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Pedersen SH, Henriksen KA, Gustafsen SD, Hansen TS, Guldager R, Juhler M. Telemetric ICP monitoring in children: a national questionnaire-based study. Childs Nerv Syst 2024:10.1007/s00381-024-06383-y. [PMID: 38587626 DOI: 10.1007/s00381-024-06383-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/27/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE Telemetric monitoring of intracranial pressure (ICP) facilitates long-term measurements and home monitoring, thus potentially reducing diagnostic imaging and acute hospital admissions in favour of outpatient appointments. Especially in paediatric patients, telemetric ICP monitoring requires a high level of collaboration and compliance from patients and parents. In this study, we aim to systematically investigate (1) patient and parent perception of telemetric ICP system utility and (2) hospital contact history and thus the potential cost-benefit of telemetric ICP monitoring in paediatric patients with a cerebrospinal fluid disorder. METHODS We conducted a nationwide questionnaire study, including paediatric patients with either a current or previous telemetric ICP sensor and their parents. Additionally, a retrospective review of electronic health records for all included children was performed. RESULTS We included 16 children (age range 3-16 years), with a total of 41 telemetric ICP sensors implanted. Following sensor implantation, the frequency of telephone contacts and outpatient visits increased. No corresponding decrease in hospital admissions or total length of stay was found. The telemetric ICP sensor provided most parents with an improved sense of security and was seen as a necessary and valuable tool in treatment guidance. The size and shape of the sensor itself were reported as disadvantages, while the external monitoring equipment was reported as easy to use but too large and heavy for a child to carry. CONCLUSION Though, in quantitative terms, there was no cost-benefit of the telemetric ICP sensor, it contributed to extended parental involvement and a sense of improved safety.
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Affiliation(s)
- Sarah Hornshøj Pedersen
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark.
| | - Kasper Amund Henriksen
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
| | - Sara Duus Gustafsen
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
| | - Torben Skovbo Hansen
- Department of Neurosurgery, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Rikke Guldager
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
- Department of Neurosurgery, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
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Pandit AS, Kamal MA, Reischer G, Aldabbagh Y, Alradhawi M, Lee FMY, Sekhon PP, Moncur EM, Banks PDW, Thompson S, Thorne L, Watkins LD, Toma AK. The Impact of Intracranial Pressure Telesensors: An Observational Propensity-Matched Control Analysis of Service Demand and Costs. Neurosurgery 2024; 95:00006123-990000000-01074. [PMID: 38445908 PMCID: PMC11155581 DOI: 10.1227/neu.0000000000002893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/06/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Implantable telemetric intracranial pressure (ICP) sensors (telesensors) enable routine, noninvasive ICP feedback, aiding clinical decision-making and attribution of pressure-related symptoms in patients with cerebrospinal fluid shunt systems. Here, we aim to explore the impact of these devices on service demand and costs in patients with adult hydrocephalus. METHODS We performed an observational propensity-matched control study, comparing patients who had an MScio/Sensor Reservoir (Christoph Miethke, GmbH & Co) against those with a nontelemetric reservoir inserted between March 2016 and March 2018. Patients were matched on demographics, diagnosis, shunt-type, and revision status. Service usage was recorded with frequencies of neurosurgical admissions, outpatient clinics, scans, and further surgical procedures in the 2 years before and after shunt insertion. RESULTS In total, 136 patients, 73 telesensors, and 63 controls were included in this study (48 matched pairs). Telesensor use led to a significant decrease in neurosurgical inpatient admissions, radiographic encounters, and procedures including ICP monitoring. After multivariate adjustment, the mean cumulative saving after 2 years was £5236 ($6338) in telesensor patients (£5498 on matched pair analysis). On break-even analysis, cost-savings were likely to be achieved within 8 months of clinical use, postimplantation. Telesensor patients also experienced a significant reduction in imaging-associated radiation (4 mSv) over 2 years. CONCLUSION The findings of this exploratory study reveal that telesensor implantation is associated with reduced service demand and provides net financial savings from an institutional perspective. Moreover, telesensor patients required fewer appointments, invasive procedures, and had less radiation exposure, indicating an improvement in both their experience and safety.
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Affiliation(s)
- Anand S. Pandit
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
- High-Dimensional Neurology, Institute of Neurology, University College London, London, UK
| | - Muhammad A. Kamal
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
| | - Gerda Reischer
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
| | - Yousif Aldabbagh
- UCL Medical School, Faculty of Medical Sciences, University College London, London, UK
| | - Mohammad Alradhawi
- UCL Medical School, Faculty of Medical Sciences, University College London, London, UK
| | - Faith M. Y. Lee
- UCL Medical School, Faculty of Medical Sciences, University College London, London, UK
| | - Priya P. Sekhon
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
| | - Eleanor M. Moncur
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
| | - Ptolemy D. W. Banks
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
| | - Simon Thompson
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
| | - Lewis Thorne
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
| | - Laurence D. Watkins
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
| | - Ahmed K. Toma
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
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Jirlow U, Arvidsson L, Magneli S, Cesarini K, Rostami E. Evaluation of Miethke M.scio Device Implantation for Intracranial Pressure Monitoring in Patients with Cerebrospinal Fluid Disorders. World Neurosurg 2023; 179:e63-e74. [PMID: 37506838 DOI: 10.1016/j.wneu.2023.07.102] [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: 06/26/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Patients with complex shunt-related problems and varying diagnoses of cerebrospinal fluid (CSF) disturbance can present with headache and clinical symptoms that may be difficult to relate to underdrainage or overdrainage. Telemetric intracranial pressure (ICP) monitoring may assist in evaluating individual patients and assessing shunt function and adjustment. We report a case series of patients receiving a Miethke M.scio sensor. METHODS Between June 2016 and August 2021, 14 patients older than 18 years with different diagnoses underwent ventriculoperitoneal shunt surgery and received a Miethke M.scio sensor. RESULTS Patients had idiopathic intracranial hypertension (n = 3), obstructive hydrocephalus caused by tumors (n = 4), and malformations (n = 5). Headaches (71%) and visual impairment (50%) were the most common symptoms before surgery and 65% of the symptoms were improved after surgery. In total, 25 measurements were made and 11 of these led to changes in the shunt settings. Postoperative measurements were taken in 8 patients and the most common indication of ICP measurement was headache and/or control of the shunt settings. CONCLUSIONS The Miethke M.scio is a safe and valuable device to use in shunt-treated patients, in particular those expected to need assessment of ICP monitoring postoperatively. Repeated ICP measurements can also assist in personalized adjustment of the shunt setting to optimize CSF flow in this diverse patient group. Future studies should include a standardized protocol with ICP measurements correlated to the symptoms and cause of CSF disturbances to provide better understanding of the dynamics of the ICP in each patient.
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Affiliation(s)
- Unni Jirlow
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Lisa Arvidsson
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sara Magneli
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Kristina Cesarini
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Elham Rostami
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden; Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden.
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Elsawaf Y, Jaklitsch E, Belyea M, Rodriguez L, Silverman A, Valley H, Koleilat I, Yaghi NK, Jaeggli M. Implantable Intracranial Pressure Sensor with Continuous Bluetooth Transmission via Mobile Application. J Pers Med 2023; 13:1318. [PMID: 37763086 PMCID: PMC10532732 DOI: 10.3390/jpm13091318] [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: 07/26/2023] [Revised: 08/24/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Hydrocephalus is a clinical disorder caused by excessive cerebrospinal fluid (CSF) buildup in the ventricles of the brain, often requiring permanent CSF diversion via an implanted shunt system. Such shunts are prone to failure over time; an ambulatory intracranial pressure (ICP) monitoring device may assist in the detection of shunt failure without an invasive diagnostic workup. Additionally, high resolution, noninvasive intracranial pressure monitoring will help in the study of diseases such as normal pressure hydrocephalus (NPH) and idiopathic intracranial hypertension (IIH). We propose an implantable, continuous, rechargeable ICP monitoring device that communicates via Bluetooth with mobile applications. The design requirements were met at the lower ICP ranges; the obtained error fell within the idealized ±2 mmHg margin when obtaining pressure values at or below 20 mmHg. The error was slightly above the specified range at higher ICPs (±10% from 20-100 mmHg). The system successfully simulates occlusions and disconnections of the proximal and distal catheters, valve failure, and simulation of A and B ICP waves. The mobile application accurately detects the ICP fluctuations that occur in these physiologic states. The presented macro-scale prototype is an ex-vivo model of an implantable, rechargeable ICP monitoring system that has the potential to measure clinically relevant ICPs and wirelessly provide accessible and continuous data to aid in the workup of shunt failure.
