether intraoperative cerebrospinal fluid (CSF) sampling during ventriculo-peritoneal (VP) shunt insertion can predict future VP shunt infection or guide its management. METHODS 83 paediatric patients undergoing VP shunt insertion between February 2013 and July 2019 were retrospectively identified. Patient demographics, presence of pre-operative extra ventricular drain (EVD), pre-operative CSF results, and intra-operative CSF results were identified from patient case notes and electronic clinical databases. All included patients were followed up for a minimum of 6 months for identification of shunt infection. RESULTS 90 VP shunt insertions were performed in 83 patients. Age at time of shunt insertion ranged from 5 days to 15.8 years (mean 44.2 months). Tumours were the most common aetiology for hydrocephalus (n = 24). 67 cases (74.4%) had intra-operative CSF samples, of which 2 revealed the presence of bacteria. Only 1 patient with intra-operative CSF sampling positive for growth developed shunt infection during follow up. Two cases developed a shunt infection despite normal intra-operative CSF results. Three cases did not have intra-operative CSF sampling but developed a shunt infection during follow up. Intra-operative CSF culture achieved 33.3% sensitivity and 98.4% specificity for predicting future shunt infection (p = 0.154). The Receiver Operator Characteristic (ROC) curve of intra-operative white cell count (WCC) and shunt infection at 6 months follow up yielded an Area Under the Curve (AUC) of 50.3%. CONCLUSION Our results show that intraoperative CSF sampling as a method to predict future risk of shunt infection and to help inform future antibiotic prescribing is unreliable. Given an AUC of 50.3%, it is no better than chance as a diagnostic tool. Further larger studies are needed to substantiate this.
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Affiliation(s)
- Wen Li Chia
- Cardiff University, School of Medicine, Cardiff, UK.
| | - Malik Zaben
- Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Paul Leach
- Department of Paediatric Neurosurgery, University Hospital of Wales, Cardiff, UK
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77
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Pirakitikulr N, Tse DT. A Natural History of Silent Brain Syndrome over 36 Years: A case report. Orbit 2021; 40:435-443. [PMID: 33722160 DOI: 10.1080/01676830.2020.1866023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
A 34-year-old Caucasian male who underwent a ventricular shunt at age 21 presented with bilateral enophthalmos, poor eyelid-globe apposition and exposure keratopathy characteristic of silent brain syndrome. Progressive enophthalmos and corneal decompensation were documented in serial photographs and radiographic studies over 36 years. Over this period, no sequelae of shunt over-drainage were observed. A lumbar puncture at the last follow-up measured CSF opening pressure to be within the normal range. Additional systemic findings included pneumosinus dilatans, loss of adipose tissue in the temporalis fossa and atrophy of the dorsal interossei of the hand. Surgical interventions to preserve ocular function included insertion of orbital floor wedge and sheet implants, sheet orbital roof implants, and retroplacement of canthal tendons. This report chronicles the long-term clinical course of a patient with silent brain syndrome. The systemic changes suggest factors beyond low intracranial pressure may contribute to the pathogenesis of the condition in our patient.
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Affiliation(s)
- Nathan Pirakitikulr
- Dr. Nasser Ibrahim Al-Rashid Orbital Vision Research Center. Bascom Palmer Eye Institute, Oculofacial Plastic and Reconstructive Surgery Service, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - David T Tse
- Dr. Nasser Ibrahim Al-Rashid Orbital Vision Research Center. Bascom Palmer Eye Institute, Oculofacial Plastic and Reconstructive Surgery Service, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Florida, USA
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78
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Ahmed O, Ungchusri E, Li J, Frim D, Leef J. Ventriculoatrial Shunt Placement after Recanalization of a Central Venous Occlusion. J Vasc Interv Radiol 2021; 32:931-933. [PMID: 33713803 DOI: 10.1016/j.jvir.2021.03.411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Osman Ahmed
- Section of Interventional Radiology, University of Chicago, Chicago, IL
| | - Ethan Ungchusri
- Section of Interventional Radiology, University of Chicago, Chicago, IL
| | - Jingfei Li
- University of Chicago Pritzker School of Medicine, Chicago, IL
| | - David Frim
- Section of Neurosurgery, University of Chicago, Chicago, IL
| | - Jeffery Leef
- Section of Interventional Radiology, University of Chicago, Chicago, IL
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Gamero M, Kim WS, Hong S, Vorobiev D, Morgan CD, Park SI. Multimodal Sensing Capabilities for the Detection of Shunt Failure. SENSORS 2021; 21:s21051747. [PMID: 33802445 PMCID: PMC7959456 DOI: 10.3390/s21051747] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 02/12/2021] [Accepted: 02/25/2021] [Indexed: 11/16/2022]
Abstract
Hydrocephalus is a medical condition characterized by the abnormal accumulation of cerebrospinal fluid (CSF) within the cavities of the brain called ventricles. It frequently follows pediatric and adult congenital malformations, stroke, meningitis, aneurysmal rupture, brain tumors, and traumatic brain injury. CSF diversion devices, or shunts, have become the primary therapy for hydrocephalus treatment for nearly 60 years. However, routine treatment complications associated with a shunt device are infection, obstruction, and over drainage. Although some (regrettably, the minority) patients with shunts can go for years without complications, even those lucky few may potentially experience one shunt malfunction; a shunt complication can require emergency intervention. Here, we present a soft, wireless device that monitors distal terminal fluid flow and transmits measurements to a smartphone via a low-power Bluetooth communication when requested. The proposed multimodal sensing device enabled by flow sensors, for measurements of flow rate and electrodes for measurements of resistance in a fluidic chamber, allows precision measurement of CSF flow rate over a long time and under any circumstances caused by unexpected or abnormal events. A universal design compatible with any modern commercial spinal fluid shunt system would enable the widespread use of this technology.
