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Zhang M, Olivero WC, Huston JM, Pappu S, Arnold PM, Biswas A, Anderson AT, Sutton BP. Measuring CSF shunt flow with MRI using flow enhancement of signal intensity (FENSI). Magn Reson Med 2024; 92:807-819. [PMID: 38469904 PMCID: PMC11142874 DOI: 10.1002/mrm.30079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 02/18/2024] [Accepted: 02/21/2024] [Indexed: 03/13/2024]
Abstract
PURPOSE To develop and validate a noninvasive imaging technique for accurately assessing very slow CSF flow within shunt tubes in pediatric patients with hydrocephalus, aiming to identify obstructions that might impede CSF drainage. THEORY AND METHODS A simulation of shunt flow enhancement of signal intensity (shunt-FENSI) signal is used to establish the relationship between signal change and flow rate. The quantification of flow enhancement of signal intensity data involves normalization, curve fitting, and calibration to match simulated data. Additionally, a phase sweep method is introduced to accommodate the impact of magnetic field inhomogeneity on the flow measurement. The method is tested in flow phantoms, healthy adults, intensive care unit patients with external ventricular drains (EVD), and shunt patients. EVDs enable shunt-flow measurements to be acquired with a ground truth measure of CSF drainage. RESULTS The flow-rate-to-signal simulation establishes signal-flow relationships and takes into account the T1 of draining fluid. The phase sweep method accurately accounts for phase accumulation due to frequency offsets at the shunt. Results in phantom and healthy human participants reveal reliable quantification of flow rates using controlled flows and agreement with the flow simulation. EVD patients display reliable measures of flow rates. Shunt patient results demonstrate feasibility of the method and consistent flow rates for functional shunts. CONCLUSION The results demonstrate the technique's applicability, accuracy, and potential for diagnosing and noninvasively monitoring hydrocephalus. Limitations of the current approach include a high sensitivity to motion and strict requirement of imaging slice prescription.
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Affiliation(s)
- Mingxiao Zhang
- Department of Bioengineering, University of Illinois, Urbana, IL, USA
- Beckman Institute, University of Illinois, Urbana, IL, USA
| | - William C. Olivero
- Carle Illinois College of Medicine, University of Illinois, Champaign, IL, USA
- Department of Neurosurgery, Carle Foundation Hospital, Urbana, IL, USA
| | - Jason M. Huston
- Carle Illinois College of Medicine, University of Illinois, Champaign, IL, USA
- Department of Radiology, Carle Foundation Hospital, Urbana, IL, USA
| | - Suguna Pappu
- Carle Illinois College of Medicine, University of Illinois, Champaign, IL, USA
- Department of Neurosurgery, Carle Foundation Hospital, Urbana, IL, USA
| | - Paul M. Arnold
- Carle Illinois College of Medicine, University of Illinois, Champaign, IL, USA
- Department of Neurosurgery, Carle Foundation Hospital, Urbana, IL, USA
| | - Arundhati Biswas
- Department of Neurosurgery, Carle Foundation Hospital, Urbana, IL, USA
| | | | - Bradley P. Sutton
- Department of Bioengineering, University of Illinois, Urbana, IL, USA
- Beckman Institute, University of Illinois, Urbana, IL, USA
- Carle Illinois College of Medicine, University of Illinois, Champaign, IL, USA
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Grullon JR, Koutsouras GW, Onwumere NF, Lehmann DF, Krishnamurthy S. Do P-glycoprotein Medications Alter the Risk of Ventriculoperitoneal Shunt in Adults with Hydrocephalus? J Clin Pharmacol 2024; 64:371-377. [PMID: 37751442 DOI: 10.1002/jcph.2359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/16/2023] [Indexed: 09/28/2023]
Abstract
Hydrocephalus is a disorder caused by excess fluid accumulation in the brain and results in brain damage with consequent cognitive and physical problems. This condition has no cure; the only treatment is brain surgery. Experimental data indicate that P-glycoprotein (P-gp) plays a crucial role in the pathogenesis of hydrocephalus due to its function in clearing macromolecules from the brain. Numerous medications frequently used are classified as P-gp inducers or inhibitors, and comprehending their effects may aid in attaining improved patient outcomes. Therefore, in this single-center retrospective study, we examined the risk of the need for ventriculoperitoneal shunt placement over 10 years among 4588 adult patients with hydrocephalus not exposed to any P-gp inhibitors/inducers or exclusively exposed to either P-gp inhibitors or inducers. Our analysis shows that patients exposed to P-gp inhibitors had a 3.2 times higher risk of requiring ventriculoperitoneal shunt surgery (P < .0001). In contrast, the relative risk was not significantly affected (P = .07) among those exposed to P-gp inducers. Our findings indicate the need for caution when prescribing P-gp inhibitors to patients with hydrocephalus. Additional studies using larger cohorts are required to confirm whether P-gp inducers in patients with hydrocephalus can mitigate the risk of ventriculoperitoneal shunt.
