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Yuri Ferreira M, Oliveira LB, Porto Júnior S, Semione G, Palavani LB, Batista S, Pari Mitre L, Borges PGLB, Abrantes Barros E, Andreão F, Porto Sousa M, Gomez D, Bertani R, Hakim F. Enhancing the quality of evidence, comparability, and reproducibility in ventriculoatrial shunt research for normal pressure hydrocephalus: A systematic review and VAS-NPH reporting guideline. J Clin Neurosci 2024; 126:328-337. [PMID: 39024937 DOI: 10.1016/j.jocn.2024.06.026] [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: 04/19/2024] [Revised: 06/03/2024] [Accepted: 06/30/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Ventriculoatrial shunt (VAS) is an important treatment option for normal pressure hydrocephalus (NPH). However, clinical studies reporting the use of VAS for NPH lack sufficient standardization for meta-analytic comparisons that could provide robust evidence regarding its use. This study aims to assess the quality of reporting in these studies and develop a reporting guideline checklist to standardize terminology, concepts, and reporting while reinforcing the essential elements to ensure comparability and reproducibility. METHODS This is a systematic literature review that followed the PRISMA guidelines with the search in Medline, Embase, and Web of Science databases, with no timeframe restriction. The level of evidence of the studies was assessed using the GRADE system, and the rigor used in the publication of the results was assessed concerning adherence to the guidelines indicated by the EQUATOR Network Group. Furthermore, the studies were scrutinized focusing on eight domains: (1) Characteristics of the included studies and baseline characteristics of the patients; (2) Reporting methodology; (3) Pivotal concepts definition; (4) Adverse events assessment; (5) Data writing and reporting; (6) Detailed outcomes reporting; (7) Specific clinical outcomes assessment and reporting; and (8) Complications reporting. RESULTS A total of 14 studies with 734 patients and 753 shunts were included in this review, and the assessment exposes notable deficiencies in reporting, specifically in baseline patient details, methodology, and outcome assessments. Only two studies followed reporting guidelines, prompting concerns about comprehensive reporting of adverse events and intraoperative complications. Varied reporting completeness existed for shunt-related issues. The absence of standardized definitions for key concepts and insufficient intervention details were observed. A VAS-NPH reporting guideline, encompassing 36 items across eight domains, was developed to address these shortcomings. CONCLUSION This systematic review reveals significant deficiencies in methodological rigor and reporting quality. The proposed VAS-NPH Reporting Guideline covers all essential aspects and is a potential solution to rectify these shortcomings and increase transparency, comparability, and reproducibility. This initiative aims to advance the level of evidence and enhance knowledge regarding the use of VAS in NPH.
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Affiliation(s)
- Marcio Yuri Ferreira
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Leonardo B Oliveira
- Department of Neurosurgery, State University of Ponta Grossa, Ponta Grossa, PR, Brazil
| | | | | | | | - Savio Batista
- Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Lucas Pari Mitre
- Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil
| | - Pedro G L B Borges
- Fundação Técnico-Educacional Souza Marques, Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Filipi Andreão
- Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Diego Gomez
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
| | - Raphael Bertani
- Department of Neurosurgery, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Fernando Hakim
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
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De John BG, Figaji AA, Enslin JMN. Analysis of non-ventriculoperitoneal shunts at Red Cross War Memorial Children's Hospital. Childs Nerv Syst 2024; 40:1099-1110. [PMID: 38091072 DOI: 10.1007/s00381-023-06242-2] [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: 11/14/2023] [Accepted: 11/28/2023] [Indexed: 03/28/2024]
Abstract
BACKGROUND At Red Cross War Memorial Children's Hospital (RCCH), it is the preferred practice to use non-ventriculoperitoneal (non-VP) shunts when the peritoneum is ineffective or contraindicated for cerebrospinal fluid (CSF) diversion and when endoscopy is not an option. The objective of this study is to evaluate the clinical course of patients having undergone these procedures. METHOD A single-centre retrospective review at RCCH wherein 43 children with a total of 59 episodes of non-VP shunt placement over a 12-year period were identified for inclusion. RESULTS Twenty-five ventriculoatrial (VA) and 32 ventriculopleural (VPL) shunts were analysed with a median age at insertion of 2.9 (0.3-14.9) and 5.3 years (0.5-13.4), respectively. The median number of previous shunt procedures prior to VA or VPL shunt insertion was 6.0 (2-28) versus 4.5 (2-17), respectively. Three VA (12.0%) and three VPL (9.4%) shunt patients were lost to follow-up. Of those remaining, 10 VA shunts (45.5%) compared to 19 (65,5%) VPL shunts required revision. One ventriculovesical shunt and one ventriculocholecystic shunt were placed in the same patient after 21 and 25 shunt-related procedures, respectively, and both were revised within 3 weeks of insertion. Median shunt survival was 8 months longer for the VA compared to the VPL shunts, being 13.5 (0-67) and 5 months (0-118), respectively. Complications for VA shunts were low, with the overall shunt sepsis rate in the VA group at 4% (n = 1) compared to 15.6% (n = 5) in the VPL group. CONCLUSION Our findings support that VA and VPL shunts are acceptable second-line options in an already compromised group of patients where safe treatment options are limited, provided attention is paid to the technical details specific to their placement.
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Affiliation(s)
- B G De John
- Department of Surgery, Division of Neurosurgery, University of Cape Town, Cape Town, South Africa.