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Affiliation(s)
- Milenka Gamero
- Department of Electrical and Computer Engineering, Texas A&M University, College Station, TX 77843, USA; (M.G.); (W.S.K.); (S.H.); (D.V.)
| | - Woo Seok Kim
- Department of Electrical and Computer Engineering, Texas A&M University, College Station, TX 77843, USA; (M.G.); (W.S.K.); (S.H.); (D.V.)
| | - Sungcheol Hong
- Department of Electrical and Computer Engineering, Texas A&M University, College Station, TX 77843, USA; (M.G.); (W.S.K.); (S.H.); (D.V.)
| | - Daniel Vorobiev
- Department of Electrical and Computer Engineering, Texas A&M University, College Station, TX 77843, USA; (M.G.); (W.S.K.); (S.H.); (D.V.)
| | - Clinton D. Morgan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ 85013, USA;
| | - Sung Il Park
- Department of Electrical and Computer Engineering, Texas A&M University, College Station, TX 77843, USA; (M.G.); (W.S.K.); (S.H.); (D.V.)
- Center of Remote Health Sciences and Technologies, Texas A&M University, College Station, TX 77843, USA
- Institute for Neuroscience, Texas A&M University, College Station, TX 77843, USA
- Correspondence: ; Tel.: +1-979-458-8579
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80
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Gorelick NL, Serra R, Iyer R, Um R, Grewal A, Monroe A, Antoine H, Beharry K, Cecia A, Kroll F, Ishida W, Perdomo-Pantoja A, Xu R, Loth F, Ye X, Suk I, Tyler B, Bayston R, Luciano MG. Evaluating the Effects of Cerebrospinal Fluid Protein Content on the Performance of Differential Pressure Valves and Antisiphon Devices Using a Novel Benchtop Shunting Model. Neurosurgery 2021; 87:1046-1054. [PMID: 32521017 DOI: 10.1093/neuros/nyaa203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 03/17/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hydrocephalus is managed by surgically implanting flow-diversion technologies such as differential pressure valves and antisiphoning devices; however, such hardware is prone to failure. Extensive research has tested them in flow-controlled settings using saline or de-aerated water, yet little has been done to validate their performance in a setting recreating physiologically relevant parameters, including intracranial pressures, cerebrospinal fluid (CSF) protein content, and body position. OBJECTIVE To more accurately chart the episodic drainage characteristics of flow-diversion technology. A gravity-driven benchtop model of flow was designed and tested continuously during weeks-long trials. METHODS Using a hydrostatic pressure gradient as the sole driving force, interval flow rates of 6 valves were examined in parallel with various fluids. Daily trials in the upright and supine positions were run with fluid output collected from distal catheters placed at alternating heights for extended intervals. RESULTS Significant variability in flow rates was observed, both within specific individual valves across different trials and among multiple valves of the same type. These intervalve and intravalve variabilities were greatest during supine trials and with increased protein. None of the valves showed evidence of overt obstruction during 30 d of exposure to CSF containing 5 g/L protein. CONCLUSION Day-to-day variability of ball-in-cone differential pressure shunt valves may increase overdrainage risk. Narrow-lumen high-resistance flow control devices as tested here under similar conditions appear to achieve more consistent flow rates, suggesting their use may be advantageous, and did not demonstrate any blockage or trend of decreasing flow over the 3 wk of chronic use.
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Affiliation(s)
- Noah L Gorelick
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Riccardo Serra
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rajiv Iyer
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard Um
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Angad Grewal
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Audrey Monroe
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hannah Antoine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kelly Beharry
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Arba Cecia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Francesca Kroll
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wataru Ishida
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Francis Loth
- Department of Mechanical Engineering, University of Akron, Akron, Ohio
| | - Xiaobu Ye
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ian Suk
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Betty Tyler
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Roger Bayston
- School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Mark G Luciano
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Rocque BG, Waldrop RP, Shamblin I, Arynchyna AA, Hopson B, Kerr T, Johnston JM, Rozzelle CJ, Blount JP. Shunt failure clusters: an analysis of multiple, frequent shunt failures. J Neurosurg Pediatr 2021; 27:287-293. [PMID: 33338992 DOI: 10.3171/2020.7.peds20199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Repeated failure of ventriculoperitoneal shunts (VPSs) is a problem familiar to pediatric neurosurgeons and patients. While there have been many studies to determine what factors are associated with the first shunt failure, studies of subsequent failures are much less common. The purpose of this study was to identify the prevalence and associated risk factors of clustered shunt failures (defined as 3 or more VPS operations within 3 months). METHODS The authors reviewed prospectively collected records from all patients who underwent VPS surgery from 2008 to 2017 at their institution and included only those children who had received all of their hydrocephalus care at that institution. Demographics, etiology of hydrocephalus, history of endoscopic third ventriculostomy or temporizing procedure, initial valve type, age at shunt placement, and other factors were analyzed. Logistic regression was used to test for the association of each variable with a history of shunt failure cluster. RESULTS Of the 465 included children, 28 (6.0%) had experienced at least one cluster of shunt failures. Among time-independent variables, etiology of hydrocephalus (OR 0.27 for non-intraventricular hemorrhage [IVH], nonmyelomeningocele, nonaqueductal stenosis etiology vs IVH, 95% CI 0.11-0.65; p = 0.003), younger gestational age at birth (OR 0.91, 95% CI 0.85-0.97; p = 0.003), history of a temporizing procedure (OR 2.77, 95% CI 1.12-6.85; p = 0.028), and smaller head circumference at time of initial shunt placement (OR 0.91, 95% CI 0.84-0.99; p = 0.044) showed significant association with shunt failure cluster on univariate analysis. None of these variables maintained significance in a multivariate model. Among children with a history of a shunt failure cluster, 21 (75%) had a shunt infection either prior to or during the shunt failure cluster. A comparison of the infecting organism between these children and 62 children with a history of infection but without a shunt failure cluster showed an association of cluster with gram-negative rod species. CONCLUSIONS Six percent of children in this institutional sample had at least one shunt failure cluster. These children accounted for 30% of the total shunt revisions in the sample. Shunt infection is an important factor associated with shunt failure cluster. Children with a history of prematurity and IVH may have a higher risk for failure cluster.