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Affiliation(s)
- Jason R Grullon
- Norton College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - George W Koutsouras
- Department of Neurosurgery, Norton College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Nneka F Onwumere
- Norton College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - David F Lehmann
- Department of Medicine, Norton College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Satish Krishnamurthy
- Department of Neurosurgery, Norton College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
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Hamed EA, Mohammad SA, Awadallah SM, Abdel-Latif AMM, Abd-Elhameed AM. MRI as a one-stop destination for evaluation of CSF shunt malfunction. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2023. [DOI: 10.1186/s43055-023-00991-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
Abstract
Abstract
Background
Despite the high-frequency rate of cerebrospinal fluid shunt malfunction, radiological evaluation of CSF shunts has remained deficient, focusing mainly on demonstrating secondary signs of shunt failure rather than evaluating the shunt tube itself. We aimed to study the utility of different MR pulse sequences in evaluating the cranial and abdominal ends of CSF shunts in order to identify the potential cause of shunt failure and its impact on patient management.
Results
Twenty-five patients (18 males, 7 females, median age 2.5 years, IQR 0.75–15) were enrolled in the study, having 28 ventriculo-peritoneal shunts and single ventriculo-gallbladder shunt. The catheter lumen and fine intraventricular septae were only demonstrated in 3D-DRIVE sequences (p < 0.001). Except for three patients (having cranial end-related complications), all patients with cranial and/or abdominal end-related complications received surgery (p < 0.001, positive likelihood and negative likelihood ratios = 7.27, 0.3, respectively, sensitivity = 0.7 and specificity = 0.9). MRI findings (luminal occlusion, disconnection, CSF collection, or migration) were consistent with operative data. There is no significant difference between patients who underwent surgery and those with conservative management, or symptomatic and asymptomatic patients in terms of the prevalence of ventricular dilatation or white matter signal abnormality. The results of the abdomino-pelvic fat-suppressed T2-WI showed excellent agreement with ultrasound findings (Cohen’s Kappa 0.9). Quantitative PC could give insights into CSF dynamics, which depend on the site and cause of shunt malfunction.
Conclusions
MRI could be a one-stop destination for evaluating patients with suspected non-acute shunt malfunction. It was found to have clinical relevance in terms of accurately locating the exact site and possible cause of shunt-related complications.