- Division of Neurosurgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.
| | - A A Figaji
- Department of Surgery, Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
- Division of Neurosurgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - J M N Enslin
- Department of Surgery, Division of Neurosurgery, University of Cape Town, Cape Town, South Africa
- Division of Neurosurgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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Momin SMB, Mullins SR, Craven CL, Watkins L, Toma AK. Ventriculo-atrial shunt in idiopathic intracranial hypertension. Acta Neurochir (Wien) 2024; 166:98. [PMID: 38386079 PMCID: PMC10884045 DOI: 10.1007/s00701-024-05985-4] [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: 01/03/2024] [Accepted: 01/15/2024] [Indexed: 02/23/2024]
Abstract
PURPOSE CSF diversion is a recognised intervention in idiopathic intracranial hypertension (IIH), particularly in the presence of vision-threatening papilledema. Although ventriculo-atrial (VA) shunt insertion is a routine neurosurgical procedure, ventriculoperitoneal and lumboperitoneal shunts have been mostly used in this particular indication. This study aims to look at a single centre's experience with VA shunts in idiopathic intracranial hypertension (IIH). METHODS Retrospective case series with a review of electronic records over a 10-year period; exclusion criteria were duplication of same shunt insertion, no VA shunt insertion, paediatric patients and indication other than IIH. Notes were reviewed for demographics, shunt survival (defined by time prior to revision) and reasons for revision. RESULTS Eight VA shunt procedures were identified in 6 patients (mean age at insertion 34 ± 10 years) with a mean follow-up of 58 ± 25 months. All shunts were secondary procedures; 2 revisions from lumbo-pleural, 2 from ventriculopleural, 2 from ventriculoatrial and one each from ventriculoperitoneal and combined lumbo-/ventriculoperitoneal. At 50 months, 75% of VA shunts had survived, compared to only 58.3% of VPleural shunts in patients with IIH. Revisions were required due to acute intracranial bleed (1 case)-revised at day 1, and thrombus at distal site (1 case)-revised at day 57. Both shunts were later reinserted. From the latest clinic letters, all patients had their treatment optimised with this procedure, although only two patients had documented resolved papilloedema post-procedure. CONCLUSIONS Ventriculo-atrial shunts are a safe and efficacious alternative option for CSF diversion in IIH. In this series, only 1 shunt was revised for a VA shunt-specific complication.
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Affiliation(s)
- Sheikh M B Momin
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK.
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Sophie R Mullins
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Claudia L Craven
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Laurence Watkins
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Ahmed K Toma
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
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Wongsirisuwan M. The Long-Term Patency of the Internal Jugular Vein and the Common Facial Vein as Entrance Sites for Venous Access in Ventriculoatrial Shunts: A Comparative Analysis from a Single-Center Study. World Neurosurg 2024; 182:e652-e656. [PMID: 38065357 DOI: 10.1016/j.wneu.2023.12.011] [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: 08/21/2023] [Revised: 12/01/2023] [Accepted: 12/02/2023] [Indexed: 01/01/2024]
Abstract
OBJECTIVE The ventriculoatrial (VA) shunt is a surgical intervention used to manage hydrocephalus, although it is less often utilized compared to the ventriculoperitoneal (VP) shunt or endoscopic third ventriculostomy. Placement of the distal catheter typically involves the utilization of either the common facial vein (CFV) or the internal jugular vein (IJV), 2 frequently employed options for venous access. This study aims to determine whether there is a statistically significant difference between the long-term patency (2 years) of the distal end of the VA shunt of these 2 options. METHODS A retrospective cohort analysis was conducted of patients who received VA shunt surgeries with the employment of the CFV or IJV as access veins at Rajavithi Hospital in Thailand between January 2015 and December 2020. The analysis focused on long-term patency and potential complications. RESULTS The study comprised a total of 42 participants. Twenty-six (61.9%) individuals underwent ventriculoatrial (VA) shunt surgery via the CFV, while the other 16 (38.1%) underwent the same procedure using the IJV. Neither of the 2 groups required shunt revision due to distal catheter malfunction. Most cases exhibited no significant complications apart from a single instance of shunt system infection. CONCLUSIONS In VA shunt surgery, both the CFV and IJV can be used as venous access sites for the right atrium because there is no discernible difference between their complications or long-term patency. Anatomical considerations, patient-specific characteristics, and the surgeon's preference should all be considered when choosing the venous access location for the placement of a VA shunt.
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Affiliation(s)
- Methee Wongsirisuwan
- Division of Neurosurgery, Department of Surgery, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand.