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82
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Shim Y, Ko JM, Cho TJ, Kim SK, Phi JH. Predictors of cervical myelopathy and hydrocephalus in young children with achondroplasia. Orphanet J Rare Dis 2021; 16:81. [PMID: 33579320 PMCID: PMC7881633 DOI: 10.1186/s13023-021-01725-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 02/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cervical myelopathy and hydrocephalus occasionally occur in young children with achondroplasia. However, these conditions are not evaluated in a timely manner in many cases. The current study presents significant predictors for cervical myelopathy and hydrocephalus in young children with achondroplasia. METHODS A retrospective analysis of 65 patients with achondroplasia who visited Seoul National University Children's Hospital since 2012 was performed. The patients were divided into groups according to the presence of cervical myelopathy and hydrocephalus, and differences in foramen magnum parameters and ventricular parameters by magnetic resonance imaging between groups were analyzed. Predictors for cervical myelopathy and hydrocephalus were analyzed, and the cut-off points for significant ones were calculated. RESULTS The group with cervical myelopathy showed foramen magnum parameters that indicated significantly lower cord thickness than in the group without cervical myelopathy, and the group with hydrocephalus showed significantly higher ventricular parameters and 'Posterior indentation' grade than the group without hydrocephalus. 'Cord constriction ratio' (OR 5199.90, p = 0.001) for cervical myelopathy and 'Frontal horn width' (OR 1.14, p = 0.001) and 'Posterior indentation' grade (grade 1: OR 9.25, p = 0.06; grade 2: OR 18.50, p = 0.01) for hydrocephalus were significant predictors. The cut-off points for cervical myelopathy were 'Cord constriction ratio' of 0.25 and 'FM AP' of 8 mm (AUC 0.821 and 0.862, respectively) and 'Frontal horn width' of 50 mm and 'Posterior indentation' grade of 0 (AUC 0.788 and 0.758, respectively) for hydrocephalus. CONCLUSION 'Cord constriction ratio' for cervical myelopathy and 'Frontal horn width' and 'Posterior indentation' grade for hydrocephalus were significant predictors and may be used as useful parameters for management. 'Posterior indentation' grade may also be used to determine the treatment method for hydrocephalus.
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Affiliation(s)
- Youngbo Shim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Republic of Korea
| | - Jung Min Ko
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae-Joon Cho
- Division of Pediatric Orthopaedics, Seoul National University Children's Hospital, Seoul, Republic of Korea
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Republic of Korea
| | - Ji Hoon Phi
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Republic of Korea.
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Forte D, Peraio S, Huttunen TJ, James G, Thompson D, Aquilina K. Ventriculoatrial and ventriculopleural shunts as second-line surgical treatment have equivalent revision, infection, and survival rates in paediatric hydrocephalus. Childs Nerv Syst 2021; 37:481-489. [PMID: 32986152 DOI: 10.1007/s00381-020-04887-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/09/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Ventriculoatrial (VA) and ventriculopleural (VPL) shunts are used as alternatives when CSF diversion to the peritoneal compartment with a ventriculoperitoneal (VP) shunt is not possible. The objective of this study is to compare directly the shunt survival and complications for both procedures in this setting in children. METHODS A retrospective analysis of 54 consecutive patients who underwent VA (36) or VPL (18) shunt insertion between January 2002 and December 2017 was conducted. RESULTS The overall mean follow-up was 4.1 (SD 4.3) years, 2.8 (SD 4.1) for VPL and 4.7 (SD 4.4) for VA shunts, respectively (p = 0.11). Twenty-four (66.7%) patients in the VA group and 9 (50.0%) in the VPL group underwent shunt revision (p = 0.236); mean number of revisions was 2.2 (SD 3.0) and 0.94 (SD 1.4) in the VA and VPL groups (p = 0.079). Median time to failure was 8.5 (IQr 78, range 0-176) months for VA and 5.50 (IQr 36, range 0-60) for VPL shunts (log rank (Mantel-Cox) 0.832). Shunt survival at 3, 6, 12 and 30 months was 60.6, 51.5, 36.4 and 27.3%, respectively, for VA and 56.3, 43.8, 37.5 and 37.5% for VPL shunts (log rank (Mantel-Cox) test value 0.727). The infection rate was 13.8% for VA and 5.6% for VPL shunts (p = 0.358). Four patients with VPL shunts (22.2%) developed pleural effusions. Fourteen deaths (25.9%) were recorded during follow-up, 8 (22.2%) in the VA and 6 (33.3%) in the VPL group (p = 0.380); two of the deaths in the VA group were shunt-related. CONCLUSION This study demonstrates that the outcomes of VA and VPL shunts, when used as second-line surgical treatment in paediatric hydrocephalus, were similar, as were the revision, infection and survival rates. The shorter longevity of these shunts compared with the general shunted population may reflect the complex nature of these children.
