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Affiliation(s)
- Bermans J Iskandar
- From the Department of Neurological Surgery, University of Wisconsin-Madison, Madison (B.J.I.); and the Departments of Molecular and Human Genetics, Molecular and Cellular Biology, and Medicine, Baylor College of Medicine, Houston (R.H.F.)
| | - Richard H Finnell
- From the Department of Neurological Surgery, University of Wisconsin-Madison, Madison (B.J.I.); and the Departments of Molecular and Human Genetics, Molecular and Cellular Biology, and Medicine, Baylor College of Medicine, Houston (R.H.F.)
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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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Finger T, Schaumann A, Pennacchietti V, Bührer C, Thomale UW, Schulz M. Reduced rates of infection after myelomeningocele closure associated with standard perioperative antibiotic treatment with ampicillin and gentamicin. Childs Nerv Syst 2021; 37:545-553. [PMID: 32720078 DOI: 10.1007/s00381-020-04832-y] [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: 07/10/2020] [Accepted: 07/22/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Postnatal closure of a myelomeningocele (MMC) is a complex procedure with frequent complications following surgery. Bacterial colonization of the placode may cause infection and subsequent complications. The objectives of this study were to determine the preoperative bacterial colonization rates, to assess the antibiotic regimen, and to evaluate the overall postoperative infection rate. METHODS All consecutive patients undergoing MMC closure in our hospital from January 2010 to January 2020 were evaluated. Epidemiological data, surgical data, complication characteristics, and microbiological results were documented. RESULTS A total of 45 patients were evaluated; in 41 patients, a wound swab of the placode was performed directly before MMC closure (91%). All patients received a prophylactic antibiotic treatment for a mean of 5.6 ± 2.7 days around the performed MMC closure. In three patients with a wound swab (7.3%), a bacterial colonization could be detected-none of the patients developed a subsequent infection. Overall, 7 other patients developed an infection (15.6%), three local surgical site infections, and four shunt-related infections. After applying a standardized perioperative prophylactic antibiotic treatment with ampicillin and gentamicin, the infection rate was observed to be lower compared with that of a non-standardized treatment (6% vs. 45%; p = 0.019). CONCLUSIONS In neonates who undergo MMC closure in the first 48 h after birth, the colonization rate of the placode was lower than previously reported. While the data presented cannot proof the benefit of a perioperative antibiotic prophylaxis, as compared with no prophylaxis, infection rates are low with a standardized antibiotic regime comprising ampicillin and gentamicin.
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Affiliation(s)
- Tobias Finger
- Department of Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Andreas Schaumann
- Department of Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Christoph Bührer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrich-Wilhelm Thomale
- Department of Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Schulz
- Department of Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Gutowski P, Gölz L, Rot S, Lemcke J, Thomale UW. Gravitational shunt valves in hydrocephalus to challenge the sequelae of over-drainage. Expert Rev Med Devices 2020; 17:1155-1168. [PMID: 33176494 DOI: 10.1080/17434440.2020.1837622] [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] [Indexed: 10/23/2022]
Abstract
INTRODUCTION In hydrocephalus treatment, ventriculo-peritoneal shunts (VPS) have become the most relevant therapy for seven decades among other treatment options. Due to the hydrostatic pressure in vertical position, CSF diversion is somehow non-physiological. The integration of gravitational valves in VPS was established to counteract the hydrostatic draining force and to approach a physiological condition of the cerebrospinal diverting system. Numerous clinical studies have shown that gravitational valves are able to reduce secondary complications of VPS treatment. It remains a challenge for the treating neurosurgeon to select the correct valve resistance based on individual anatomies and different etiologies of hydrocephalus as well as varying levels of activity of the patient. AREAS COVERED This review covers the development of gravitational shunt valves from historical, theoretical and clinical aspects for pediatric and adult etiologies of hydrocephalus. We discuss the role of gravitational shunt valves in preventing over-drainage issues and present the state-of-the-art literature. Furthermore, ongoing prospective trials are presented. EXPERT OPINION Counteracting the hydrostatic force by selecting the correct valve in a VPS system to achieve physiological balance in CSF diversion during vertical and horizontal body changes has become the current standard for hydrocephalus management. Gravitational shunt valves reliably address this need to minimize over-drainage events in the vertical position without affecting the CSF flow in the horizontal position. The results of ongoing prospective studies on the safety and efficacy of adjustable gravitational valves are still pending. Due to the complexity of the CSF flow, lifelong follow-up care for patients with VPS is critical.
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Affiliation(s)
- Paweł Gutowski
- Department of Neurosurgery, Unfallkrankenhaus Berlin , Berlin, Germany.,Department of Neurosurgery, Bródno Mazovia Hospital , Warsaw, Poland
| | - Leonie Gölz
- Institute of Radiology and Neuroradiology, Unfallkrankenhaus , Berlin, Germany
| | - Sergej Rot
- Department of Neurosurgery, Unfallkrankenhaus Berlin , Berlin, Germany
| | - Johannes Lemcke
- Department of Neurosurgery, Unfallkrankenhaus Berlin , Berlin, Germany
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Koueik J, Kraemer MR, Hsu D, Rizk E, Zea R, Haldeman C, Iskandar BJ. A 12-year single-center retrospective analysis of antisiphon devices to prevent proximal ventricular shunt obstruction for hydrocephalus. J Neurosurg Pediatr 2019; 24:642-651. [PMID: 31491755 DOI: 10.3171/2019.6.peds1951] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 06/17/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Recent evidence points to gravity-dependent chronic shunt overdrainage as a significant, if not leading, cause of proximal shunt failure. Yet, shunt overdrainage or siphoning persists despite innovations in valve technology. The authors examined the effectiveness of adding resistance to flow in shunt systems via antisiphon devices (ASDs) in preventing proximal shunt obstruction. METHODS A retrospective observational cohort study was completed on patients who had an ASD (or additional valve) added to their shunt system between 2004 and 2016. Detailed clinical, radiographic, and surgical findings were examined. Shunt failure rates were compared before and after ASD addition. RESULTS Seventy-eight patients with shunted hydrocephalus were treated with placement of an ASD several centimeters distal to the primary valve. The records of 12 of these patients were analyzed separately due to a complex shunt revision history (i.e., > 10 lifetime shunt revisions). The authors found that adding an ASD decreased the 1-year ventricular catheter obstruction rates in the "simple" and "complex" groups by 67.3% and 75.8%, respectively, and the 5-year rates by 43.3% and 65.6%, respectively. The main long-term ASD complication was ASD removal for presumed valve pressure intolerance in 5 patients. CONCLUSIONS Using an ASD may result in significant reductions in ventricular catheter shunt obstruction rates. If confirmed with prospective studies, this observation would lend further evidence that chronic shunt overdrainage is a central cause of shunt malfunction, and provide pilot data to establish clinical and laboratory studies that assess optimal ASD type, number, and position, and eventually develop shunt valve systems that are altogether resistant to siphoning.
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Affiliation(s)
| | | | | | - Elias Rizk
- 3Department of Neurological Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Ryan Zea
- 4Biostatistics and Medical Informatics, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin; and
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