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Nava Chavez CC, García Prieto A, Verde Moreno E, Melero Martín R, Rodríguez Benítez P, Villa Valdés M, Acosta Barrios A, Gurjiain Arena A, Díaz-Crespo F, Goicoechea Diezhandino M. Shunt nephritis: An exceptional disease that still subsist. Nefrologia 2023; 43 Suppl 2:121-123. [PMID: 38278717 DOI: 10.1016/j.nefroe.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024] Open
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Oliveira LDB, Welling LC, Viegas FAF, Ribas LRC, Junior EOM, Wesselovicz RM, Batista S, Bertani R, Palavani LB, Rabelo NN, Figueiredo EG. Incidence and nature of complications associated with ventriculoatrial shunt placement: A systematic review and single-arm meta-analysis. Clin Neurol Neurosurg 2023; 233:107950. [PMID: 37673013 DOI: 10.1016/j.clineuro.2023.107950] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/22/2023] [Accepted: 08/22/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Ventriculoatrial shunt (VAS) is considered the second option for treating hydrocephalus, but there remains a lack of robust evidence regarding its complications profile. PURPOSE Evaluate the complications associated with VAS. METHODS Adhering to PRISMA guidelines, the authors searched Embase, PubMed, and Web of Science databases to identify articles reporting on the complications of VAS. Eligible articles were required to report whether complications occurred in a cohort of at least four patients. The extraction process focused on various outcome measures, including overall complications, pulmonary complications, cardiac complications, mortality, shunt revisions, glomerulonephritis, intracranial hemorrhage, and hygroma. Complications were defined as any adverse events related to the procedure, including revisions. RESULTS After retrieving a total of 2828 articles, 53 studies met the predefined criteria, involving 2862 patients. The overall complication rate was estimated at 33 % (95 % CI: 25-42 %), while the long-term complications rate was found to be 49 % (95 % CI: 32-67 %). Among the pediatric population, the complication rate was calculated to be 53 % (95 % CI: 39-68 %). The overall revision rate was estimated at 32 % (95 % CI: 23-41 %), with an infection rate of 5 % (95 % CI: 3-7 %). Notably, in the pediatric group, the infection rate was 10 % (95 % CI: 6-13 %). The random analysis indicated an estimated risk of 0 % for glomerulonephritis, intracranial hemorrhage, hygroma, cardiac complications, pulmonary complications, and shunt-related mortality. CONCLUSION VAS is a safe alternative when ventriculoperitoneal shunting is not feasible. Risk of classic severe complications is minimal. Nevertheless, caution is required when shunting critical patients. Further randomized studies are warranted to establish the ideal shunt for different patients.
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Affiliation(s)
| | | | | | | | | | | | - Savio Batista
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Raphael Bertani
- Department of Neurosurgery, University of São Paulo, São Paulo, Brazil
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Akram Asif A, Mahmood K, Riaz S, McHugh T, Sultan S. Bacterial ventriculoperitoneal shunt infections: changing trends in antimicrobial susceptibility, a 7-year retrospective study from Pakistan. Antimicrob Resist Infect Control 2023; 12:75. [PMID: 37553715 PMCID: PMC10408103 DOI: 10.1186/s13756-023-01283-3] [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: 06/16/2023] [Accepted: 07/27/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Ventriculoperitoneal (VP) shunt infections in adults represent a severe complication and make treatment more challenging. Therefore, drug susceptibility patterns are crucial for therapeutic decisions and infection control in neurosurgical centers. This 7-year retrospective study aimed to identify the bacteria responsible for adult VP shunt infections and determine their drug susceptibility patterns. METHODS This single-center study was performed from 2015 to 2021 in Lahore, Pakistan, and included CSF cultures from VP shunt infections. Demographic data, causative organisms, and antimicrobial susceptibility testing results were collected. Multivariate analysis of variance (MANOVA) and two-sample t-tests were used to analyze and compare the antibiotic sensitivity trends over the study period. RESULTS 14,473 isolates recovered from 13,937 CSF samples of VP shunt infections were identified and analyzed for their susceptibility patterns to antimicrobials. The proportion of Gram-negative and Gram-positive bacteria were 11,030 (76%) and 3443 (24)%, respectively. The predominant bacteria were Acinetobacter species (n = 5898, 41%), followed by Pseudomonas species (n = 2368, 16%) and coagulase-negative Staphylococcus (CoNS) (n = 1880, 13%). 100% of Staphylococcus aureus (S.aureus) and CoNS were sensitive to vancomycin and linezolid (n = 2580). However, 52% of S. aureus (719/1,343) were methicillin-resistant Staphylococcus aureus (MRSA). Acinetobacter showed maximum sensitivity to meropenem at 69% (2759/4768). Pseudomonas was 80% (1385/1863 sensitive to piperacillin-tazobactam, Escherichia coli (E. coli) showed 72% to amikacin (748/1055), while Klebsiella spp. was 57% (574/1170) sensitive to piperacillin-tazobactam. The sensitivity of piperacillin-tazobactam and meropenem for Gram-negative bacteria decreased significantly (p < 0.05) over 7 years, with 92.2% and 88.91% sensitive in 2015 and 66.7% and 62.8% sensitive in 2021, respectively. CONCLUSION The significant decrease in the effectiveness of carbapenem and beta-lactam/beta-lactamase inhibitor combination drugs for the common Gram-negative causative agents of VP shunt infections suggests that alternative antibiotics such as colistin, fosfomycin, ceftazidime/avibactam, ceftolozane/tazobactam, and tigecycline should be considered and in consequence included in testing panels. Additionally, it is recommended to adopt care bundles for the prevention of VP shunt infection.
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Affiliation(s)
- Amina Akram Asif
- University of the Punjab, Lahore, Pakistan.
- Lahore General Hospital, Punjab Institute of Neurosciences, Lahore, Pakistan.
| | - Khalid Mahmood
- Lahore General Hospital, Punjab Institute of Neurosciences, Lahore, Pakistan
| | - Saba Riaz
- University of the Punjab, Lahore, Pakistan
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Thompson TZ, Rearick WA, Pizzuto MF, Quinsey C, Enyart CE, Trau SP. Increasing Seizures, Encephalopathy, and Hypothermia in an 18-Year-Old Woman. Pediatrics 2023; 151:190641. [PMID: 36756724 DOI: 10.1542/peds.2022-057229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 02/10/2023] Open
Abstract
ABSTRACT An 18-year-old woman with a history of focal epilepsy presents with increasingly frequent seizures, encephalopathy, multiple laboratory abnormalities, and hypothermia. During her hospital course, her symptoms waxed and waned. Multiple etiologies of her symptoms were considered, but the spontaneous resolution of her symptoms and an abnormal MRI of the brain revealed the final diagnosis.