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Affiliation(s)
- Yasmeen Elsawaf
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR 97201, USA
| | - Erik Jaklitsch
- Department of Biomedical Engineering, Northeastern University, Boston, MA 02115, USA
| | - Madison Belyea
- Department of Biomedical Engineering, Northeastern University, Boston, MA 02115, USA
| | - Levon Rodriguez
- Department of Biomedical Engineering, Northeastern University, Boston, MA 02115, USA
| | - Alexandra Silverman
- Department of Biomedical Engineering, Northeastern University, Boston, MA 02115, USA
| | - Halyn Valley
- Department of Biomedical Engineering, Northeastern University, Boston, MA 02115, USA
| | - Issam Koleilat
- Department of Surgery, Community Medical Center, RWJ/Barnabas Health, Toms River, NJ 08753, USA
| | - Nasser K. Yaghi
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ 85013, USA;
| | - Michael Jaeggli
- Department of Biomedical Engineering, Northeastern University, Boston, MA 02115, USA
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Manga S, Muthavarapu N, Redij R, Baraskar B, Kaur A, Gaddam S, Gopalakrishnan K, Shinde R, Rajagopal A, Samaddar P, Damani DN, Shivaram S, Dey S, Mitra D, Roy S, Kulkarni K, Arunachalam SP. Estimation of Physiologic Pressures: Invasive and Non-Invasive Techniques, AI Models, and Future Perspectives. SENSORS (BASEL, SWITZERLAND) 2023; 23:5744. [PMID: 37420919 DOI: 10.3390/s23125744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/25/2023] [Accepted: 06/12/2023] [Indexed: 07/09/2023]
Abstract
The measurement of physiologic pressure helps diagnose and prevent associated health complications. From typical conventional methods to more complicated modalities, such as the estimation of intracranial pressures, numerous invasive and noninvasive tools that provide us with insight into daily physiology and aid in understanding pathology are within our grasp. Currently, our standards for estimating vital pressures, including continuous BP measurements, pulmonary capillary wedge pressures, and hepatic portal gradients, involve the use of invasive modalities. As an emerging field in medical technology, artificial intelligence (AI) has been incorporated into analyzing and predicting patterns of physiologic pressures. AI has been used to construct models that have clinical applicability both in hospital settings and at-home settings for ease of use for patients. Studies applying AI to each of these compartmental pressures were searched and shortlisted for thorough assessment and review. There are several AI-based innovations in noninvasive blood pressure estimation based on imaging, auscultation, oscillometry and wearable technology employing biosignals. The purpose of this review is to provide an in-depth assessment of the involved physiologies, prevailing methodologies and emerging technologies incorporating AI in clinical practice for each type of compartmental pressure measurement. We also bring to the forefront AI-based noninvasive estimation techniques for physiologic pressure based on microwave systems that have promising potential for clinical practice.
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Affiliation(s)
- Sharanya Manga
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Neha Muthavarapu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Renisha Redij
- GIH Artificial Intelligence Laboratory (GAIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Avneet Kaur
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Sunil Gaddam
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Keerthy Gopalakrishnan
- GIH Artificial Intelligence Laboratory (GAIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Rutuja Shinde
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Poulami Samaddar
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Devanshi N Damani
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Internal Medicine, Texas Tech University Health Science Center, El Paso, TX 79995, USA
| | - Suganti Shivaram
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Shuvashis Dey
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Electrical and Computer Engineering, North Dakota State University, Fargo, ND 58105, USA
| | - Dipankar Mitra
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Computer Science, University of Wisconsin-La Crosse, La Crosse, WI 54601, USA
| | - Sayan Roy
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Electrical Engineering and Computer Science, South Dakota Mines, Rapid City, SD 57701, USA
| | - Kanchan Kulkarni
- Centre de Recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, INSERM, U1045, 33000 Bordeaux, France
- IHU Liryc, Heart Rhythm Disease Institute, Fondation Bordeaux Université, Bordeaux, 33600 Pessac, France
| | - Shivaram P Arunachalam
- GIH Artificial Intelligence Laboratory (GAIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA
- Microwave Engineering and Imaging Laboratory (MEIL), Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Afshari FT, Samara M, Thant KZ, Byrne ME, Sinclair AJ, Mollan SP, Tsermoulas G. Interpretation of telemetric intracranial pressure recordings in people with idiopathic intracranial hypertension after shunt implantation. Acta Neurochir (Wien) 2023; 165:1523-1531. [PMID: 37071182 DOI: 10.1007/s00701-023-05572-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/26/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND The M.scio telesensor (Aesculap-Miethke, Germany) is a device integrated within a ventriculoperitoneal (VP) shunt for non-invasive measurement of the intracranial pressure (ICP). The purpose of this study was to analyze the telemetric recordings with the M.scio system in shunted patients with idiopathic intracranial hypertension (IIH), in order to determine reference values and assist the interpretation of telemetric data. METHODS This was a cohort study of consecutive patients with fulminant IIH who underwent primary VP shunt insertion between July 2019 and June 2022. The first telemetric measurements after surgery in the sitting and supine positions were analyzed. Telemetric ICP values, wave morphology, and pulse amplitude were determined for functioning and malfunctioning shunts. RESULTS Fifty-seven out of 64 patients had available telemetric recordings. The mean ICP was - 3.8 mmHg (standard deviation (SD) = 5.9) in the sitting and 16.4 mmHg (SD = 6.3) in the supine position. The ICP curve demonstrated pulsatility in 49 (86%) patients. A pulsatile curve with mean ICP in the above ranges indicated a functioning shunt, whereas the lack of pulsatility was challenging to interpret. There was a significant positive correlation between ICP versus amplitude, ICP versus body mass index (BMI), and amplitude versus BMI. CONCLUSIONS This clinical study defined ICP values and curves in IIH patients with a shunt. The results will assist the interpretation of telemetric ICP recordings in clinical decision making. More research is required to model longitudinal recordings and explore the link between telemetric measurements with clinical outcomes.
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Affiliation(s)
- Fardad T Afshari
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, B15 2TH, UK
| | - Mahmoud Samara
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, B15 2TH, UK
| | - Kyaw Zayar Thant
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, B15 2TH, UK
| | - Marian E Byrne
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, B15 2TH, UK
| | - Alexandra J Sinclair
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Susan P Mollan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Georgios Tsermoulas
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, B15 2TH, UK.
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
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Müller SJ, Henkes E, Gounis MJ, Felber S, Ganslandt O, Henkes H. Non-Invasive Intracranial Pressure Monitoring. J Clin Med 2023; 12:jcm12062209. [PMID: 36983213 PMCID: PMC10051320 DOI: 10.3390/jcm12062209] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 03/15/2023] Open
Abstract
(1) Background: Intracranial pressure (ICP) monitoring plays a key role in the treatment of patients in intensive care units, as well as during long-term surgeries and interventions. The gold standard is invasive measurement and monitoring via ventricular drainage or a parenchymal probe. In recent decades, numerous methods for non-invasive measurement have been evaluated but none have become established in routine clinical practice. The aim of this study was to reflect on the current state of research and shed light on relevant techniques for future clinical application. (2) Methods: We performed a PubMed search for “non-invasive AND ICP AND (measurement OR monitoring)” and identified 306 results. On the basis of these search results, we conducted an in-depth source analysis to identify additional methods. Studies were analyzed for design, patient type (e.g., infants, adults, and shunt patients), statistical evaluation (correlation, accuracy, and reliability), number of included measurements, and statistical assessment of accuracy and reliability. (3) Results: MRI-ICP and two-depth Doppler showed the most potential (and were the most complex methods). Tympanic membrane temperature, diffuse correlation spectroscopy, natural resonance frequency, and retinal vein approaches were also promising. (4) Conclusions: To date, no convincing evidence supports the use of a particular method for non-invasive intracranial pressure measurement. However, many new approaches are under development.