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Patel MS, Zhang JK, Khan ASR, Alexopoulos G, Khan MQ, Mercier PJ, Kemp JM. Delayed peritoneal shunt catheter migration into the pulmonary artery with indolent thrombosis: A case report and narrative review. Surg Neurol Int 2022; 13:77. [PMID: 35399878 PMCID: PMC8986728 DOI: 10.25259/sni_1150_2021] [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] [Received: 11/17/2021] [Accepted: 02/02/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Ventriculoperitoneal (VP) shunts are the preferred surgical treatment for hydrocephalus, and rarely, these operations may be complicated by catheter migration to ectopic sites. We present the case of an asymptomatic VP shunt patient with delayed peritoneal catheter migration into the pulmonary artery shunt catheter migration into the pulmonary artery (SCMPA) complicated by knotting and indolent thrombosis, necessitating open-heart surgery for system retrieval. Methods: We conducted a literature review in PubMed, Scopus, and Web of Science of prior similar reported cases and present the results of 24 cases of SCMPA. Results: An asymptomatic 12-year-old male presented with SCMPA noted on routine annual follow-up imaging. Preoperative CT angiogram indicated extensive catheter looping into the pulmonary artery without evidence of thrombosis. Less invasive attempts to retrieve the retained catheter were unsuccessful, and open-heart surgery was required. Intraoperatively, a nonocclusive pulmonary arterial thrombus surrounding the knotted catheter was discovered that was lysed successfully before system retrieval. Conclusion: VP shunt catheter migration into the pulmonary artery (SCMPA) with concurrent large vessel thrombosis can develop in pediatric patients incidentally without any clinical symptoms. Our report suggests that preoperative CT angiogram may be insufficient to detect arterial thrombosis in the presence of extensive intravascular catheter knotting. An open-chest approach may be the only viable surgical option for catheter retrieval in the presence of complex catheter coiling. The use of anticoagulation following open-heart surgery for retrieval of a migrated VP shunt catheter remains unclear, we here propose that continuation of long-term therapeutic anticoagulation may successfully prevent thrombus relapse.
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Affiliation(s)
- Mayur S. Patel
- Department of Neurosurgery, Saint Louis University School of Medicine, Saint Louis, Missouri, United States
| | - Justin K. Zhang
- Department of Neurosurgery, Saint Louis University School of Medicine, Saint Louis, Missouri, United States
| | - Ali Saif Raza Khan
- Department of Neurosurgery, Texas Tech University Health Sciences Center, Lubbock, Texas, United States
| | - Georgios Alexopoulos
- Department of Neurosurgery, Saint Louis University School of Medicine, Saint Louis, Missouri, United States
| | - Maheen Q. Khan
- Department of Neurosurgery, Saint Louis University, Saint Louis, Missouri, United States
| | - Philippe J. Mercier
- Department of Neurosurgery, Saint Louis University School of Medicine, Saint Louis, Missouri, United States
| | - Joanna M. Kemp
- Department of Neurosurgery, Saint Louis University School of Medicine, Saint Louis, Missouri, United States
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Abstract
Magnetic resonance (MR) imaging is a crucial tool for evaluation of the skull base, enabling characterization of complex anatomy by utilizing multiple image contrasts. Recent technical MR advances have greatly enhanced radiologists' capability to diagnose skull base pathology and help direct management. In this paper, we will summarize cutting-edge clinical and emerging research MR techniques for the skull base, including high-resolution, phase-contrast, diffusion, perfusion, vascular, zero echo-time, elastography, spectroscopy, chemical exchange saturation transfer, PET/MR, ultra-high-field, and 3D visualization. For each imaging technique, we provide a high-level summary of underlying technical principles accompanied by relevant literature review and clinical imaging examples.
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Affiliation(s)
- Claudia F Kirsch
- Division Chief, Neuroradiology, Professor of Neuroradiology and Otolaryngology, Department of Radiology, Northwell Health, Zucker Hofstra School of Medicine at Northwell, North Shore University Hospital, Manhasset, NY
| | - Mai-Lan Ho
- Associate Professor of Radiology, Director of Research, Department of Radiology, Director, Advanced Neuroimaging Core, Chair, Asian Pacific American Network, Secretary, Association for Staff and Faculty Women, Nationwide Children's Hospital and The Ohio State University, Columbus, OH; Division Chief, Neuroradiology, Professor of Neuroradiology and Otolaryngology, Department of Radiology, Northwell Health, Zucker Hofstra School of Medicine at Northwell, North Shore University Hospital, Manhasset, NY.
