Ventriculo-subgaleal shunt: evaluation by computed tomography

Hydroxychloroquine versus lopinavir/ritonavir in severe COVID-19 patients : Results from a real-life patient cohort

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with a high mortality. To date no trial comparing hydroxychloroquine (HCQ) and lopinavir/ritonavir (LPV/RTV) has been performed.

METHODS

Hospitalized patients ≥18 years old with severe coronavirus disease 2019 (COVID-19) were treated with either HCQ or LPV/RTV if they had either respiratory insufficiency (SpO2 ≤ 93% on room air or the need for oxygen insufflation) or bilateral consolidations on chest X‑ray and at least 2 comorbidities associated with poor COVID-19 prognosis. Outcomes investigated included in-hospital mortality, intensive care unit (ICU) admission, length of stay, PCR (polymerase chain reaction) negativity and side effects of treatment.

RESULTS

Of 156 patients (41% female) with a median age of 72 years (IQR 55.25-81) admitted to our department, 67 patients fulfilled the inclusion criteria (20 received HCQ, 47 LPV/RTV). Groups were comparable regarding most baseline characteristics. Median time from symptom onset to treatment initiation was 8 days and was similar between the groups (p = 0.727). There was no significant difference (HCQ vs. LPV/RTV) in hospital mortality (15% vs. 8.5%, p = 0.418), ICU admission rate (20% vs. 12.8%, p = 0.470) and length of stay (9 days vs. 11 days, p = 0.340). A PCR negativity from nasopharyngeal swabs was observed in approximately two thirds of patients in both groups. Side effects led to treatment discontinuation in 15% of patients in the LPV/RTV group.

CONCLUSION

No statistically significant differences were observed in outcome parameters in patients treated with HCQ or LPV/RTV but patients in the LPV/RTV group showed a numerically lower hospital mortality rate. Additionally, in comparison to other studies we demonstrated a lower mortality in patients treated with LPV/RTV despite having similar patient groups, perhaps due to early initiation of treatment.

The first 12 months of COVID-19: a timeline of immunological insights

Since the initial reports of a cluster of pneumonia cases of unidentified origin in Wuhan, China, in December 2019, the novel coronavirus that causes this disease - severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) - has spread throughout the world, igniting the twenty-first century's deadliest pandemic. Over the past 12 months, a dizzying array of information has emerged from numerous laboratories, covering everything from the putative origin of SARS-CoV-2 to the development of numerous candidate vaccines. Many immunologists quickly pivoted from their existing research to focus on coronavirus disease 2019 (COVID-19) and, owing to this unprecedented convergence of efforts on one viral infection, a remarkable body of work has been produced and disseminated, through both preprint servers and peer-reviewed journals. Here, we take readers through the timeline of key discoveries during the first year of the pandemic, which showcases the extraordinary leaps in our understanding of the immune response to SARS-CoV-2 and highlights gaps in our knowledge as well as areas for future investigations.

Interferons and Multiple Sclerosis: Lessons from 25 Years of Clinical and Real-World Experience with Intramuscular Interferon Beta-1a (Avonex)

Recombinant interferon (IFN) β-1b was approved by the US Food and Drug Administration as the first disease-modifying therapy (DMT) for multiple sclerosis (MS) in 1993. Since that time, clinical trials and real-world observational studies have demonstrated the effectiveness of IFN therapies. The pivotal intramuscular IFN β-1a phase III trial published in 1996 was the first to demonstrate that a DMT could reduce accumulation of sustained disability in MS. Patient adherence to treatment is higher with intramuscular IFN β-1a, given once weekly, than with subcutaneous formulations requiring multiple injections per week. Moreover, subcutaneous IFN β-1a is associated with an increased incidence of injection-site reactions and neutralizing antibodies compared with intramuscular administration. In recent years, revisions to MS diagnostic criteria have improved clinicians' ability to identify patients with MS and have promoted the use of magnetic resonance imaging (MRI) for diagnosis and disease monitoring. MRI studies show that treatment with IFN β-1a, relative to placebo, reduces T2 and gadolinium-enhancing lesions and gray matter atrophy. Since the approval of intramuscular IFN β-1a, a number of high-efficacy therapies have been approved for MS, though the benefit of these high-efficacy therapies should be balanced against the increased risk of serious adverse events associated with their long-term use. For some subpopulations of patients, including pregnant women, the safety profile of IFN β formulations may provide a particular benefit. In addition, the antiviral properties of IFNs may indicate potential therapeutic opportunities for IFN β in reducing the risk of viral infections such as COVID-19.