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Affiliation(s)
- Dalila Forte
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Simone Peraio
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Terhi J Huttunen
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Greg James
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Dominic Thompson
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
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Zahedi S, Hudson M, Jin X, Garling RJ, Gluski J, Nowak C, Marupudi NI, Begeman P, Harris CA. Investigation of ventriculoperitoneal shunt disconnection for hydrocephalus treatment. J Neurosurg Pediatr 2021; 27:125-130. [PMID: 33186903 PMCID: PMC8116348 DOI: 10.3171/2020.6.peds20454] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This investigation is aimed at gaining a better understanding of the factors that lead to mechanical failure of shunts used for the treatment of hydrocephalus, including shunt catheter-valve disconnection and shunt catheter fracture. METHODS To determine the root cause of mechanical failure, the authors created a benchtop mechanical model to mimic mechanical stressors on a shunt system. To test shunt fracture, cyclical loading on the catheter-valve connection site was tested with the shunt catheter held perpendicular to the valve. Standard methods were used to secure the catheter and valves with Nurolon. These commercial systems were compared to integrated catheters and valves (manufactured as one unit). To test complete separation/disconnection of the shunt catheter and valve, a parallel displacement test was conducted using both Nurolon and silk sutures. Finally, the stiffness of the catheters was assessed. All mechanical investigations were conducted on shunts from two major shunt companies, assigned as either company A or company B. RESULTS Cyclical loading experiments found that shunts from company B fractured after a mean of 4936 ± 1725 cycles (95% CI 2990-6890 cycles), while those of company A had not failed after 8000 cycles. The study of parallel displacement indicated complete disconnection of company B's shunt catheter-valve combination using Nurolon sutures after being stretched an average 32 ± 5.68 mm (95% CI 25.6-38.4 mm), whereas company A's did not separate using either silk or Nurolon sutures. During the stiffness experiments, the catheters of company B had statistically significantly higher stiffness of 13.23 ± 0.15 N compared to those of company A, with 6.16 ± 0.29 N (p < 0.001). CONCLUSIONS Mechanical shunt failure from shunt catheter-valve disconnection or fracture is a significant cause of shunt failure. This study demonstrates, for the first time, a correlation between shunt catheters that are less mechanically stiff and those that are less likely to disconnect from the valve when outstretched and are also less likely to tear when held at an angle from the valve outlet. The authors propose an intervention to the standard of care wherein less stiff catheters are trialed to reduce disconnection.
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Affiliation(s)
- Sulmaz Zahedi
- College of Medicine, Central Michigan University, Mount Pleasant, Michigan
| | - Miles Hudson
- School of Medicine, Wayne State University, Detroit, Michigan
| | - Xin Jin
- Department of Biomedical Engineering, Wayne State University, Detroit, Michigan
| | | | - Jacob Gluski
- School of Medicine, Wayne State University, Detroit, Michigan
| | - Caden Nowak
- School of Medicine, Wayne State University, Detroit, Michigan
| | - Neena I. Marupudi
- School of Medicine, Wayne State University, Detroit, Michigan
- Department of Neurosurgery, Wayne State University, Detroit, Michigan
| | - Paul Begeman
- Department of Biomedical Engineering, Wayne State University, Detroit, Michigan
| | - Carolyn A. Harris
- Department of Biomedical Engineering, Wayne State University, Detroit, Michigan
- Department of Neurosurgery, Wayne State University, Detroit, Michigan
- Department of Chemical Engineering and Material Science, Wayne State University, Detroit, Michigan
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Harris CA, Morales DM, Arshad R, McAllister JP, Limbrick DD. Cerebrospinal fluid biomarkers of neuroinflammation in children with hydrocephalus and shunt malfunction. Fluids Barriers CNS 2021; 18:4. [PMID: 33514409 PMCID: PMC7845119 DOI: 10.1186/s12987-021-00237-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 01/09/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Approximately 30% of cerebrospinal fluid (CSF) shunt systems for hydrocephalus fail within the first year and 98% of all patients will have shunt failure in their lifetime. Obstruction remains the most common reason for shunt failure. Previous evidence suggests elevated pro-inflammatory cytokines in CSF are associated with worsening clinical outcomes in neuroinflammatory diseases. The aim of this study was to determine whether cytokines and matrix metalloproteinases (MMPs) contribute towards shunt failure in hydrocephalus. METHODS Using multiplex ELISA, this study examined shunt failure through the CSF protein concentration profiles of select pro-inflammatory and anti-inflammatory cytokines, as well as select MMPs. Interdependencies such as the past number of previous revisions, length of time implanted, patient age, and obstruction or non-obstruction revision were examined. The pro-inflammatory cytokines were IL-1β, IL-2, IL-5, IL-6, IL-8, IL-12, IL-17, TNF-α, GM-CSF, IFN-γ. The anti-inflammatory cytokines were IL-4 and IL-10, and the MMPs were MMP-2, MMP-3, MMP-7, MMP-9. Protein concentration is reported as pg/mL for each analyte. RESULTS Patient CSF was obtained at the time of shunt revision operation; all pediatric (< 18), totaling n = 38. IL-10, IL-6, IL-8 and MMP-7 demonstrated significantly increased concentrations in patient CSF for the non-obstructed subgroup. Etiological examination revealed IL-6 was increased in both obstructed and non-obstructed cases for PHH and congenital hydrocephalic patients, while IL-8 was higher only in PHH patients. In terms of number of past revisions, IL-10, IL-6, IL-8, MMP-7 and MMP-9 progressively increased from zero to two past revisions and then remained low for subsequent revisions. This presentation was notably absent in the obstruction subgroup. Shunts implanted for three months or less showed significantly increased concentrations of IL-6, IL-8, and MMP-7 in the obstruction subgroup. Lastly, only patients aged six months or less presented with significantly increased concentration of IL-8 and MMP-7. CONCLUSION Non-obstructive cases are reported here to accompany significantly higher CSF cytokine and MMP protein levels compared to obstructive cases for IL-10, IL-6, IL-8, MMP-7 and MMP-9. A closer examination of the definition of obstruction and the role neuroinflammation plays in creating shunt obstruction in hydrocephalic patients is suggested.