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Affiliation(s)
| | | | | | | | | | - Steven P Trau
- Division of Child Neurology, Department of Neurology
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9
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Muram S, Isaacs AM, Sader N, Holubkov R, Fong A, Conly J, Hamilton MG. A standardized infection prevention bundle for reduction of CSF shunt infections in adult ventriculoperitoneal shunt surgery performed without antibiotic-impregnated catheters. J Neurosurg 2023; 138:494-502. [PMID: 35916085 DOI: 10.3171/2022.5.jns22430] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Ventriculoperitoneal (VP) shunt insertion and revision surgeries are some of the most common procedures that are performed by neurosurgeons. Shunt infections within the adult population are associated with significant morbidity and mortality and rates remain high. The objective of the current study was to use quality improvement (QI) methodology to create a standardized infection prevention bundle aimed at reducing the rate of shunt infections. METHODS A prospective, single-center, single-surgeon QI study was undertaken. Patients were included if they were 18 years of age or older and were undergoing a VP shunt insertion or revision. The primary outcome of the study was the development of a shunt-related surgical site infection, within 1 year of surgery, as defined according to the Canadian Nosocomial Infection Surveillance Program guidelines. There was no standardized protocol prior to July 2013. A bundle coined as the Calgary Adult Shunt Infection Prevention Protocol (CASIPP) was implemented on July 1, 2013, and updated on July 1, 2015, when 2% chlorhexidine gluconate in 70% isopropyl alcohol replaced povidone-iodine for preoperative skin antisepsis. Protocol compliance was regularly monitored using a standardized process. No antibiotic-impregnated catheters were used. RESULTS A total of 621 consecutive VP shunt insertions and revisions were included in the study. The rate of shunt infection was 5.8% during the period in which there was no standardized shunt protocol. After the implementation of the CASIPP the infection rate decreased to 4.0%, and after introduction of the chlorhexidine/alcohol skin antisepsis, the infection rate was 0% in 379 consecutive procedures (p < 0.0001). Multivariable logistic regression analysis demonstrated that the use of chlorhexidine/alcohol with CASIPP was associated with a significant reduction in the odds of developing a shunt infection (OR 0.032, 95% CI 0-0.19, p = 0.0005). CONCLUSIONS The implementation of a standardized shunt infection prevention bundle within the adult population, without the use of antibiotic-impregnated catheters, significantly reduced the rate of shunt infections which was sustained over many years. The use of 2% chlorhexidine gluconate in 70% isopropyl alcohol for preoperative antisepsis may have played a significant role. Multicenter studies should be completed to verify the effectiveness of the authors' protocol.
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Affiliation(s)
- Sandeep Muram
- 1Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Alberta.,2Alberta Health Services, Calgary, Alberta, Canada
| | - Albert M Isaacs
- 1Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Alberta.,2Alberta Health Services, Calgary, Alberta, Canada
| | - Nicholas Sader
- 1Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Alberta.,2Alberta Health Services, Calgary, Alberta, Canada
| | | | - Annie Fong
- 2Alberta Health Services, Calgary, Alberta, Canada.,4Infection Prevention and Control, Alberta Health Services, Calgary
| | - John Conly
- 4Infection Prevention and Control, Alberta Health Services, Calgary.,8O'Brien Institute for Public Health; and
| | - Mark G Hamilton
- 1Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Alberta.,2Alberta Health Services, Calgary, Alberta, Canada.,9The Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
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Ventricular Peritoneal Shunting Using Modified Keen’s Point Approach: Technical Report and Cases Series. SURGERIES 2022. [DOI: 10.3390/surgeries3040034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Ventricular peritoneal shunting (VPS) is a frequent procedure in neurosurgery, unfortunately still burdened with a significant rate of complications. The frontal Kocher’s point is the most frequently used landmark for ventricular puncture. Keen’s point (posterior parietal approach) seems to be a valid alternative. We report a newly described access to the lateral ventricle located in posterior temporal area and the results of a large series of adult patients. Methods: Retrospective analysis of a series of 188 cases of VPS performed with this approach. Results: Mean surgical time was 51.5 +/− 13.1 min (range 25–90 min). Twenty-one patients (11.2%) were subjected to revision surgery: eight cases (4.3%) for displacement or malfunction of ventricular catheter, eight cases (4.3%) for abdominal issues, three cases (1.6%) for hardware failure, and two cases (1.1%) for infection. Optimal catheter placement was reached in 90.1%. Conclusions: The modified Keen’s point approach seems to be safe, technically feasible, and reproducible, showing some potential advantages such as short surgical time, precision in ventricular catheter placement, and short tunneling tract. The need for surgical revision is similar to that reported in the literature, while the rate of catheter malpositioning and infections seems to be low; hemorrhages around catheter and seizures were not reported.