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König RE, Stucht D, Baecke S, Rashidi A, Speck O, Sandalcioglu IE, Luchtmann M. Phase‐Contrast MRI Detection of Ventricular Shunt CSF Flow: Proof of Principle. J Neuroimaging 2020; 30:746-753. [DOI: 10.1111/jon.12794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 09/13/2020] [Accepted: 09/15/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- Rebecca E. König
- Department of Neurosurgery, Medical Faculty Otto‐von‐Guericke University Magdeburg Magdeburg Germany
| | - Daniel Stucht
- Department of Biomedical Magnetic Resonance Otto‐von‐Guericke University Magdeburg Magdeburg Germany
- Institute of Biometrics and Medical Informatics, Medical Faculty Otto‐von‐Guericke University Magdeburg Magdeburg Germany
| | - Sebastian Baecke
- Institute of Biometrics and Medical Informatics, Medical Faculty Otto‐von‐Guericke University Magdeburg Magdeburg Germany
| | - Ali Rashidi
- Department of Neurosurgery, Medical Faculty Otto‐von‐Guericke University Magdeburg Magdeburg Germany
| | - Oliver Speck
- Department of Biomedical Magnetic Resonance Otto‐von‐Guericke University Magdeburg Magdeburg Germany
- Leibniz Institute for Neurobiology Magdeburg Germany
| | - I. Erol Sandalcioglu
- Department of Neurosurgery, Medical Faculty Otto‐von‐Guericke University Magdeburg Magdeburg Germany
| | - Michael Luchtmann
- Department of Neurosurgery, Medical Faculty Otto‐von‐Guericke University Magdeburg Magdeburg Germany
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Blitz AM, Huynh PP, Bonham LW, Gujar SK, Sorte DE, Moghekar A, Luciano MG, Rigamonti D. High-Resolution MRI for Evaluation of Ventriculostomy Tubes: Assessment of Positioning and Proximal Patency. AJNR Am J Neuroradiol 2020; 41:57-63. [PMID: 31924603 PMCID: PMC6975305 DOI: 10.3174/ajnr.a6320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 10/02/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Imaging evaluation of ventriculostomy tubes, despite the frequency of malfunction, has remained inadequate due to the absence of a systematic way of assessing the catheter itself. In this retrospective review, we assessed the utility of high-resolution 3D MR imaging techniques, including CISS and volumetric interpolated breath-hold examination sequences, in the evaluation of ventriculostomy catheters. MATERIALS AND METHODS We performed a retrospective review of 23 clinical MR imaging cases of shunted hydrocephalus spanning a 3-year period, all depicting ventriculostomy catheters. The MR imaging examinations included isotropic CISS and volumetric interpolated breath-hold examination sequences performed with and without contrast. These were independently evaluated by 2 neuroradiologists with respect to the catheter course, side hole position, relationship of the side holes to the ventricles, patency, and the presence or absence of intraluminal debris. RESULTS The catheter tip was best seen on isotropic CISS sequences reformatted in an oblique plane, and side holes were visualized as CSF signal defects along the catheter wall in 10/23 (43%) cases. The relationship of the catheter side holes to the ventricles was seen in 47% of cases and was best visualized on the coronal CISS sequences. Catheter patency was confirmed in 12/23 (52%) cases, while the other 48% were notable for T2 hypointense filling defects compatible with luminal obstruction. Enhancement of some of these filling defects on imaging is suggestive of choroid plexus ingrowth rather than debris. CONCLUSIONS High-resolution 3D MR imaging using isotropic CISS sequences allows systematic evaluation of catheter positioning, patency, and potential etiologic differentiation of filling defects when shunt dysfunction is suspected.
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Affiliation(s)
- A M Blitz
- From the Department of Radiology (A.M.B.), University Hospitals, Case Western Reserve University
- Departments of Radiology and Radiological Sciences (A.M.B., P.P.H., L.W.B., S.E.G.)
- Neurosurgery (A.M.B., M.G.L., D.R.), Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - P P Huynh
- Departments of Radiology and Radiological Sciences (A.M.B., P.P.H., L.W.B., S.E.G.)
| | - L W Bonham
- Departments of Radiology and Radiological Sciences (A.M.B., P.P.H., L.W.B., S.E.G.)
| | - S K Gujar
- Departments of Radiology and Radiological Sciences (A.M.B., P.P.H., L.W.B., S.E.G.)
| | - D E Sorte
- Department of Radiology (D.E.S.), University of New Mexico, Albuquerque, New Mexico
| | | | - M G Luciano
- Neurosurgery (A.M.B., M.G.L., D.R.), Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - D Rigamonti
- Neurosurgery (A.M.B., M.G.L., D.R.), Johns Hopkins Medical Institutions, Baltimore, Maryland
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