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Affiliation(s)
- Carolyn A Harris
- Wayne State University Dept. of Chemical Engineering and Materials Science, 6135 Woodward Avenue, Rm 1413, Detroit, MI, 48202, USA.
| | - Diego M Morales
- Department of Neurosurgery, Washington University in St. Louis, 425 S. Euclid, St. Louis, MO, 63110, USA
| | - Rooshan Arshad
- Wayne State University Dept. of Chemical Engineering and Materials Science, 6135 Woodward Avenue, Rm 1413, Detroit, MI, 48202, USA
| | - James P McAllister
- Department of Neurosurgery, Washington University in St. Louis, 425 S. Euclid, St. Louis, MO, 63110, USA
| | - David D Limbrick
- Division of Pediatric Neurosurgery, and Department of Pediatrics, Department of Neurosurgery, Washington University in St. Louis, 425 S. Euclid, St. Louis, MO, 63110, USA
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86
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Morosanu CO, Priscu A, Florian IS. Evaluation of the ventriculocholecystic shunt-an overview of present practice in adult and pediatric hydrocephalus. Neurosurg Rev 2021; 44:2533-2543. [PMID: 33481136 PMCID: PMC8490219 DOI: 10.1007/s10143-021-01472-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 01/14/2023]
Abstract
In the context of hydrocephalus, there are a multitude of therapeutic options that can be explored in order to improve patient outcomes. Although the peritoneum is the current elected clinical solution, various receptacles have been utilized when experiencing contraindications. Along with the ventriculoatrial or ventriculopleural, the ventriculocholecystic shunt was also described as an alternative. In order to make a decision on a place for drainage, the surgeon must be knowledgeable on details from modern literature. The main target of this review was to summarize the currently available information on this topic and assess the status of the gallbladder as a viable option for cerebrospinal fluid diversion.
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Affiliation(s)
| | - Adelina Priscu
- Department of Internal Medicine, Indiana University Health Ball Memorial Hospital, Muncie, IN, USA
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87
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Mammadkhanli O, Dogan I, Tuna H. Diagnosis of Shunt Failure in the Lack of Hydrocephalus: a Case Report. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02209-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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88
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Complications of CSF Shunts in Pediatrics: Functional Assessment With CSF Shunt Scintigraphy—Performance and Interpretation. AJR Am J Roentgenol 2020; 215:1474-1489. [DOI: 10.2214/ajr.20.22899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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89
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Management of Hydrocephalus in Children: Anatomic Imaging Appearances of CSF Shunts and Their Complications. AJR Am J Roentgenol 2020; 216:187-199. [PMID: 33112667 DOI: 10.2214/ajr.20.22888] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. This article addresses the management of hydrocephalus and the CSF shunts used to treat this entity. CONCLUSION. CSF shunts have a high failure rate. Imaging plays a pivotal role in assessing CSF shunt failure and determining the need for surgical revision. An in-depth knowledge of CSF shunt components, their failure modes, and the corresponding findings on anatomic imaging studies is necessary to ensure timely diagnosis and prevent permanent neurologic damage.
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90
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Entezami P, Devejian NS, Rubino S, Smith N, Savery P, Crnkovic A, Adamo MA. Vegetation of Ventriculoatrial Shunt Managed via Multidisciplinary Surgical Approach. World Neurosurg 2020; 144:15-18. [PMID: 32791225 DOI: 10.1016/j.wneu.2020.08.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The popularity of the ventriculoatrial shunt as a means for cerebrospinal fluid diversion was temporally limited, overcome by the success of the peritoneum as a site for distal drainage. Nevertheless, it remains an important tool for patients for whom ventriculoperitoneal shunting is not an option. CLINICAL PRESENTATION We present the case of a 9-year-old girl with a ventriculoatrial shunt, who had undergone multiple revisions. Ultimately, she suffered a wound dehiscence, resulting in infectious seeding of the bloodstream and formation of a thrombus, presumed granuloma, at the tip of the distal catheter in the right atrium. She underwent successful removal of the lesion via an open approach by our cardiothoracic colleagues. DISCUSSION Previous authors have noted a high number of mortalities as a result of these lesions. A collaborative approach resulted in a successful outcome for our patient. Although limited in utility today, the ventriculoatrial shunt remains a common procedure for neurosurgeons today. CONCLUSION Recognizing the potential for atrial thrombus formation and using a team approach can help avoid a poor outcome.
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Affiliation(s)
- Pouya Entezami
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA.
| | - Neil S Devejian
- Department of Pediatric Cardiothoracic Surgery, Albany Medical College, Albany, New York, USA
| | - Sebastian Rubino
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Nathan Smith
- Department of Pediatric Cardiothoracic Surgery, Albany Medical College, Albany, New York, USA
| | - Patrick Savery
- Department of Anesthesia, Albany Medical College, Albany, New York, USA
| | - Anica Crnkovic
- Department of Anesthesia, Albany Medical College, Albany, New York, USA
| | - Matthew A Adamo
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
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91
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When Opposites Attract: Pediatric Cochlear Implantation in the Setting of Cerebrospinal Fluid Shunts. Otol Neurotol 2020; 41:e1193-e1200. [PMID: 32740548 DOI: 10.1097/mao.0000000000002780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The Food and Drug Administration (FDA) has recently raised concern regarding the safety of cochlear implantation in the setting of programmable cerebrospinal fluid shunts. The purpose of this study was to evaluate the outcomes and complications of cochlear implantation in children who have a cerebrospinal fluid shunt. STUDY DESIGN Retrospective chart review. SETTING Tertiary academic referral center. PATIENTS Twenty pediatric subjects with a cerebrospinal fluid shunt and cochlear implant (CI). INTERVENTION Cochlear implantation in the setting of a cerebrospinal fluid shunt. MAIN OUTCOME MEASURES Primary outcome measures included descriptive data regarding age at implantation, etiology of hearing loss, medical management, complications, and speech perception outcomes. RESULTS The average age of CI candidacy was 30 months with an average 21.5 months delay to implantation. In 45% of cases the laterality of the shunt determined the ear to be implanted. Three of the subjects required a surgical intervention on the shunt before cochlear implantation. Three subjects had a concurrently programmable shunt and activated CI. Two of the three subjects had no complications as a result of the two devices; however, the third subject had significant interactions requiring multiple revision surgeries. For those with the cognitive ability to perform open set, recoded speech perception, the average postoperative Consonant Nucleus Consonant word score in the best aided condition was 65.2% (n = 5). CONCLUSIONS Children with a cerebrospinal fluid shunt are viable candidates for cochlear implantation, although they often require additional procedures and considerations before and after implantation.