Managing rheumatic diseases during COVID-19

Rheumatology practice, during Coronavirus Disease 2019 (COVID-19) pandemic, has faced multifaceted challenges. Rheumatologists routinely prescribe immunosuppressant medications to their patients with multisystem autoimmune rheumatic diseases who are concerned about the increased risk of acquiring COVID-19 infection and are anxious to know if they should continue or hold these medications. Rheumatologists are often inundated by calls from their patients and physician colleagues caring for COVID-19 patients in hospitals, about how to manage the immunosuppression. Physicians face the challenging task of keeping up with the most up-to-date information on COVID-19. There are uncertainties about the mode of spread, clinical features, management options as well as long-term complications of COVID-19. Data are rapidly evolving and different studies on treatment options are showing contradictory results. It is known that viral illnesses can trigger a flare-up of underlying rheumatic disease that was previously in remission. To further complicate the scenario, some of the immunosuppressants have shown to have antiviral properties. This has created dilemma in the light of current COVID-19 crisis, as whether to continue or stop the immunosuppressive agents which could be essential to prevent complications of the rheumatic diseases including organ failure but also there is concern about acquiring COVID-19 or developing serious infection. Until we get an effective vaccine, immunosuppressant management for rheumatic diseases as well as other autoimmune diseases and transplants will pose difficult questions. This article is an attempt to review and understand COVID-19 and its impact on the immune system with special emphasis on managing medications used for autoimmune rheumatic diseases. We have provided general guidance about decision making, in regards to the immunosuppressive agents used in rheumatology practice with an understanding that this may change in near future.

Surgical management of intraventricular hemorrhage and posthemorrhagic hydrocephalus in premature infants

Perinatal intraventricular hemorrhage (IVH) with or without development of posthemorrhagic hydrocephalus (PHH) in premature neonates may lead to severe neurological disability. Although the percentage of preterm infants developing IVH has been greatly reduced in the last three decades, increased survival of these very immature infants has meant that large IVH with subsequent PHH is still a serious unsolved problem. Early cerebrospinal fluid diversion as a temporizing measure or a permanent shunt is the treatment of choice. This review summarizes the surgical modalities, techniques, and their complications in the management of IVH and PHH in premature infants. Though there is no level-one evidence to support the superiority of any of the currently available managements in the initial treatment of PHH over others, this review aims to provide pediatric neurosurgeons a comprehensive understanding of the pros and cons of various surgical treatment modalities, focusing on the temporizing measures before the infants is heavy enough to undergo ventriculoperitoneal shunt insertion. Based on the patient's condition, the facility and man power of the institution with minimal complication rate, the pediatric neurosurgeons may choose the best initial approach for the management of IVH and PHH in premature infants.

Ventriculosubgaleal shunting-a comprehensive review and over two-decade surgical experience

INTRODUCTION

The subgaleal space is the fibroareolar layer found between the galea aponeurotica and the periosteum of the scalp. Due to its elastic and absorptive capabilities, the subgaleal space can be used as a shunt to drain excess cerebrospinal fluid from the ventricles. A subgaleal shunt consists of a shunt tube with one end in the lateral ventricles while the other end is inserted into the subgaleal space of the scalp. This will allow for the collection and absorption of excess cerebrospinal fluid. Indications for ventriculosubgaleal shunting (VSG) include acute head trauma, subdural hematoma, and malignancies.

DISCUSSION

VSG shunt is particularly advantageous for premature infants suffering from post-hemorrhagic hydrocephalus due to their inability to tolerate long-term management such as a ventriculoperitoneal shunt. Complications include infection and shunt blockage. In comparison with other short-term treatments of hydrocephalus, the VSG exhibits significant advantages in the drainage of excess cerebrospinal fluid. VSG shunt is associated with lower infection rates than other external ventricular drain due to the closed system of CSF drainage and lack of external tubes.

CONCLUSION

This review discusses the advantages and disadvantages of the VSG shunt, as well as our personal experience with the procedure.

Ventriculosubgaleal shunting--a strategy to reduce the incidence of shunt revisions and slit ventricles: an institutional experience and review of the literature

BACKGROUND/AIMS

Slit ventricles and multiple episodes of shunt failure are problematic in many infants and preterm neonates shunted for hydrocephalus. We utilized ventriculosubgaleal (VSG) shunting as the initial neurosurgical intervention in neonates with hydrocephalus associated with intraventricular hemorrhage and infants with myelomeningocele.

METHODS

We conducted a chart review of 21 children initially treated with a VSG shunt between November 2002 and July 2009. Patient records and imaging studies were reviewed. Demographics, case data and clinical outcome were collected.

RESULTS

Five patients (27.8%) required a revision after conversion to a ventriculoperitoneal (VP) shunt. There were 9 cases of radiographic slit ventricles (45%). Average follow-up was 59.5 months (range 12-97 months). Average time interval to shunt conversion was 81.5 days. Two patients have not required conversion to a VP shunt (one with an 8-year follow-up). To date, none of these patients has required a subtemporal window or cranial vault expansion.