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Affiliation(s)
- Sebastian Johannes Müller
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany
- Correspondence: ; Tel.: +49-(0)711-278-34501
| | - Elina Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany
| | - Matthew J. Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts, Worcester, MA 01655, USA
| | - Stephan Felber
- Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Stiftungsklinikum Mittelrhein, D-56068 Koblenz, Germany
| | - Oliver Ganslandt
- Neurochirurgische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany
- Medizinische Fakultät, Universität Duisburg-Essen, D-47057 Duisburg, Germany
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Pennacchietti V, Schaumann A, Thomale UW. Maneuver protocol for outpatient telemetric intracranial pressure monitoring in hydrocephalus patients. Childs Nerv Syst 2023; 39:185-195. [PMID: 36098768 PMCID: PMC9968677 DOI: 10.1007/s00381-022-05659-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 09/01/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Telemetric intracranial pressure measurement (tICPM) offers new opportunities to acquire objective information in shunted and non-shunted patients. The sensor reservoir (SR) provides tICPM modality at a decent sampling rate as an integrated component of the CSF shunt system. The aim of this study is to perform tICPM during a defined protocol of maneuvers in an outpatient setting as feasibility study including either shunt-dependent patients or candidates for possible shunt therapy. METHODS A total of 17 patients received a SR and were investigated within a protocol of maneuver measurements involving different body postures (90°, 10°, 0°, and - 10°), breathing patterns (hypo- and hyperventilation), and mild venous congestion (Valsalva, Jugular vein compression), while the latter two were performed in lying postures (10° and 0°). The cohort included 11 shunted and 6 non-shunted (stand-alone-SR) patients. All measurements were evaluated using an ICP-analysis software (ICPicture, Miethke, Germany) looking at ICP changes and amplitude (AMP) characteristics. RESULTS The shunted patient group consisted of 11 patients (median age: 15.8 years; range: 4-35.2 years) with either a primary shunt (n=9) and 2 patients received a shunt after stand-alone-SR tICPM. Six patients were enrolled with a stand-alone SR (median age 11.9 years, range 3.6-17.7 years). In the stand-alone SR group, maneuver related ICP and AMP changes were more sensitive compared to shunted patients. Postural maneuvers caused significant ICP changes in all body positions in both groups. The highest ICP values were seen during Valsalva maneuver, provoked by the patients themselves. In the stand-alone group, significant higher ICP values during hyperventilation were observed compared to shunted individuals. In shunted patients, a significant correlation between ICP and AMP was observed only during hyperventilation maneuver, while this correlation was additionally seen in Valsalva and jugular vein compression in stand-alone patients. CONCLUSION SR-related tICPM is helpful to objectify diagnostic evaluation in patients with CSF dynamic disturbances. The defined protocol did result in a wide range of ICP changes with promising potential for effective outpatient tICPM investigation. Since the correlation of ICP and AMP was observed during mild venous congestion maneuvers it appears to be specifically helpful for the evaluation of intracranial compliance. Further investigations of maneuver-related tICPM in a larger population, including variable pathologies, are needed to further establish the protocol in the clinical practice.
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Affiliation(s)
- Valentina Pennacchietti
- Pediatric Neurosurgery, Charité Universitaetsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Andreas Schaumann
- Pediatric Neurosurgery, Charité Universitaetsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Ulrich-Wilhelm Thomale
- Pediatric Neurosurgery, Charité Universitaetsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
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Tsermoulas G, Thant KZ, Byrne ME, Whiting JL, White AM, Sinclair AJ, Mollan SP. The Birmingham Standardized Idiopathic Intracranial Hypertension Shunt Protocol: Technical Note. World Neurosurg 2022; 167:147-151. [PMID: 36089279 DOI: 10.1016/j.wneu.2022.08.154] [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: 05/17/2022] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Insertion of cerebrospinal fluid (CSF) shunts in patients with idiopathic intracranial hypertension (IIH) is challenging mainly due to the small ventricles and phenotypical body habitus. In this report the authors present their surgical protocol for insertion of a ventriculoperitoneal shunt (VPS) in patients with IIH and the associated revision rates. METHODS The protocol comprises the following: shunt surgery by neurosurgeons with expertise in CSF disorders; a frontal VPS usually right sided but left sided if the left ventricle is bigger; use of the proGAV 2.0 valve with gravitational unit, set at 10 and the M.scio telemetric sensor; cannulation of the ventricle with StealthStation EM navigation system; and laparoscopic insertion of the peritoneal catheter. The authors describe the protocol and rationale and evidence behind each component and present the results of a prospective analysis on revision rates. RESULTS The protocol has been implemented since 1 July, 2019, and by 28 February, 2022, sixty-two patients with IIH had undergone primary VPS insertion. The 30-day revision rate was 6.5%, and overall 11.3% of patients underwent revision during the study period, which compares favorably with the literature. The etiology for early failures was related to the surgical technique. CONCLUSIONS The components of the Birmingham standardized IIH shunt protocol are evidence based and address the technical challenges of CSF diversion in patients with IIH. This protocol is associated with a low revision rate, and the authors recommend standardization for CSF shunting in IIH.
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Affiliation(s)
- Georgios Tsermoulas
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.
| | - Kyaw Zayar Thant
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Marian E Byrne
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - John L Whiting
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Anwen M White
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Alexandra J Sinclair
- Department of Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
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Veletić M, Apu EH, Simić M, Bergsland J, Balasingham I, Contag CH, Ashammakhi N. Implants with Sensing Capabilities. Chem Rev 2022; 122:16329-16363. [PMID: 35981266 DOI: 10.1021/acs.chemrev.2c00005] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Because of the aging human population and increased numbers of surgical procedures being performed, there is a growing number of biomedical devices being implanted each year. Although the benefits of implants are significant, there are risks to having foreign materials in the body that may lead to complications that may remain undetectable until a time at which the damage done becomes irreversible. To address this challenge, advances in implantable sensors may enable early detection of even minor changes in the implants or the surrounding tissues and provide early cues for intervention. Therefore, integrating sensors with implants will enable real-time monitoring and lead to improvements in implant function. Sensor integration has been mostly applied to cardiovascular, neural, and orthopedic implants, and advances in combined implant-sensor devices have been significant, yet there are needs still to be addressed. Sensor-integrating implants are still in their infancy; however, some have already made it to the clinic. With an interdisciplinary approach, these sensor-integrating devices will become more efficient, providing clear paths to clinical translation in the future.
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Affiliation(s)
- Mladen Veletić
- Department of Electronic Systems, Norwegian University of Science and Technology, 7491 Trondheim, Norway.,The Intervention Centre, Technology and Innovation Clinic, Oslo University Hospital, 0372 Oslo, Norway
| | - Ehsanul Hoque Apu
- Institute for Quantitative Health Science and Engineering (IQ) and Department of Biomedical Engineering (BME), Michigan State University, East Lansing, Michigan 48824, United States.,Division of Hematology and Oncology, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan 48105, United States
| | - Mitar Simić
- Faculty of Electrical Engineering, University of Banja Luka, 78000 Banja Luka, Bosnia and Herzegovina
| | - Jacob Bergsland
- The Intervention Centre, Technology and Innovation Clinic, Oslo University Hospital, 0372 Oslo, Norway
| | - Ilangko Balasingham
- Department of Electronic Systems, Norwegian University of Science and Technology, 7491 Trondheim, Norway.,The Intervention Centre, Technology and Innovation Clinic, Oslo University Hospital, 0372 Oslo, Norway
| | - Christopher H Contag
- Institute for Quantitative Health Science and Engineering (IQ) and Department of Biomedical Engineering (BME), Michigan State University, East Lansing, Michigan 48824, United States
| | - Nureddin Ashammakhi
- Institute for Quantitative Health Science and Engineering (IQ) and Department of Biomedical Engineering (BME), Michigan State University, East Lansing, Michigan 48824, United States.,Department of Bioengineering, University of California, Los Angeles, California 90095, United States
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11
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Kamo M, Kajimoto Y, Ohmura T, Kameda M, Tucker A, Miyake H, Wanibuchi M. Weight and Abdominal Pressure-Induced Shunt Trouble in Patients With Shunted Normal Pressure Hydrocephalus: A Comprehensive Study on Pressure Environment of Shunt System. Front Neurol 2022; 13:882757. [PMID: 35677338 PMCID: PMC9167924 DOI: 10.3389/fneur.2022.882757] [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: 02/24/2022] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives We identified a new type of shunt malfunction (SM) in patients with normal pressure hydrocephalus (NPH). It is induced by weight change and can be treated with valve readjustment. There were two types of SM as follows: Underdrainage induced by the weight gain and overdrainage induced by the weight loss. This study aims to elucidate this mechanism by assessing the shunt pressure environment. Methods The total pressure environment of the shunt system was prospectively studied in patients with shunted NPH at Osaka Medical College Hospital from 1999 to 2005. We measured the pressure environment during the initial pressure setting of the valve by the intracranial pressure (ICP) guide, after setting the valve, and when SM was suspected. We evaluated ICP, intra-abdominal pressure (IAP), and hydrostatic and perfusion pressures of the shunt system in the sitting and supine positions. The target ICP for valve setting was empirically set at the range from −8 to −13 mm Hg in the sitting position, referring to the external auditory meatus. During the study period, we identified five cases of SM induced by weight change and assessed the changes in the pressure environment across pre-SM, SM, and post-SM. Results In four cases of underdrainage, gait disturbance worsened with an average weight gain of 6.8 ± 1.2 kg. With weight gain, IAP and ICP increased by 8.8 ± 1.6 and 4.8 ± 1.0 mm Hg, respectively. Consequently, ICP increased to −6.5 ± 1.9 mm Hg. One overdrainage patient developed an asymptomatic chronic subdural hematoma (CSDH) with a weight loss of 10 kg. With the weight loss, both IAP and ICP decreased by 5 mm Hg, and concomitantly, ICP decreased to −18 mm Hg. In all patients, the valve readjustment restored their ICP to the target pressure. After the valve readjustment, the gait disturbance improved immediately, and the CSDH disappeared after 1 month. Conclusion In patients with shunts, the weight change was linked to ICP via IAP. Due to the weight change, the underdrainage occurred when ICP was above the target pressure, and the overdrainage occurred when ICP was below it. We named this SM as the weight and abdominal pressure-induced shunt trouble. The patients with SM along with weight changes should be the first to be tried for the valve readjustment.