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92
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Lee S, Kwok N, Holsapple J, Heldt T, Bourouiba L. Enhanced wall shear stress prevents obstruction by astrocytes in ventricular catheters. J R Soc Interface 2020; 17:20190884. [PMID: 32603649 PMCID: PMC7423414 DOI: 10.1098/rsif.2019.0884] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 05/04/2020] [Indexed: 01/09/2023] Open
Abstract
The treatment of hydrocephalus often involves the placement of a shunt catheter into the cerebrospinal ventricular space, though such ventricular catheters often fail by tissue obstruction. While diverse cell types contribute to the obstruction, astrocytes are believed to contribute to late catheter failure that can occur months after shunt insertion. Using in vitro microfluidic cultures of astrocytes, we show that applied fluid shear stress leads to a decrease of cell confluency and the loss of their typical stellate cell morphology. Furthermore, we show that astrocytes exposed to moderate shear stress for an extended period of time are detached more easily upon suddenly imposed high fluid shear stress. In light of these findings and examining the range of values of wall shear stress in a typical ventricular catheter through computational fluid dynamics (CFD) simulation, we find that the typical geometry of ventricular catheters has low wall shear stress zones that can favour the growth and adhesion of astrocytes, thus promoting obstruction. Using high-precision direct flow visualization and CFD simulations, we discover that the catheter flow can be formulated as a network of Poiseuille flows. Based on this observation, we leverage a Poiseuille network model to optimize ventricular catheter design such that the distribution of wall shear stress is above a critical threshold to minimize astrocyte adhesion and growth. Using this approach, we also suggest a novel design principle that not only optimizes the wall shear stress distribution but also eliminates a stagnation zone with low wall shear stress, which is common to current ventricular catheters.
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Affiliation(s)
- S. Lee
- The Fluid Dynamics of Disease Transmission Laboratory, MIT, Cambridge, MA 02139, USA
| | - N. Kwok
- Health Sciences and Technology Program, Harvard Medical School, Boston, MA 02115, USA
| | - J. Holsapple
- Department of Neurosurgery, Boston Medical Center, Boston, MA 02118, USA
| | - T. Heldt
- Institute for Medical Engineering and Science, MIT, Cambridge, MA 02139, USA
- Health Sciences and Technology Program, Harvard Medical School, Boston, MA 02115, USA
| | - L. Bourouiba
- The Fluid Dynamics of Disease Transmission Laboratory, MIT, Cambridge, MA 02139, USA
- Institute for Medical Engineering and Science, MIT, Cambridge, MA 02139, USA
- Health Sciences and Technology Program, Harvard Medical School, Boston, MA 02115, USA
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93
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García-Martín A, Otero-Rodríguez A, Miranda-Zambrano D, Arandia-Guzmán DA, Torres-Carretero L, Sousa-Casasnovas P, Pascual-Argente D. Abdominal pseudocysts, an unusual complication of ventriculoperitoneal shunt systems: Literature systematic review. Neurocirugia (Astur) 2020; 32:69-77. [PMID: 32430242 DOI: 10.1016/j.neucir.2020.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 11/07/2019] [Accepted: 03/18/2020] [Indexed: 10/24/2022]
Abstract
Since the first report in 1954, abdominal pseudocysts have been recognized as a particularly uncommon complication of ventriculoperitoneal shunts of CSF, so their etiology, diagnosis, and therapeutic management remain very controversial. Our objective is to offer a critical and updated systematic review of those controversial points, using a thorough search and review of the most relevant literature available. The clinical presentation of pseudocysts is normally through non-specific abdominal symptoms. The most validated etiology consists on the existence of a concomitant infection of the CSF shunt system, and so, treatment needs of antibiotherapy and total or partial substitution of the system. However, the pseudocyst itself doesn't need an active treatment, except for some specific cases. This management, algorithmically presented in the present work, achieves a lower recurrence rate than other options, but this one is still important, and is also associated with other complications of those shunts related with several other factors which need to be taken in account.
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Affiliation(s)
- Andoni García-Martín
- Servicio de Neurocirugía, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain.
| | - Alvaro Otero-Rodríguez
- Servicio de Neurocirugía, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - David Miranda-Zambrano
- Servicio de Neurocirugía, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | | | - Luis Torres-Carretero
- Servicio de Neurocirugía, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Pablo Sousa-Casasnovas
- Servicio de Neurocirugía, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Daniel Pascual-Argente
- Servicio de Neurocirugía, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
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94
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Weeks SR, Gosztyla CE, Davidson L, Pryor HI. Innovative approach to the difficult ventricular shunt using pleural access device for maintenance drainage: case report. J Neurosurg Pediatr 2020; 25:407-410. [PMID: 31899886 DOI: 10.3171/2019.10.peds19122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 10/15/2019] [Indexed: 11/06/2022]
Abstract
Patients with complex medical problems and multiple failed ventricular shunts require continued innovation for hydrocephalus management. The authors report the case of a 4-year-old boy with refractory hydrocephalus and secondary reduced ability to absorb CSF in both the pleural and peritoneal cavities following renal transplantation. A novel management approach was devised with split shunting to pleural and peritoneal targets as well as prophylactic pleural port placement to provide a method for minimally invasive thoracentesis should symptomatic pleural effusions develop. Fluid was successfully aspirated via the pleural port with relief of symptoms over a period of 16 months without complication. The authors demonstrate that a previously undescribed approach to distal shunting can prevent neurological sequelae of shunt failure and permit noninvasive maintenance drainage for patients in whom symptomatic pleural effusion is a recurrent complication.