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Champeaux-Depond C, Ramasy Razafindratovo RM, Chevret S. Gastrostomy and internal cerebrospinal fluid shunt in adults. A systematic review and meta-analysis of the risk of infection. Neurochirurgie 2022; 68:e75-e83. [PMID: 36030926 DOI: 10.1016/j.neuchi.2022.08.001] [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: 07/06/2022] [Accepted: 08/05/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Hydrocephalus is a frequent neurological condition, commonly treated by ventriculoperitoneal shunting (VPS), a neurosurgical procedure with significant risk of infection. Some severely brain-injured hydrocephalic patients with swallowing dysfunction may require percutaneous endoscopic gastrostomy (PEG). There are few data on the safety of PEG in patients with VPS, with contradictory results reported. OBJECTIVE The aim of this systematic review and meta-analysis was to determine the rate of VPS infection in the setting of PEG. METHODS Six databases were searched for the period January 1990 to June 2022. Only original articles reporting the rate of shunt infection in the setting of PEG in adults were included. Random-effects meta-analysis was used to assess the rate of infection. RESULTS Fifteen of the 1,703 identified articles were selected, reporting 701 internal cerebrospinal fluid shunts, with 63 infections. The pooled rate of infection in patients with both PEG and VPS was 7.41% (95% CI [3.67-14.38]). There was a significantly higher risk of VPS infection in the PEG group vs. the control group with VPS without PEG: relative risk (RR)=2.33 (95% CI [1.11-4.89]). On the other hand, the risk of infection was the same whether the PEG was placed before or after the VPS surgery: RR=1.05 (95% CI [0.57-1.92]). CONCLUSION Gastrostomy tube placement is a significant risk factor for VPS infection. However, onset of infection was not related to the sequence of or interval between VPS and PEG. TRIAL REGISTRATION This meta-analysis is registered in https://www.crd.york.ac.uk/PROSPERO/, PROSPERO ID: CRDCRD42022326774.
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Affiliation(s)
- C Champeaux-Depond
- Service de Biostatistique et Information Médicale, Hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France; INSERM U1153, Center of Research in Epidemiology and Statistics (CRESS), Sorbonne Paris Cité, ECSTRRA team, Université de Paris, Paris, France; Department of Neurosurgery, Lariboisière Hospital, 75010 Paris, France.
| | - R M Ramasy Razafindratovo
- Service de Biostatistique et Information Médicale, Hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - S Chevret
- Service de Biostatistique et Information Médicale, Hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France; INSERM U1153, Center of Research in Epidemiology and Statistics (CRESS), Sorbonne Paris Cité, ECSTRRA team, Université de Paris, Paris, France
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Nava Chavez CC, García Prieto A, Verde Moreno E, Melero Martín R, Rodríguez Benítez P, Villa Valdés M, Acosta Barrios A, Gurjiain Arena A, Díaz-Crespo F, Goicoechea Diezhandino M. Nefritis del shunt: una enfermedad excepcional que aún existe. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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13
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Ajlan B, Maghrabi Y, Almukhtar G, Baeesa S. Timing of Ventriculoatrial Shunt Removal on Renal Function Recovery of Patients with Shunt Nephritis: Case Report and Systematic Review. Clin Neurol Neurosurg 2022; 218:107279. [DOI: 10.1016/j.clineuro.2022.107279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 04/26/2022] [Accepted: 05/02/2022] [Indexed: 11/16/2022]
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Segura-Hernández A, Hakim F, Ramón JF, Jiménez-Hakim E, Mejía-Cordovez JA, Quintero-Rueda D, Araque-Puello Y, Pedraza-Ciro C, Leal-Isaza JP, Mendoza-Mantilla J, Robles V, Gonzalez M, Jaramillo-Velásquez D, Gómez DF. Ventriculo-atrial shunt. Comparison of an ultrasound-guided peel-away technique versus conventional technique in the management of normal pressure hydrocephalus: A retrospective cohort. Surg Neurol Int 2021; 12:531. [PMID: 34754581 PMCID: PMC8571261 DOI: 10.25259/sni_613_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 09/14/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Normal pressure hydrocephalus (NPH) is a common neurodegenerative syndrome among the elderly characterized by ventriculomegaly and the classic triad of symmetric gait disturbance, cognitive decline and urinary incontinence. To date, the only effective treatment is a cerebrospinal fluid shunting procedure that can either be ventriculo-atrial, ventriculo-peritoneal, or lumbo-peritoneal shunt. The conventional ventriculo-atrial shunt uses venodissection, whereas the peel-away is a percutaneous ultrasound (US)-guided technique that shows some advantages over conventional technique. We sought to compare perioperative complication rates, mean operating time and clinical outcomes for both techniques in NPH patients at our institution. Methods: A retrospective cohort-type analytical study was conducted, using clinical record data of patients diagnosed with NPH and treated at our center from January 2009 to September 2019. Parameters to be compared include: Perioperative complication rates, intraoperative bleeding, mortality, and mean operating time. Perioperative complication rates are those device-related such as shunt infection, dysfunction, and those associated with the procedure. Complications are further classified in immediate (occurring during the first inpatient stay), early (within the first 30 days of surgery), and late (after day 30 of surgery). Results: A total of 123 patients underwent ventriculo-atrial shunt. Eighty-two patients (67%) underwent conventional venodissection technique and 41 patients (33%) underwent a peel-away technique. Immediate complications were 3 (3.6%) and 0 for conventional and peel-away groups, respectively. Early complications were 0 and 1 (2.4%) for conventional and peel-away groups, respectively. Late complications were 5 (6.1%) and 2 (4.9%) for conventional and peel-away groups, respectively. Mean operating time was lower in the peel-away group (P = 0.0000) and mortality was 0 for both groups. Conclusion: Ventriculo-atrial shunt is an effective procedure for patients with NPH. When comparing the conventional venodissection technique with a percutaneous US-guided peel-away technique, the latter offers advantages such as shorter operating time and lower perioperative complication rates.