CONCLUSION

Based on our results, initial management of selected hydrocephalic infants with a VSG shunt may prove to be advantageous in the long run for these children as the number of shunt revisions and the incidence of slit ventricles are significantly less than those reported in the literature.

Complications of ventriculosubgaleal shunts in infants and children

INTRODUCTION

The ventriculosubgaleal shunt has been used for the temporary bypass of the normal cerebrospinal fluid (CSF) pathways. To date, a large series of complications from this procedure has not been elaborated upon in the literature.

PATIENTS AND METHODS

We retrospectively reviewed all such shunts (170) placed at our institution over the last 6 years and documented all complications from this procedure. The majority of patients operated upon were premature infants with intraventricular hemorrhage and subsequent hydrocephalus. This technique was used in a much smaller group of patients in whom the peritoneal cavities were not currently candidates for distal shunt implantation but would have been with time. Other patients in whom this technique was used were those with malignant brain tumors, intraventricular abscesses, chronic truncal wounds, chronic subdural hygromas, and meningitis.

RESULTS

Complications from subgaleal shunting included infection (5.9%), intracranial hemorrhage (1.1%), and wound leakage (4.7%).

CONCLUSIONS

We believe the benefits afforded by ventriculosubgaleal shunting significantly outweigh the risks of the procedure and greatly ease the burden of care for this select population of children. Based on the literature and our own experience, the complications from this procedure are not excessive or extraordinarily unique compared with other neurosurgical CSF diversion techniques.

Subgaleal shunting: A 20-year experience

Object

The authors undertook a retropective study to evaluate the effectiveness of diverting intracranial fluid into the subgaleal space for temporary absorption by the membranes of the scalp.

Methods

Eighty-one patients were treated over a 20-year period. There were 22 cases of hypertensive hydrocephalus, 52 cases of acute head trauma, and seven cases of chronic subdural hematoma. The simple surgical technique is described.

Subgaleal shunting provided effective short-term treatment of hydrocephalus and increased intracranial pressure, which was monitored directly in 22 cases of cerebral contusion and edema.

Conclusions

The closed method for drainage of cerebrospinal fluid avoids the complications of open ventriculostomy or open drainage of the subdural space.

Neonatal ventriculosubgaleal shunts

OBJECTIVE

We report on 32 neonates treated with ventriculosubgaleal (VSG) shunts to determine VSG shunt survival and associated complications.

METHODS

Between 1993 and 1997, 37 VSG shunts were placed in 32 neonates when the cerebrospinal fluid (CSF) or the abdomen was considered unsuitable for ventriculoperitoneal shunt placement. In each child, a ventricular catheter was attached to 3 cm of a closed-end peritoneal tube via a right-angle connector, which drained into a surgically created subgaleal pocket.

RESULTS

The causes of hydrocephalus were as follows: intraventricular hemorrhage (IVH) in 20 neonates, meningitis/ventriculitis in 6, IVH and infection in 2, and other causes in 4. The mean postconception age at the time of VSG shunt insertion was 37.2 weeks (33.1 wk in the IVH group), and the mean weight was 2227 g (1724 g in the IVH group). The average preoperative head circumference was 33.6 cm. The average survival of these 37 VSG shunts (five children had two VSG shunts) was 35.1 days. The complications were as follows: one CSF leakage occurred when sutures were removed; one catheter fell into the ventricle and required removal, and one child died immediately after VSG shunt revision. There were no VSG shunt infections. All surviving children followed for a minimum of 4 months after insertion of a VSG shunt (n = 24) have required a ventriculoperitoneal shunt. Mean follow-up from the time of first VSG shunt insertion was 21.6 months. Four children died as a result of causes unrelated to the VSG shunt.

CONCLUSION

VSG shunts offer a simple, effective, and relatively safe means of temporizing hydrocephalus, and they avoid the need for external drainage or frequent CSF aspiration in these medically unstable infants until the CSF characteristics and abdomen are acceptable for ventriculoperitoneal shunting.

Ventriculosubgaleal shunt: a treatment option for progressive posthemorrhagic hydrocephalus

Among premature infants born at less than 1500 g, the incidence of intraventricular hemorrhage is greater than 45%. Of these, 40% will develop progressive posthemorrhagic hydrocephalus (PPHH). Optimum treatment remains controversial. Ventriculosubgaleal (VSG) shunts were first proposed as a means of temporarily diverting cerebrospinal fluid (CSF) in a more physiological manner for those infants less than 1500 g in weight who would not tolerate a ventriculoperitoneal (VP) shunt. The VSG shunt could then be converted into a VP shunt when the infant had gained the desired weight. Despite favourable reports, the procedure has not gained universal acceptance and is unknown to many neurosurgeons. The present authors report a series of 15 patients who had VSG shunts inserted with excellent temporary CSF diversion and no complications. Furthermore, 3 out of the 15 patients required no further treatment. We suggest that VSG shunting is a safe and effective means of treating the premature infant with PPHH.