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Affiliation(s)
- Masatsugu Kamo
- Department Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Yoshinaga Kajimoto
- Department Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
- *Correspondence: Yoshinaga Kajimoto
| | - Tomohisa Ohmura
- Department Neurosurgery, Nishinomiya Kyoritsu Neurosurgical Hospital, Nishinomiya, Japan
| | - Masahiro Kameda
- Department Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Adam Tucker
- Department Neurosurgery, Kitami Red Cross Hospital, Kitami, Japan
| | - Hiroji Miyake
- Department Neurosurgery, Nishinomiya Kyoritsu Rehabilitation Hospital, Nishinomiya, Japan
| | - Masahiko Wanibuchi
- Department Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
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12
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Cerebrospinal fluid hydrocephalus shunting: cisterna magna, ventricular frontal, ventricular occipital. Neurosurg Rev 2022; 45:2615-2638. [PMID: 35513737 DOI: 10.1007/s10143-022-01798-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/08/2022] [Accepted: 04/21/2022] [Indexed: 10/18/2022]
Abstract
Despite advances in cerebrospinal fluid shunting technology, complications remain a significant concern. There are some contradictions about the effectiveness of proximal catheter entry sites that decrease shunt failures. We aim to compare efficiency of shunts with ventricular frontal, ventricular occipital, and cisterna magna entry sites. The systemic search was conducted in the database from conception to February 16, 2022 following guidelines of PRISMA. Between 2860 identified articles, 24 articles including 6094 patients were used for data synthesis. The aggregated results of all patients showed that "overall shunt failure rate per year" in mixed hydrocephalus with ventricular frontal and occipital shunts, and cisterna magna shunt (CMS) were 9.0%, 12.6%, and 30.7%, respectively. The corresponding values for "shunt failure rate" due to obstruction were 15.3%, 31.5%, and 10.2%, respectively. The similar results for "shunt failure rate" due to infection were 11.3%, 9.1%, and 27.2%, respectively. The related values for "shunt failure rate" due to overdrainage were 2.9%, 3.9%, and 13.6%, respectively. CMS was successful in the immediate resolution of clinical symptoms. Shunting through an occipital entry site had a greater likelihood of inaccurate catheter placement and location. Contrary to possible shunt failure due to overdrainage, the failure likelihood due to obstruction and infection in pediatric patients was higher than that of mixed hydrocephalus patients. In both mixed and pediatric hydrocephalus, obstruction and overdrainage were the most and least common complications of ventricular frontal and occipital shunts, respectively. The most and least common complications of mixed CMS were infection and obstruction, respectively.
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13
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Jannelli G. Telemetric monitoring of intracystic pressure with sensor reservoir for recurrent sellar arachnoid cysts. BRAIN AND SPINE 2022; 2:100874. [PMID: 36248164 PMCID: PMC9562225 DOI: 10.1016/j.bas.2022.100874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/05/2022] [Accepted: 02/10/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Gianpaolo Jannelli
- Corresponding author. Department of Neurosurgery B, Skull Base Unit, Neurological Hospital Pierre Wertheimer, University Hospital of Lyon, 59 Boulevard Pinel, 69500, Bron, France.
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14
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Perrotte M, Lazardeux J, Sistiaga PP, Chazalviel L, Saulnier R, Metayer T, Isnard C, Emery E, Auvray P, Vivien D, Gaberel T. An updated model of hydrocephalus in sheep to evaluate the performance of a device for ambulatory wireless monitoring of cerebral pressure through shunts. Neurochirurgie 2021; 68:300-308. [PMID: 34774581 DOI: 10.1016/j.neuchi.2021.10.006] [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: 03/16/2021] [Revised: 07/16/2021] [Accepted: 10/04/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) diversion by shunts is the most common surgical treatment for hydrocephalus. Though effective, shunts are associated with risk of dysfunction leading to multiple surgical revisions, affecting patient quality-of-life and incurring high healthcare costs. There is a need for ambulatory monitoring systems for life-long assessment of shunt status. The present study aimed to develop a preclinical model assessing the feasibility of our wireless device for continuous monitoring of cerebral pressure in shunts. METHODS We first adapted a previous hydrocephalus model in sheep, which used an intracisternal kaolin injection. Seven animals were used to establish the model, and 1 sheep with naturally dilated ventricles was used as control. Hydrocephalus was confirmed by clinical examination and brain imaging before inserting the ventriculoperitoneal shunts and the monitoring device allowing continuous measurement of the pressure through the shunt for a few days in 3 sheep. An external ventricular drain was used as gold-standard. RESULTS Our results showed that a reduction in kaolin dose associated to postoperative management was crucial to reduce morbidity and mortality rates in the model. Ventriculomegaly was confirmed by imaging 4 days after injection of 75 mg kaolin into the cisterna magna. For the implanted sheep, recordings revealed high sensitivity of our sensor in detecting fluctuations in cerebral pressure compared to conventional measurements. CONCLUSIONS This proof-of-concept study highlights the potential of this preclinical model for testing new shunt devices.
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Affiliation(s)
- Morgane Perrotte
- Research and Development Department, Neurallys, Colombelles, Normandie, France.
| | - Johan Lazardeux
- Research and Development Department, Neurallys, Colombelles, Normandie, France
| | | | - Laurent Chazalviel
- UMR6301-ISTCT, CNRS, CERVOxy Group, GIP Cyceron, Caen, Normandie, France
| | | | - Thomas Metayer
- Department of Neurosurgery, University Hospital of Caen, Caen, Normandie, France; INSERM, UMR-S U1237, Pathophysiology and Imaging of Neurological Disorders, University Caen-Normandy, University Hospital of Caen, GIP Cyceron, Caen, Normandie, France
| | - Christophe Isnard
- Department of Microbiology, University Caen-Normandy, UNICAEN, University Hospital of Caen, Caen, Normandie, France; UNICAEN/UNIROUEN, EA2656 GRAM 2.0, University Caen-Normandy, Caen, Normandie, France
| | - Evelyne Emery
- Department of Neurosurgery, University Hospital of Caen, Caen, Normandie, France; INSERM, UMR-S U1237, Pathophysiology and Imaging of Neurological Disorders, University Caen-Normandy, University Hospital of Caen, GIP Cyceron, Caen, Normandie, France
| | - Philippe Auvray
- Research and Development Department, Neurallys, Colombelles, Normandie, France
| | - Denis Vivien
- INSERM, UMR-S U1237, Pathophysiology and Imaging of Neurological Disorders, University Caen-Normandy, University Hospital of Caen, GIP Cyceron, Caen, Normandie, France; Department of Clinical Research, University Hospital of Caen, Caen, Normandie, France
| | - Thomas Gaberel
- Department of Neurosurgery, University Hospital of Caen, Caen, Normandie, France; INSERM, UMR-S U1237, Pathophysiology and Imaging of Neurological Disorders, University Caen-Normandy, University Hospital of Caen, GIP Cyceron, Caen, Normandie, France
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15
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Galloway L, Karia K, White AM, Byrne ME, Sinclair AJ, Mollan SP, Tsermoulas G. Cerebrospinal fluid shunting protocol for idiopathic intracranial hypertension for an improved revision rate. J Neurosurg 2021:1-6. [PMID: 34624853 DOI: 10.3171/2021.5.jns21821] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/17/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cerebrospinal fluid (CSF) shunting in idiopathic intracranial hypertension (IIH) is associated with high complication rates, primarily because of the technical challenges that are related to small ventricles and a large body habitus. In this study, the authors report the benefits of a standardized protocol for CSF shunting in patients with IIH as relates to shunt revisions. METHODS This was a retrospective study of consecutive patients with IIH who had undergone primary insertion of a CSF shunt between January 2014 and December 2020 at the authors' hospital. In July 2019, they implemented a surgical protocol for shunting in IIH. This protocol recommended IIH shunt insertion by neurosurgeons with expertise in CSF disorders, a frontal ventriculoperitoneal (VP) shunt with an adjustable gravitational valve and integrated intracranial pressure monitoring device, frameless stereotactic insertion of the ventricular catheter, and laparoscopic insertion of the peritoneal catheter. Thirty-day revision rates before and after implementation of the protocol were compared in order to assess the impact of standardizing shunting for IIH on shunt complications. RESULTS The 81 patients included in the study were predominantly female (93%), with a mean age of 31 years at primary surgery and mean body mass index (BMI) of 37 kg/m2. Forty-five patients underwent primary surgery prior to implementation of the protocol and 36 patients after. Overall, 12 (15%) of 81 patients needed CSF shunt revision in the first 30 days, 10 before and 2 after introduction of the protocol. This represented a significant reduction in the early revision rate from 22% to 6% after the protocol (p = 0.036). The most common cause of shunt revision for the whole cohort was migration or misplacement of the peritoneal catheter, occurring in 6 of the 12 patients. Patients with a higher BMI were significantly more likely to have a shunt revision within 30 days (p = 0.022). CONCLUSIONS The Birmingham standardized IIH shunt protocol resulted in a significant reduction in revisions within 30 days of primary shunt surgery in patients with IIH. The authors recommend standardization for shunting in IIH as a method for improving surgical outcomes. They support the notion of subspecialization for IIH shunts, the use of a frontal VP shunt with sophisticated technology, and laparoscopic insertion of the peritoneal end.