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Affiliation(s)
| | | | | | - Howard I Pryor
- 3Pediatric Surgery, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
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95
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Pradini-Santos L, Craven CL, Watkins LD, Toma AK. Ventriculoatrial Shunt Catheter Tip Migration Causing Tricuspid Regurgitation: Case Report and Review of the Literature. World Neurosurg 2020; 136:83-89. [DOI: 10.1016/j.wneu.2020.01.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/02/2020] [Accepted: 01/03/2020] [Indexed: 11/29/2022]
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96
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Olszewska A, Farke D, Schmidt MJ. Spontaneous hemispheric ventricular collapse and subarachnoid haemorrhages in a dog with congenital hydrocephalus internus. Ir Vet J 2020; 73:5. [PMID: 32226604 PMCID: PMC7098093 DOI: 10.1186/s13620-020-00159-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 03/18/2020] [Indexed: 11/10/2022] Open
Abstract
Background Overdrainage and collapse of the hemispheres is a potential severe complication after surgical treatment of internal hydrocephalus using ventriculoperitoneal shunts. Here we describe a case of a spontaneous hemispheric ventricular collapse in an untreated dog with congenital hydrocephalus internus. Case presentation A twelve-week-old, male, intact Golden Retriever was presented with a history of peracute obtundation, impaired vision, and progressive gait abnormalities of all limbs for three days. Neurological examination revealed a dome shaped skull, a broad-based stance and a moderate cerebellar ataxia. The postural responses were markedly delayed in all limbs. Moderate ventro-lateral strabismus, vertical nystagmus and absent menace response were observed bilaterally. Clinical signs indicated multifocal localisation (forebrain, cerebellum). Magnetic resonance imaging (MRI) showed dilation of all cerebral ventricles, irregular thinning of the periventricular white and grey matter, consistent with internal hydrocephalus. In addition, the hemispheres were collapsed at the right temporal and left frontal lobe with haemorrhage filling the adjacent subarachnoid space. The dog underwent left frontal and right temporal craniotomy for removal of the haemorrhage. The dog improved on all neurological signs and was discharged after seven days. A repeat MRI three months postsurgical intervention showed reexpansion of the cerebral hemispheres. Subarachnoid haemorrhages were markedly reduced. Conclusions Collapse of the hemispheres can occur spontaneously in dogs with hydrocephalus internus. Removal of the haemorrhage can improve clinical signs.
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Affiliation(s)
- Agnieszka Olszewska
- Department of Veterinary Clinical Sciences, Small Animal Clinic, Neurosurgery, Neuroradiology and Clinical Neurology, Justus-Liebig-University, Frankfurter Strasse 108, 35392, Giessen, Germany
| | - Daniela Farke
- Department of Veterinary Clinical Sciences, Small Animal Clinic, Neurosurgery, Neuroradiology and Clinical Neurology, Justus-Liebig-University, Frankfurter Strasse 108, 35392, Giessen, Germany
| | - Martin Jürgen Schmidt
- Department of Veterinary Clinical Sciences, Small Animal Clinic, Neurosurgery, Neuroradiology and Clinical Neurology, Justus-Liebig-University, Frankfurter Strasse 108, 35392, Giessen, Germany
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97
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Hameed MQ, Zurakowski D, Proctor MR, Stone SSD, Warf BC, Smith ER, Goumnerova LC, Swoboda M, Anor T, Madsen JR. Noninvasive Thermal Evaluation of Ventriculoperitoneal Shunt Patency and Cerebrospinal Fluid Flow Using a Flow Enhancing Device. Neurosurgery 2020; 85:240-249. [PMID: 29917093 DOI: 10.1093/neuros/nyy246] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 05/29/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND While a noninvasive flow determination would be desirable in the diagnosis of cerebrospinal fluid shunt malfunction, existing studies have not yet defined a role for thermal flow detection. OBJECTIVE To evaluate a revised test protocol using a micropumper designed to transiently enhance flow during thermal testing to determine whether thermal detection of flow is associated with progression to shunt revision surgery. METHODS Eighty-two unique tests were performed in 71 shunts. The primary outcome, need for revision within 7 d of testing, was compared with results of micropumper-augmented thermal flow detection. Statistical analysis was based on blind interpretation of test results and raw temperature data recorded during testing. RESULTS The test was sensitive (73%) and specific (68%) in predicting need for revision, with 5.6-fold higher probability of revision when flow was not detected. Negative predictive value in our sample was 94.2%. The probability of not requiring revision increased with increasing total temperature drop. Analysis of various possible thresholds showed that the optimal temperature cutoff may be lower than suggested by the manufacturer (0.125°C vs 0.2°C). CONCLUSION This is the first study to report a strong association between thermal flow evaluation and a clinical impression that a shunt is not malfunctioning. The current recommended threshold may increase the false positive rate unnecessarily, and as clinicians gain experience with the method, they may find value in examining the temperature curves themselves. Multicenter studies are suggested to further define a role for this diagnostic test.