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Affiliation(s)
- Andrés Segura-Hernández
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
| | - Fernando Hakim
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
| | - Juan F Ramón
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
| | - Enrique Jiménez-Hakim
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
| | - Juan A Mejía-Cordovez
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
| | - Diego Quintero-Rueda
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
| | - Yessid Araque-Puello
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
| | - Camila Pedraza-Ciro
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
| | - Juan P Leal-Isaza
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
| | - Juliana Mendoza-Mantilla
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
| | - Vanesa Robles
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
| | - Martina Gonzalez
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
| | - Daniel Jaramillo-Velásquez
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
| | - Diego F Gómez
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
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Udayakumaran S, Pillai S, Dwarakanath S, Bhattacharjee S, Mehrotra N, Raju S, Gupta D, Panigrahi M, Venkataramana NK, Rajshekhar V, Sankhla S. Indian Society of Pediatric Neurosurgery Consensus Guidelines on Preventing and Managing Shunt Infection: Version 2020-21. Neurol India 2021; 69:S526-S555. [PMID: 35103012 DOI: 10.4103/0028-3886.332268] [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] [Indexed: 11/04/2022]
Abstract
Background Shunt infection is the most significant morbidity associated with shunt surgery. Based on the existing literature for the prevention and management of shunt infection, region and resource-specific recommendations are needed. Methods In February 2020, a Guidelines Development Group (GDG) was created by the Indian Society of Paediatric Neurosurgery (IndSPN) to formulate guidelines on shunt infections, which would be relevant to our country and LMIC in general. An initial email survey identified existing practices among the membership of the IndSPN, and eight broad issues pertaining to shunt infection were identified. Next, members of the GDG performed a systematic review of the literature on the prevention and management of shunt infection. Then, through a series of virtual meetings of the GDG over 1 year, evidence from the literature was presented to all the members and consensus was built on different aspects of shunt infection. Finally, the guidelines document was drafted and circulated among the GDG for final approval. Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to grade the evidence and strength of recommendation. Results The guidelines are divided into eight sections. Level I and Level II evidence was available for only five recommendations and led to a moderate level of recommendations. Most of the available evidence was at Level III and below, and hence the level of recommendation was low or very low. A consensus method was used to provide recommendations for several issues. Conclusions Although most of the recommendations for the prevention and management of shunt infections are based on a low level of evidence, we believe that this document will provide a useful reference to neurosurgeons not only in India but also in other low and middle income countries. These guidelines need to be updated as and when new evidence emerges.
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Affiliation(s)
- Suhas Udayakumaran
- Division of Paediatric Neurosurgery, Department of Neurosurgery, Amrita Institute Of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Shibu Pillai
- Department of Neurosurgery, Narayana Institute of Neurosciences, Bengaluru, Karnataka, India
| | - Srinivas Dwarakanath
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Suchanda Bhattacharjee
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Naveen Mehrotra
- Consultant Neurosurgeon, Sunshine Hospitals, Secunderabad, Telangana, India
| | - Subodh Raju
- Institute of Neurosciences, AIG Hospitals, Hyderabad, Telangana, India
| | - Deepak Gupta
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manas Panigrahi
- Department of Neurosurgery, Krishna Institute of Medical Science, Hyderabad, Telangana, India
| | | | - Vedantam Rajshekhar
- Department of Neurological Sciences, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Suresh Sankhla
- Department of Neurosurgery, Global Hospital, Mumbai, Maharashtra, India
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16
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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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17
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Ventriculoatrial shunt as a feasible regimen for certain patients of hydrocephalus: clinical features and surgical management. Acta Neurol Belg 2021; 121:403-408. [PMID: 31273606 DOI: 10.1007/s13760-019-01180-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/27/2019] [Indexed: 12/26/2022]
Abstract
Ventriculoatrial (VA) shunt is one of the most commonly used solutions for hydrocephalus. In recent years, the number of VA shunt has decreased worldwide, given the perceived technical challenges and the potentially serious complications associated with VA shunt. However, VA shunt remains as a viable treatment option for hydrocephalus in selected patients. Novel placement strategies and monitoring methods have been developed to reduce complications following VA shunt. In this article, we reported that seven consecutive cases who received a VA shunt. VA shunts were applied in seven hydrocephalic patients who experienced previous ventriculoperitoneal (VP) shunt failures or had contraindications to abdominal catheter placement. The insertion of VA shunt catheters was guided with the aid of intraoperative electromagnetic neuronavigation and electrocardiographic technique. There were three female and four male patients with a mean age of 46 years (range 22-68 years) received VA shunts under the guidance of electromagnetic neuronavigation and electrocardiographic method intraoperatively. In all cases, postoperative cranial CT scans and chest radiography demonstrated appropriate positioning of the catheter tips. And no postoperative complications occurred during the follow-up period of 3-26 months. VA shunts are potential favorable alternatives for patients who cannot tolerate VP shunts. It is noteworthy that VA is not free of complications. Intraoperative application of electromagnetic neuronavigation and electrocardiographic technique contributes to safe and optimal catheter placement of VA shunts.
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18
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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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Wong E, Jeganathan V, Wreghitt S, Davis G, Wimaleswaran H, Howard ME. Worsening respiratory failure in an adult hydrocephalic patient with a ventriculo-pleural shunt. Respirol Case Rep 2020; 8:e00660. [PMID: 33005422 PMCID: PMC7519950 DOI: 10.1002/rcr2.660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/27/2020] [Indexed: 11/30/2022] Open
Abstract
Ventriculo-pleural (VPL) shunt insertion is performed in hydrocephalic patients when alternative sites of cerebrospinal fluid (CSF) diversion are contraindicated. These include patients with peritoneal complications from ventriculo-peritoneal shunts. Despite its utility, VPL shunts are uncommon. Hydrothoraces should be considered as a potential cause of dyspnoea in the setting of a VPL shunt. We present a case of worsening respiratory failure in the setting of a massive CSF hydrothorax in a hydrocephalic patient with a VPL shunt to highlight this potential complication of pleural CSF diversion, and present a potential management strategy in patients with premorbid underlying lung pathology. In this case, the hydrothorax was drained and the shunt was converted to ventriculo-atrial (VA) shunt.