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Affiliation(s)
| | | | | | | | - Alexandra J Sinclair
- 2Neurology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham.,3Institute of Metabolism and Systems Research, University of Birmingham; and
| | - Susan P Mollan
- 4Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, United Kingdom
| | - Georgios Tsermoulas
- Departments of1Neurosurgery and.,3Institute of Metabolism and Systems Research, University of Birmingham; and
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16
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Ros B, Iglesias S, Linares J, Cerro L, Casado J, Arráez MA. Shunt Overdrainage: Reappraisal of the Syndrome and Proposal for an Integrative Model. J Clin Med 2021; 10:jcm10163620. [PMID: 34441916 PMCID: PMC8396927 DOI: 10.3390/jcm10163620] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/05/2021] [Accepted: 08/12/2021] [Indexed: 11/16/2022] Open
Abstract
Although shunt overdrainage is a well-known complication in hydrocephalus management, the problem has been underestimated. Current literature suggests that the topic requires more examination. An insight into this condition is limited by a lack of universally agreed-upon diagnostic criteria, heterogeneity of published series, the multitude of different management options and misunderstanding of relationships among pathophysiological mechanisms involved. We carried out a review of the literature on clinical, radiological, intracranial pressure (ICP), pathophysiological and treatment concepts to finally propose an integrative model. Active prophylaxis and management are proposed according to this model based on determination of pathophysiological mechanisms and predisposing factors behind each individual case. As pathophysiology is progressively multifactorial, prevention of siphoning with gravitational valves or antisiphon devices is mandatory to avoid or minimize further complications. Shunt optimization or transferal and neuroendoscopy may be recommended when ventricular collapse and cerebrospinal fluid isolation appear. Cranial expansion may be useful in congenital or acquired craniocerebral disproportion and shunting the subarachnoid space in communicating venous hydrocephalus and idiopathic intracranial hypertension.
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Affiliation(s)
- Bienvenido Ros
- Pediatric Neurosurgery Division, Department of Neurosurgery, Regional University Hospital, Avda. Carlos Haya s/n, 29010 Malaga, Spain;
- Correspondence:
| | - Sara Iglesias
- Pediatric Neurosurgery Division, Department of Neurosurgery, Regional University Hospital, Avda. Carlos Haya s/n, 29010 Malaga, Spain;
| | - Jorge Linares
- Department of Neurosurgery, Regional University Hospital, Avda. Carlos Haya s/n, 29010 Malaga, Spain; (J.L.); (L.C.); (J.C.); (M.A.A.)
| | - Laura Cerro
- Department of Neurosurgery, Regional University Hospital, Avda. Carlos Haya s/n, 29010 Malaga, Spain; (J.L.); (L.C.); (J.C.); (M.A.A.)
| | - Julia Casado
- Department of Neurosurgery, Regional University Hospital, Avda. Carlos Haya s/n, 29010 Malaga, Spain; (J.L.); (L.C.); (J.C.); (M.A.A.)
| | - Miguel Angel Arráez
- Department of Neurosurgery, Regional University Hospital, Avda. Carlos Haya s/n, 29010 Malaga, Spain; (J.L.); (L.C.); (J.C.); (M.A.A.)
- Department of Surgery, Malaga University, 29010 Malaga, Spain
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17
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Norager NH, Olsen MH, Pedersen SH, Riedel CS, Czosnyka M, Juhler M. Reference values for intracranial pressure and lumbar cerebrospinal fluid pressure: a systematic review. Fluids Barriers CNS 2021; 18:19. [PMID: 33849603 PMCID: PMC8045192 DOI: 10.1186/s12987-021-00253-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although widely used in the evaluation of the diseased, normal intracranial pressure and lumbar cerebrospinal fluid pressure remain sparsely documented. Intracranial pressure is different from lumbar cerebrospinal fluid pressure. In addition, intracranial pressure differs considerably according to the body position of the patient. Despite this, the current reference values do not distinguish between intracranial and lumbar cerebrospinal fluid pressures, and body position-dependent reference values do not exist. In this study, we aim to establish these reference values. METHOD A systematic search was conducted in MEDLINE, EMBASE, CENTRAL, and Web of Sciences. Methodological quality was assessed using an amended version of the Joanna Briggs Quality Appraisal Checklist. Intracranial pressure and lumbar cerebrospinal fluid pressure were independently evaluated and subdivided into body positions. Quantitative data were presented with mean ± SD, and 90% reference intervals. RESULTS Thirty-six studies were included. Nine studies reported values for intracranial pressure, while 27 reported values for the lumbar cerebrospinal fluid pressure. Reference values for intracranial pressure were - 5.9 to 8.3 mmHg in the upright position and 0.9 to 16.3 mmHg in the supine position. Reference values for lumbar cerebrospinal fluid pressure were 7.2 to 16.8 mmHg and 5.7 to 15.5 mmHg in the lateral recumbent position and supine position, respectively. CONCLUSIONS This systematic review is the first to provide position-dependent reference values for intracranial pressure and lumbar cerebrospinal fluid pressure. Clinically applicable reference values for normal lumbar cerebrospinal fluid pressure were established, and are in accordance with previously used reference values. For intracranial pressure, this study strongly emphasizes the scarcity of normal pressure measures, and highlights the need for further research on the matter.
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Affiliation(s)
| | | | | | - Casper Schwartz Riedel
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
- Department of Neurophysiology, Rigshospitalet, Glostrup, Denmark
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Marianne Juhler
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
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18
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Oertel JMK, Huelser MJM. Benefits and obstacles of telemetric ICP monitoring. Acta Neurochir (Wien) 2021; 163:1083-1085. [PMID: 33550517 PMCID: PMC7966137 DOI: 10.1007/s00701-021-04730-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 01/21/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Joachim M K Oertel
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Saarland, Germany.
| | - Matthias J M Huelser
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
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19
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Bjornson A, Henderson D, Lawrence E, McMullan J, Ushewokunze S. The Sensor Reservoir-does it change management? Acta Neurochir (Wien) 2021; 163:1087-1095. [PMID: 33587185 DOI: 10.1007/s00701-021-04729-y] [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: 09/16/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND The Miethke Sensor Reservoir sits within a ventriculoperitoneal shunt system to give a reading of the pressure within the shunt. This information can guide the management of hydrocephalus patients who present frequently with headaches. METHODS We reviewed a cohort of 12 patients who underwent implantation of a Sensor Reservoir to assess how the management of their symptoms changed over a 4-year period. RESULTS When comparing the group before the Sensor Reservoir and after the Sensor Reservoir insertion, there was a 75% reduction in number of CT head scans (P<0.05), 100% reduction in episodes of ICP monitoring (P<0.05), 55% reduction in number of X-ray shunt series, and a 50% reduction in acute presentation to hospital with shunt-related symptoms. The number of clinic attendances increased by 44%. In addition, cost analysis showed a saving of £6952 per patients over the 2-year period following Sensor Reservoir insertion as a result of reduced admissions and investigations. Complications were seen in 3 patients-two patients developed shunt-related infections, and 1 patient underwent shunt revision due to a proximal shunt obstruction. Seventy-five percent of patients showed an improvement in their symptoms at the end of the 4-year period. CONCLUSION Implantation of a Sensor Reservoir in shunt patients with chronic headaches can reduce the number of investigations and hospital admissions and guide management resulting in a clinical improvement.