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Affiliation(s)
- Mustafa Q Hameed
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Zurakowski
- Department of Anesthesiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark R Proctor
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Scellig S D Stone
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Liliana C Goumnerova
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marek Swoboda
- Drexel University, School of Biomedical Engineering, Science and Health Systems, Philadelphia, Pennsylvania
| | - Tomer Anor
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph R Madsen
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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98
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Luther E, McCarthy D, Sedighim S, Niazi T. Endoscopic third ventriculostomy inpatient failure rates compared with shunting in post-hemorrhagic hydrocephalus of prematurity. Childs Nerv Syst 2020; 36:559-568. [PMID: 31863148 DOI: 10.1007/s00381-019-04465-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Endoscopic third ventriculostomy (ETV) has gained traction as a method for treating post-hemorrhagic hydrocephalus of prematurity (PHHP) in an effort to obviate lifelong shunt dependence in neonates. However, data remains limited regarding inpatient failures. METHODS A retrospective analysis of the NIS between 1998 and 2014 was performed. Discharges with age < 1 year and ICD-9-CM codes indicating intraventricular hemorrhage of prematurity (772.1x) and ETV/shunt (02.22 and 02.3x) were included. Patients with ICD-9-CM codes for ventricular drain/reservoir (02.21) were excluded to prevent confounding. Time trend series plots were created. Yearly trends were quantified using logarithmic regression analysis. Kaplan-Meier curves were utilized to analyze time to treatment failure. Time to failure for each treatment was compared using log-rank. RESULTS A total of 11,017 discharges were identified. ETV was more likely to be utilized at < 29 weeks gestational age (p = 0.0039) and birth weight < 1000 g (p = 0.0039). Shunts were less likely to fail in older and heavier newborns (OR 0.836 p = 0.00456, OR 0.828 p = 0.0001, respectively). Those initially shunted had lower failure rates compared with ETV (OR 0.44, p < 0.0001) but time to failure was longer with ETV (p = 0.04562). 79.5% of ETVs that failed were shunted after the first failure. Shunts were much less likely to undergo ETV if they failed (OR 0.21, p < 0.0001). Higher grade IVH was predictive of shunt failure but not ETV (OR 2.36, p = 0.0129). CONCLUSIONS Although ETV can be effective in PHHP, it has a much higher initial failure rate than shunting and should thus be chosen based on a multifactorial approach.
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Affiliation(s)
- Evan Luther
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 2nd floor, 1095 NW 14th Terrace, Miami, FL, 33136, USA.
| | - David McCarthy
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 2nd floor, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - Shaina Sedighim
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 2nd floor, 1095 NW 14th Terrace, Miami, FL, 33136, USA
| | - Toba Niazi
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 2nd floor, 1095 NW 14th Terrace, Miami, FL, 33136, USA.,Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, FL, USA
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99
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Baro V, Leon FF, Sartori L, Denaro L. Ultrasound-guided percutaneous ventriculopleural shunt placement: a minimally invasive technique. Childs Nerv Syst 2020; 36:617-620. [PMID: 31897630 DOI: 10.1007/s00381-019-04475-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 12/10/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Ventriculopleural shunt is still considered a third-line option for CSF diversion, when both peritoneal and atrial cavity are contraindicated. Different approaches have been used and in modern surgery, lesser invasive techniques are predominant. The goal of this manuscript is to present a minimally invasive placement of a pleural catheter. METHODS We describe a minimally invasive approach to the pleural space using an a-traumatic peel-away introducer under ultrasonographic intraoperative control. Furthermore, consideration about complications, follow-up and advantages of the abovementioned technique will be discussed. CONCLUSIONS Percutaneous US guided placement for pleural catheter is a safer and modern minimally invasive approach to the pleural space. Pleural effusion is the predominant complication, encountered especially in younger children.
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Affiliation(s)
- Valentina Baro
- Department of Neurosciences, Academic Neurosurgery, University of Padova Medical School, Via Giustiniani 2, 35128, Padova, Italy.
| | - Francesco Fascetti Leon
- Department of Women's and Children's Health, Paediatric Surgery Unit, University of Padova, Padova, Italy
| | - Luca Sartori
- Department of Neurosciences, Academic Neurosurgery, University of Padova Medical School, Via Giustiniani 2, 35128, Padova, Italy
| | - Luca Denaro
- Department of Neurosciences, Academic Neurosurgery, University of Padova Medical School, Via Giustiniani 2, 35128, Padova, Italy
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100
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Long-Term Outcomes in Ventriculoatrial Shunt Surgery in Patients with Pediatric Hydrocephalus: Retrospective Single-Center Study. World Neurosurg 2020; 138:e112-e118. [PMID: 32061956 DOI: 10.1016/j.wneu.2020.02.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/04/2020] [Accepted: 02/05/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Long-term outcomes are rarely reported for patients with pediatric hydrocephalus. Ventriculoperitoneal shunting is the surgical standard; nevertheless, in selected patients, a ventriculoatrial shunt (VAS) remains an important alternative. This study aimed to analyze the causes of VAS revisions and complications. METHODS Pediatric patients who underwent their first shunt operation between 1982 and 1992 were included. The timing, cause, and modality of VAS revisions were retrospectively determined. RESULTS Overall, 138 patients were treated for hydrocephalus and 61 patients received a VAS during the follow-up period. A primary VAS was the first shunt type in 42 (68.85%) patients. In 19 (31.15%) patients, conversions to second-line VAS were carried out. The rates of VAS revisions performed for dysfunction or elective lengthening of a short atrial catheter were 52.2% and 22.9%, respectively. There was no difference in the number of VAS revisions between patients with primary VASs and second-line VASs. Age at VAS and etiology of hydrocephalus had no effect on the number of revisions. Specific VAS complications were observed in 2 patients. Deep positioning of the distal catheter led to asymptomatic tricuspid regurgitation that was reversible after shortening of the atrial catheter. Another patient presented with shunt nephritis and completely recovered after the atrial catheter was replaced with a peritoneal catheter. CONCLUSIONS VAS remains an appropriate second-line alternative in selected patients. Specific VAS complications were rarely observed and completely reversible after treatment. However, regular and specific follow-up examinations are strongly recommended to avoid cardiopulmonary or renal complications.
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