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Affiliation(s)
- Edmond Wong
- Department of Respiratory and Sleep MedicineAustin HealthHeidelbergVICAustralia
| | - Vishnu Jeganathan
- Department of Respiratory and Sleep MedicineAustin HealthHeidelbergVICAustralia
- Institute for Breathing and SleepHeidelbergVICAustralia
| | - Samuel Wreghitt
- Department of NeurosurgeryAustin HealthHeidelbergVICAustralia
| | - Gavin Davis
- Department of NeurosurgeryAustin HealthHeidelbergVICAustralia
| | - Hari Wimaleswaran
- Department of Respiratory and Sleep MedicineAustin HealthHeidelbergVICAustralia
- Institute for Breathing and SleepHeidelbergVICAustralia
- Faculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleVICAustralia
| | - Mark E Howard
- Department of Respiratory and Sleep MedicineAustin HealthHeidelbergVICAustralia
- Institute for Breathing and SleepHeidelbergVICAustralia
- Faculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleVICAustralia
- Turner Institute for Brain and Mental HealthMonash UniversityClaytonVICAustralia
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20
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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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21
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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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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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Kaestner S, Fraij A, Fass J, Deinsberger W. Ventriculoperitoneal Shunt Infections Cause Acute Abdomen and Peritonitis: A Case Series. J Surg Res 2020; 248:153-158. [PMID: 31901642 DOI: 10.1016/j.jss.2019.11.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 11/14/2019] [Accepted: 11/26/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with ventriculoperitoneal shunt (VPS) often present to emergency departments with acute abdomen. It is challenging to distinguish between the abdominal problems caused by a VPS and acute surgical abdomen having another cause because VPS infections occasionally cause peritonitis. The frequencies and clinical features of acute abdomen caused by VPS infection are unknown. METHODS This was a retrospective analysis of all patients with a VPS who presented with acute abdomen to emergency department for a 10-year period. Clinical data, diagnostic workflow, and subsequent treatment were assessed using patient medical records. RESULTS In total, 1679 patients presented with acute abdomen; of these, 24 (1.4%) had a VPS at the time of presentation. Of the 24 patients, 12 had an acute surgical abdomen related to gastrointestinal sources with subsequent therapy. In the remaining 12 patients (50%), peritonitis was caused by a VPS infection; seven of these had erroneous abdominal surgeries because of misdiagnosis. Patients with shunt infections as a source of peritonitis underwent shunt surgeries within the past 10 wk (mean, 58 d). Patients with an acute surgical abdomen with gastrointestinal sources had their most recent shunt surgery at a mean of 4.7 y before presentation to the emergency department. CONCLUSIONS Acute abdomen and peritonitis are challenging in the presence of a VPS. Shunt infections frequently mimic acute surgical abdomen and may lead to misdiagnosis, unnecessary diagnostic procedures, unnecessary surgery, and delay in receiving the appropriate treatment. Shunt surgery in recent patient history is suggestive of VPS infection, and a shunt tap should be performed to confirm the diagnosis.
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Affiliation(s)
- Stefanie Kaestner
- Department of Neurosurgery, Klinikum Kassel, Kassel, Germany; Kassel School of Medicine, University of Southampton, Southampton, UK.
| | - Amina Fraij
- Educational Science, Center for Teacher Education, University of Giessen, Giessen Germany
| | - Juegen Fass
- Department of General and Visceral Surgery, Klinikum Kassel, Kassel, Germany
| | - Wolfgang Deinsberger
- Department of Neurosurgery, Klinikum Kassel, Kassel, Germany; Kassel School of Medicine, University of Southampton, Southampton, UK
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24
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Lumboperitoneal and Ventriculoperitoneal Shunt Surgery for Posthemorrhagic Communicating Hydrocephalus: A Comparison. World Neurosurg 2019; 127:e638-e643. [DOI: 10.1016/j.wneu.2019.03.235] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 03/21/2019] [Accepted: 03/22/2019] [Indexed: 11/22/2022]
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25
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Morosanu CO, Filip GA, Nicolae L, Florian IS. From the heart to the bladder-particularities of ventricular shunt topography and the current status of cerebrospinal fluid diversion sites. Neurosurg Rev 2018; 43:847-860. [PMID: 30338415 DOI: 10.1007/s10143-018-1033-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/28/2018] [Accepted: 09/17/2018] [Indexed: 12/01/2022]
Abstract
Hydrocephalus represents the pathological elevation of cerebrospinal fluid (CSF) levels as a consequence of various embryological or acquired defects. Although the classic method of treatment is by means of diverting the CSF from the ventricular system towards the peritoneum, there are other sites of diversion that have proven their efficiency through time, in the context of complications related to the more common option of intraperitoneal insertion. The aim of the review is to assess and organize a database of all the types of shunt locations from the oldest shunt attempts until present, using Pubmed and Medline and to underline the particularities related to technique, indications, complications and associated epidemiological background. Current literature reveals up to 36 sites of diversion of CSF with a diverse topography varying from cephalic regions such as venous sinuses or mastoid bone, thoracic elements such as the heart or the pleura and abdominopelvic segments such as the peritoneum or the urinary bladder. Several atypical locations were studied such as the fallopian and intestinal shunts. Although ventriculoperitoneal and ventriculoatrial shunts are the most commonly used shunts today, there are some systems such as the ventriculosinusal and ventriculolymphatic shunts that prove to be equally as efficient. The successful treatment of hydrocephalus requires a complete comprehension of the indications and therapeutic options and a reliable evaluation of the risks and possible complications. The profile of cerebral ventricular shunts is highly dynamic and the spectrum of cerebrospinal fluid diversion offers multiple solutions in the benefit of the patient.