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20
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Hamarat Y, Bartusis L, Deimantavicius M, Lucinskas P, Siaudvytyte L, Zakelis R, Harris A, Mathew S, Siesky B, Janulevicienė I, Ragauskas A. Can the Treatment of Normal-Pressure Hydrocephalus Induce Normal-Tension Glaucoma? A Narrative Review of a Current Knowledge. ACTA ACUST UNITED AC 2021; 57:medicina57030234. [PMID: 33802375 PMCID: PMC7999145 DOI: 10.3390/medicina57030234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 11/16/2022]
Abstract
Ventriculoperitoneal shunt placement is the most commonly used treatment of normal-pressure hydrocephalus (NPH). It has been hypothesized that normal-tension glaucoma (NTG) is caused by the treatment of NPH by using the shunt to reduce intracranial pressure (ICP). The aim of this study is to review the literature published regarding this hypothesis and to emphasize the need for neuro-ophthalmic follow-up for the concerned patients. The source literature was selected from the results of an online PubMed search, using the keywords "hydrocephalus glaucoma" and "normal-tension glaucoma shunt". One prospective study on adults, one prospective study on children, two retrospective studies on adults and children, two case reports, three review papers including medical hypotheses, and one prospective study on monkeys were identified. Hypothesis about the association between the treatment of NPH using the shunt to reduce ICP and the development of NTG were supported in all reviewed papers. This suggests that a safe lower limit of ICP for neurological patients, especially shunt-treated NPH patients, should be kept. Thus, we proposed to modify the paradigm of safe upper ICP threshold recommended in neurosurgery and neurology into the paradigm of safe ICP corridor applicable in neurology and ophthalmology, especially for shunt-treated hydrocephalic and glaucoma patients.
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Affiliation(s)
- Yasin Hamarat
- Health Telematics Science Institute, Kaunas University of Technology, K. Barsausko Str. 59-A557, LT-51423 Kaunas, Lithuania; (L.B.); (M.D.); (P.L.); (R.Z.); (A.R.)
- Correspondence:
| | - Laimonas Bartusis
- Health Telematics Science Institute, Kaunas University of Technology, K. Barsausko Str. 59-A557, LT-51423 Kaunas, Lithuania; (L.B.); (M.D.); (P.L.); (R.Z.); (A.R.)
| | - Mantas Deimantavicius
- Health Telematics Science Institute, Kaunas University of Technology, K. Barsausko Str. 59-A557, LT-51423 Kaunas, Lithuania; (L.B.); (M.D.); (P.L.); (R.Z.); (A.R.)
| | - Paulius Lucinskas
- Health Telematics Science Institute, Kaunas University of Technology, K. Barsausko Str. 59-A557, LT-51423 Kaunas, Lithuania; (L.B.); (M.D.); (P.L.); (R.Z.); (A.R.)
| | - Lina Siaudvytyte
- Eye Clinic, Lithuanian University of Health Sciences, Eiveniu Str. 2, LT-50009 Kaunas, Lithuania; (L.S.); (I.J.)
| | - Rolandas Zakelis
- Health Telematics Science Institute, Kaunas University of Technology, K. Barsausko Str. 59-A557, LT-51423 Kaunas, Lithuania; (L.B.); (M.D.); (P.L.); (R.Z.); (A.R.)
| | - Alon Harris
- Glaucoma Research and Diagnostic Center, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (A.H.); (S.M.); (B.S.)
| | - Sunu Mathew
- Glaucoma Research and Diagnostic Center, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (A.H.); (S.M.); (B.S.)
| | - Brent Siesky
- Glaucoma Research and Diagnostic Center, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (A.H.); (S.M.); (B.S.)
| | - Ingrida Janulevicienė
- Eye Clinic, Lithuanian University of Health Sciences, Eiveniu Str. 2, LT-50009 Kaunas, Lithuania; (L.S.); (I.J.)
| | - Arminas Ragauskas
- Health Telematics Science Institute, Kaunas University of Technology, K. Barsausko Str. 59-A557, LT-51423 Kaunas, Lithuania; (L.B.); (M.D.); (P.L.); (R.Z.); (A.R.)
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21
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Liminga G, Grabowska A, Pétursdóttir D, Cesarini KG, Rostami E, Ehrstedt C. Acute disseminated encephalomyelitis with delayed onset and feasibility of the Miethke shunt and sensor reservoir system: a case report. Childs Nerv Syst 2021; 37:3891-3895. [PMID: 34136944 PMCID: PMC8604833 DOI: 10.1007/s00381-021-05188-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/25/2021] [Indexed: 11/30/2022]
Abstract
Acute disseminated encephalomyelitis (ADEM) is an immune-mediated demyelinating central nervous system disorder with predilection for early childhood. Delayed onset of ADEM is rare, and herein we present a previously healthy 5-year-old boy, with an unusual clinical course of ADEM with high intracranial pressure (ICP) and acute visual loss that was at first diagnosed as idiopathic intracranial hypertension without papilledema (IIHWOP). The boy underwent acute neurosurgical intervention with ventriculoperitoneal (VP) shunt using Miethke valve and sensor reservoir system and received high-dose steroid treatment with symptom relieve within days. This is the first case report using this system in such a young child, and we find it feasible and valuable also in younger children when VP shunt with ICP measurement is indicated.
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Affiliation(s)
- Gunnar Liminga
- Department of Women’s and Children’s Health, Uppsala University , Uppsala, Sweden
| | - Anna Grabowska
- Department of Surgical Sciences, Radiology, Uppsala University, Uppsala, Sweden
| | | | | | - Elham Rostami
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden ,Department of Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Christoffer Ehrstedt
- Department of Women's and Children's Health, Uppsala University , Uppsala, Sweden.
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Rot S, Dweek M, Gutowski P, Goelz L, Meier U, Lemcke J. Comparative investigation of different telemetric methods for measuring intracranial pressure: a prospective pilot study. Fluids Barriers CNS 2020; 17:63. [PMID: 33069242 PMCID: PMC7568395 DOI: 10.1186/s12987-020-00225-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/08/2020] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES Measurement of intracranial pressure (ICP) plays an important role in long-term monitoring and neuro-intensive treatment of patients with a cerebral shunt. Currently, only two complete telemetric implants with different technical features are available worldwide. This prospective pilot study aims to examine patients who had both probes implanted at overlapping times for clinical reasons and represents the first in vivo comparison of both measurement methods. MATERIALS AND METHODS Patients with a primary subarachnoid hemorrhage or a spontaneous intracerebral hemorrhage with ventricular hemorrhage who had received a telemetric ICP probe (Raumedic® NEUROVENT®-P-tel) were included in the study. Conventional external ventricular drainages (EVD) and ventriculoperitoneal shunts with a telemetric ICP probe (Miethke Sensor Reservoir) were implanted in patients with hydrocephalus who required CSF (cerebrospinal fluid) drainage. Absolute ICP values from all systems were obtained. Due to the overlapping implantation time, parallel ICP measurements were performed via two devices simultaneously. ICP measurements via the sensor reservoir were repeated after 3 and 9 months. Differences between the absolute ICP values measured via the NEUROVENT®-P-tel probe, the Miethke sensor reservoir®, and the EVD were analyzed. RESULTS Seventeen patients were included in the present study between 2016 and 2018. 63% of all patients were male. In 11 patients the ICP measurements were followed up with both devices for 3 months. ICP measurements of the sensor reservoir showed corresponding trends in 9 cases compared to ICP measurement via the telemetry probe or EVD. Difference in absolute ICP values ranged between 14.5 mmHg and 0.0 mmHg. The average difference of the absolute ICP values in 8 cases was ≤ 3.5 mmHg. CONCLUSION ICP measurements with both systems continuously showed synchronous absolute ICP values, however absolute values of ICP measurement with the different systems did not match.
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Affiliation(s)
- S Rot
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany.
| | - M Dweek
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany
| | - P Gutowski
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany
| | - L Goelz
- Department of Radiology and Neuroradiology, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany
| | - U Meier
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany
| | - J Lemcke
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany
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Paradoxical response of intracranial pressure to shunt valve setting adjustments. Acta Neurochir (Wien) 2020; 162:2451-2458. [PMID: 32583083 PMCID: PMC7496047 DOI: 10.1007/s00701-020-04462-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/11/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The hydrodynamics of cerebrospinal fluid shunts have been described in vitro; however, knowledge on the response of intracranial pressure (ICP) to valve settings adjustments in vivo is limited. This study describes the effect of adjusting the shunt valve setting on ICP in a cohort of patients with complex symptom management. METHOD Single-centre retrospective observational study. Patients who underwent ICP-guided valve setting adjustments during 24-h continuous ICP monitoring, between 2014 and 2019, were included. Patients with suspected shunt malfunction were excluded. Median night ICP before and after the valve adjustments were compared (Δ night ICP). The responses of ICP to valve adjustment were divided into 3 different groups as follows: expected, paradoxical and no response. The frequency of the paradoxical response and its potential predicting factors were investigated. RESULTS Fifty-one patients (37 females, 14 males, mean age 38 years) receiving 94 valve setting adjustments met the study inclusion criteria. Patients' underlying conditions were most commonly hydrocephalus (47%) or idiopathic intracranial hypertension (43%). The response of ICP to valve setting adjustments was classified as 'expected' in 54 cases (57%), 'paradoxical' in 17 cases (18%) and 'no effect' (Δ night ICP < 1 mmHg) in 23 cases (24%). There was a significant correlation between the Δ night ICP and the magnitude of valve setting change in both the investigated valves (Miethke ProGAV, p = 0.01 and Medtronic Strata, p = 0.02). CONCLUSIONS Paradoxical ICP changes can occur after shunt valve setting adjustments. This observation should be taken into account when performing ICP-guided valve adjustments and is highly relevant for the future development of "smart" shunt systems.
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Single center experiences with telemetric intracranial pressure measurements in patients with CSF circulation disturbances. Acta Neurochir (Wien) 2020; 162:2487-2497. [PMID: 32495080 PMCID: PMC7496065 DOI: 10.1007/s00701-020-04421-7] [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: 11/05/2019] [Accepted: 05/19/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Hydrocephalus may present with heterogeneous signs and symptoms. The indication for its treatment and the optimal drainage in complex cases may be challenging. Telemetric intracranial pressure measurements (TICPM) may open new perspectives for those circumstances. We report our experiences using the Neurovent-P-tel and the Sensor Reservoir in a retrospective study. METHODS A series of 21 patients (age range 10-39.5 years) treated in our Pediatric Neurosurgical Unit receiving a TICPM was analyzed. In 8 patients, a Neurovent-P-Tel was implanted; 13 patients received a Sensor Reservoir, 6 of which as a stand-alone implant, while 7 were already shunted. TICPM were performed on an outpatient basis. Possible complications, follow-up surgeries, and TICPM were analyzed. RESULTS Concerning the complications, one infection was seen in each group and one postoperative seizure was observed in the P-tel group. TICPM-assisted shunt adjustments lead to clinical improvements in six patients in the P-tel group and six patients in the Sensor Reservoir group. In four out of six non-shunted patients, TICPM contributed to the indication toward shunt implantation. CONCLUSIONS TICPM seems to be a promising tool to improve clinical management of shunted patients with complex hydrocephalus. The two available systems will need further technical improvements, concerning implantation time, measurements, and data analysis in order to optimize handling and interpretation of the data.
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Abstract
Telemetric intracranial pressure (ICP) monitoring is a new method of measuring ICP which eliminates some of the shortcomings of previous methods. However, there are limited data on specific characteristics, including the advantages and disadvantages of this method. The main aim of this study was to demonstrate the indications, benefits, and complications of telemetric ICP monitoring. PubMed, MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for relevant studies without language or date restriction in May 2019. Human studies in which telemetric ICP monitoring was the main subject of the study were included. Our initial search resulted in 1650 articles from which 50 studies were included. There were no randomized controlled trials. The majority of the studies were case reports or case series (68%). The most common aim of studies was testing of the device (52%), and monitoring the disease progression or recovery (46%). The most common indications for telemetric ICP monitoring in these studies were testing cerebrospinal fluid shunt function (46%), ICP control after the procedure (36%), and diagnosing intracranial hypertension (22%) and hydrocephalus (12%). In total, 1423 brain disease patients had been monitored in studies. The possibility of long-term ICP monitoring as the main benefit was reported in 38 (76%) studies. The associated complication rate was 7.1%. Despite the increasing application of telemetric monitoring devices, studies to evaluate specific characteristics of this method have been infrequent and inadequate. Future research using a higher level of scientific methods is needed to evaluate advantage and disadvantages.
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26
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Lalou AD, Czosnyka M, Garnett MR, Nabbanja E, Petrella G, Hutchinson PJ, Pickard JD, Czosnyka Z. Shunt infusion studies: impact on patient outcome, including health economics. Acta Neurochir (Wien) 2020; 162:1019-1031. [PMID: 32078047 PMCID: PMC7156359 DOI: 10.1007/s00701-020-04212-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 01/06/2020] [Indexed: 12/03/2022]
Abstract
Objectives The diagnosis of shunt malfunction is often not straightforward. We have explored, in symptomatic shunted patients with hydrocephalus or pseudotumour cerebri syndrome (PTCS), the accuracy of CSF infusion tests in differentiating a functioning shunt from one with possible problems, and the health economic consequences. Methods Participants: hydrocephalus/PTCS patients with infusion tests performed from January 2013 until December 2015. We followed patients up after 6 and 12 months from the test to determine whether they had improved, had persisting symptoms or had required urgent revision. We calculated the total cost savings of revision versus infusion tests and standard protocol of revision and ICP monitoring versus infusion tests. Results Three hundred sixty-five shunt infusion tests had been performed where a shunt prechamber/reservoir was present. For hydrocephalus patients, more than half of the tests (~ 55%, 155 out of 280) showed no shunt malfunction versus 125 with possible malfunction (ages 4 months to 90 years old). For PTCS patients aged 10 to 77 years old, 47 had possible problems and 38 no indication for shunt malfunction. Overall, > 290 unnecessary revisions were avoided over 3 years’ time. Two hundred fifty-eight (> 85%) of those non-surgically managed, remained well, did not deteriorate and did not require surgery. No infections were associated with infusion studies. For Cambridge, the overall savings from avoiding revisions was £945,415 annually. Conclusions Our results provide evidence of the importance of shunt testing in vivo to confirm shunt malfunction. Avoiding unnecessary shunt revisions carries a strong health benefit for patients that also translates to a significant financial benefit for the National Health Service and potentially for other healthcare systems worldwide. Electronic supplementary material The online version of this article (10.1007/s00701-020-04212-0) contains supplementary material, which is available to authorized users.
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27
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Pedersen SH, Lilja-Cyron A, Astrand R, Juhler M. Monitoring and Measurement of Intracranial Pressure in Pediatric Head Trauma. Front Neurol 2020; 10:1376. [PMID: 32010042 PMCID: PMC6973131 DOI: 10.3389/fneur.2019.01376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/12/2019] [Indexed: 01/09/2023] Open
Abstract
Purpose of Review: Monitoring of intracranial pressure (ICP) is an important and integrated part of the treatment algorithm for children with severe traumatic brain injury (TBI). Guidelines often recommend ICP monitoring with a treatment threshold of 20 mmHg. This focused review discusses; (1) different ICP technologies and how ICP should be monitored in pediatric patients with severe TBI, (2) existing evidence behind guideline recommendations, and (3) how we could move forward to increase knowledge about normal ICP in children to support treatment decisions. Summary: Current reference values for normal ICP in adults lie between 7 and 15 mmHg. Recent studies conducted in “pseudonormal” adults, however, suggest a normal range below this level where ICP is highly dependent on body posture and decreases to negative values in sitting and standing position. Despite obvious physiological differences between children and adults, no age or body size related reference values exist for normal ICP in children. Recent guidelines for treatment of severe TBI in pediatric patients recommend ICP monitoring to guide treatment of intracranial hypertension. Decision on ICP monitoring modalities are based on local standards, the individual case, and the clinician's choice. The recommended treatment threshold is 20 mmHg for a duration of 5 min. Both prospective and retrospective observational studies applying different thresholds and treatment strategies for intracranial hypertension were included to support this recommendation. While some studies suggest improved outcome related to ICP monitoring (lower rate of mortality and severe disability), most studies identify high ICP as a marker of worse outcome. Only one study applied age-differentiated thresholds, but this study did not evaluate the effect of these different thresholds on outcome. The quality of evidence behind ICP monitoring and treatment thresholds in severe pediatric TBI is low and treatment can potentially be improved by knowledge about normal ICP from observational studies in healthy children and cohorts of pediatric “pseudonormal” patients expected to have normal ICP. Acceptable levels of ICP − and thus also treatment thresholds—probably vary with age, disease and whether the patient has intact cerebral autoregulation. Future treatment algorithms should reflect these differences and be more personalized and dynamic.