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Affiliation(s)
- Cezar Octavian Morosanu
- Department of Neurosurgery, North Bristol NHS Trust, Southmead Hospital, Southmead Rd, Westbury-on-Trym, Bristol, United Kingdom.
| | - Gabriela Adriana Filip
- Department of Physiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Liviu Nicolae
- Department of Neurosurgery, North Bristol NHS Trust, Southmead Hospital, Southmead Rd, Westbury-on-Trym, Bristol, United Kingdom
| | - Ioan Stefan Florian
- Department of Neurosurgery, Cluj County Emergency Hospital, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
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Roux A, Botella C, Still M, Zanello M, Dhermain F, Metellus P, Pallud J. Posterior Fossa Metastasis-Associated Obstructive Hydrocephalus in Adult Patients: Literature Review and Practical Considerations from the Neuro-Oncology Club of the French Society of Neurosurgery. World Neurosurg 2018; 117:271-279. [PMID: 29935321 DOI: 10.1016/j.wneu.2018.06.084] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 06/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND There is no consensus concerning the management of adult patients with posterior fossa metastasis-associated obstructive hydrocephalus, especially regarding surgical procedures. A literature review was performed to assess the surgical strategy in the management of patients with metastatic brain tumor. METHODS A literature search was conducted of PubMed in November 2017 to identify all studies concerning brain metastases and obstructive hydrocephalus in English. All studies (except case reports and pediatric studies) between December 1953 and November 2017 that were about posterior fossa metastasis-associated obstructive hydrocephalus in adult patients were eligible. Eligible studies were classified by level of evidence. We assessed epidemiology, clinical and imaging findings, neurosurgical management, and prognosis of adult patients with posterior fossa metastasis-associated obstructive hydrocephalus. We suggest some practical considerations and a management decision tree on behalf of the Neuro-oncology Club of the French Society of Neurosurgery, with evidence-based analysis. RESULTS Direct surgical resection could be considered for patients with asymptomatic obstructive hydrocephalus, and endoscopic third ventriculostomy seems to be a reasonable procedure for patients with symptomatic obstructive hydrocephalus. A ventriculoperitoneal or atrial shunt seems to be a valid alternative when patients have a history of central nervous system infection or ventricular hemorrhage, leptomeningeal carcinomatosis, or unfavorable anatomy for an endoscopic third ventriculostomy to be performed. CONCLUSIONS The Neuro-oncology Club of the French Society of Neurosurgery suggests a prospective assessment of these neurosurgical procedures to compare their safety and efficacy.
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Affiliation(s)
- Alexandre Roux
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; Inserm, U894, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
| | - Céline Botella
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; Department of Neurosurgery, Henri-Mondor Hospital, Créteil, France
| | - Megan Still
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Marc Zanello
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; Inserm, U894, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France
| | - Frédéric Dhermain
- Department of Radiotherapy, Gustave Roussy University Hospital, Villejuif, France
| | - Philippe Metellus
- Department of Neurosurgery, Clairval Private Hospital, Ramsay-Générale de Santé, Marseille, France
| | - Johan Pallud
- Department of Neurosurgery, Sainte-Anne Hospital, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; Inserm, U894, IMA-Brain, Centre de Psychiatrie et Neurosciences, Paris, France.
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Hung AL, Vivas-Buitrago T, Adam A, Lu J, Robison J, Elder BD, Goodwin CR, Jusué-Torres I, Rigamonti D. Ventriculoatrial versus ventriculoperitoneal shunt complications in idiopathic normal pressure hydrocephalus. Clin Neurol Neurosurg 2017; 157:1-6. [DOI: 10.1016/j.clineuro.2017.03.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 03/16/2017] [Accepted: 03/17/2017] [Indexed: 10/19/2022]
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Delayed Manifestation of Shunt Nephritis: A Case Report and Review of the Literature. Case Rep Nephrol 2017; 2017:1867349. [PMID: 28487790 PMCID: PMC5401727 DOI: 10.1155/2017/1867349] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 03/30/2017] [Indexed: 11/18/2022] Open
Abstract
We present an unusual case of shunt nephritis in a 39-year-old male who presented 21 years after placement of a ventriculoperitoneal (VP) shunt. He complained of fevers, headaches, dizziness, and urticarial plaques on arms, trunks, and legs and was found to have anemia, low complement levels, elevated serum creatinine, proteinuria, and new onset microhematuria. Blood and urine cultures were negative. Renal biopsy showed features of acute tubulointerstitial nephritis attributed to vancomycin use. Glomeruli showed increased mesangial hypercellularity and segmental endocapillary proliferation. Immunofluorescence showed focal IgM and C3 staining. Electron microscopy revealed small subendothelial electron-dense deposits. Symptoms and renal insufficiency appeared to improve with antibiotic therapy. He was discharged and readmitted 2 months later with similar presentation. CSF grew Propionibacterium acnes and shunt hardware grew coagulase-negative Staphylococcus. He completed an intravenous antibiotic course and was discharged. On 1-month follow-up, skin lesions persisted but he was otherwise asymptomatic. Follow-up labs showed significant improvement. We did a brief systematic review of the literature on shunt nephritis and report our findings on 79 individual cases. In this review, we comment on the presentation, lab findings, pathological features, and management of this rare, potentially fatal, but curable disease entity.
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