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Affiliation(s)
| | | | - Ramona Astrand
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
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28
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Pedersen SH, Norager NH, Lilja-Cyron A, Juhler M. Telemetric intracranial pressure monitoring in children. Childs Nerv Syst 2020; 36:49-58. [PMID: 31309286 DOI: 10.1007/s00381-019-04271-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 06/19/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE Repeated intracranial pressure (ICP) measurements are essential in treatment of patients with complex cerebrospinal fluid (CSF) disorders. These patients often have a long surgical history with numerous invasive lumbar or intracranial pressure monitoring sessions and/or ventriculoperitoneal (VP) shunt revisions. Telemetric ICP monitoring might be an advantageous tool in treatment of these patients. In this paper, we evaluate our experience with this technology in paediatric patients. METHODS During a 4-year period, we implanted telemetric ICP sensors (Raumedic NEUROVENT-P-tel) in 20 paediatric patients to minimise the number of future invasive procedures. Patients were diagnosed with hydrocephalus, idiopathic intracranial hypertension (IIH) or an arachnoid cyst. Most patients (85%) had a VP shunt at the time of sensor implantation. RESULTS In total, 32 sensors were inserted in the 20 patients; the cause of re-implantation was technical malfunction of the implant. One sensor was explanted due to wound infection and one due to skin erosion. We experienced no complications directly related to the implantation/explantation procedures. A total of 149 recording sessions were conducted, including 68 home monitoring sessions. The median implantation period was 523 days with a median duration of clinical use at 202 days. The most likely consequence of a recording session was non-surgical treatment alteration (shunt valve adjustment or acetazolamide dose adjustment). CONCLUSION Telemetric ICP monitoring in children is safe and potentially decreases the number of invasive procedures. We find that telemetric ICP monitoring aids the clinical management of patients with complex CSF disorders and improves everyday life for both patient and parents. It allows continuous ICP measurement in the patient's home and thereby potentially reducing hospitalisations, leading to significant cost savings.
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Affiliation(s)
- Sarah Hornshøj Pedersen
- Department of Neurosurgery, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark.
| | - Nicolas Hernandez Norager
- Department of Neurosurgery, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Alexander Lilja-Cyron
- Department of Neurosurgery, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
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29
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Tschan CA, Velazquez Sanchez VF, Heckelmann M, Antes S. Home telemonitoring of intracranial pressure. Acta Neurochir (Wien) 2019; 161:1605-1617. [PMID: 31168730 DOI: 10.1007/s00701-019-03959-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 03/30/2019] [Accepted: 05/24/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND As technical progress advances, telemonitoring has become an important part of patient care in many areas of medical treatment. However, distanced surveillance of intracranial pressure (ICP) could not be established so far. With the recent introduction of a telemetric ICP measurement probe, new possibilities arise. Here, we report on a new home setup enabling home telemonitoring of intracranial pressure. METHODS Twenty patients suffering from disturbances of cerebrospinal fluid circulation, who underwent insertion of a telemetric ICP measurement probe, were provided with medical equipment to read ICP at home and save the data on an internet-enabled computer. Training in handling the equipment was performed during in-patient stay; recorded and uploaded ICP data was then analyzed online. Therefore, the treating medical team was able to access the ICP data via a secure internet connection while telephone conferencing with the patient. RESULTS Almost 7400 h of ICP data were recorded at home and evaluated via an internet connection according to the telemonitoring setup. This corresponds to an average record time of about 370 h per patient. ICP profiles were observed following endoscopic treatment, shunting procedures, or valve adjustments. The mean distance between the patients' residence and the consulting hospital was 172 km (range, 16-649 km). CONCLUSIONS ICP measurements have become accessible for telemonitoring purposes. This new management of hydrocephalus reflects an alternative method in patient care, especially for those who live far away from specialized centers.
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Affiliation(s)
- Christoph A Tschan
- Department of Neurosurgery, Hospital Ludmillenstift, Ludmillenstr. 4-6, 49716, Meppen, Germany.
| | | | - Michael Heckelmann
- Department of Neurosurgery, Hospital Ludmillenstift, Ludmillenstr. 4-6, 49716, Meppen, Germany
| | - Sebastian Antes
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Saar, Germany
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Oertel JMK, Huelser MJM. Telemetric home monitoring of intracranial pressure-where are we now. Acta Neurochir (Wien) 2019; 161:1603-1604. [PMID: 31187266 DOI: 10.1007/s00701-019-03962-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Joachim M K Oertel
- Department of Neurosurgery, Saarland University Medical Center, Kirrbergerstrasse, Building 90.5, 66421, Homburg, Germany.
- Faculty of Medicine, Saarland University, Saarbrücken, Germany.
| | - Matthias J M Huelser
- Department of Neurosurgery, Saarland University Medical Center, Kirrbergerstrasse, Building 90.5, 66421, Homburg, Germany
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31
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Deciding on Appropriate Telemetric Intracranial Pressure Monitoring System. World Neurosurg 2019; 126:564-569. [DOI: 10.1016/j.wneu.2019.03.077] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 12/18/2022]
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Mitchell JL, Mollan SP, Vijay V, Sinclair AJ. Novel advances in monitoring and therapeutic approaches in idiopathic intracranial hypertension. Curr Opin Neurol 2019; 32:422-431. [PMID: 30865008 PMCID: PMC6522204 DOI: 10.1097/wco.0000000000000690] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The current article appraises the recent developments in idiopathic intracranial hypertension (IIH), with particular attention to novel therapeutic avenues and advanced clinical assessment and monitoring with optical coherence tomography and telemetric intracranial pressure devices. RECENT FINDINGS The incidence of IIH is increasing. The first consensus guidelines for IIH have been published detailing investigation and management algorithms for adult IIH. Improved understanding, clinical assessment and monitoring are emerging with the use of optical coherence tomography. Intracranial pressure telemetry is providing unique insights into the physiology of raised intracranial pressure in IIH. There are now an increasing number of ongoing clinical trials evaluating weight loss methods and novel targeted therapies, such as 11ß-HSD1 inhibition and Glucagon-like peptide 1 (GLP-1) receptor agonists. SUMMARY Several studies are evaluating new therapies for IIH. Monitoring techniques are advancing, aiding diagnosis and allowing the clinician to accurately evaluate changes in papilloedema and intracranial pressure.
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Affiliation(s)
- James L. Mitchell
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham
- Department of Neurology, University Hospitals Birmingham
| | | | - Vivek Vijay
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham
- Department of Neurology, University Hospitals Birmingham
| | - Alexandra J. Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, University of Birmingham
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
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Harary M, Dolmans RGF, Gormley WB. Intracranial Pressure Monitoring-Review and Avenues for Development. SENSORS (BASEL, SWITZERLAND) 2018; 18:E465. [PMID: 29401746 PMCID: PMC5855101 DOI: 10.3390/s18020465] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 01/25/2018] [Accepted: 02/01/2018] [Indexed: 12/27/2022]
Abstract
Intracranial pressure (ICP) monitoring is a staple of neurocritical care. The most commonly used current methods of monitoring in the acute setting include fluid-based systems, implantable transducers and Doppler ultrasonography. It is well established that management of elevated ICP is critical for clinical outcomes. However, numerous studies show that current methods of ICP monitoring cannot reliably define the limit of the brain's intrinsic compensatory capacity to manage increases in pressure, which would allow for proactive ICP management. Current work in the field hopes to address this gap by harnessing live-streaming ICP pressure-wave data and a multimodal integration with other physiologic measures. Additionally, there is continued development of non-invasive ICP monitoring methods for use in specific clinical scenarios.
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Affiliation(s)
- Maya Harary
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Rianne G F Dolmans
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
- Department of Neurosurgery, University Medical Center, 3584 CS Utrecht, The Netherlands.
| | - William B Gormley
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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