Complications in Ventricular Cerebrospinal Fluid Shunting

Chronic Pleural Effusion in Ventriculoperitoneal Shunt due to Diaphragmatic CSF Fistula: Report of a Case Treated by Endoscopic Choroid Plexus Coagulation and Literature Review

INTRODUCTION

Chronic pleural cerebrospinal fluid (CSF) effusion is a rare complication after ventriculoperitoneal (VP) shunt insertion and only 18 cases in children and adults have been described so far without catheter dislocation to the intrathoracic cavity.

CASE PRESENTATION

We report on a 4-year-old girl with a complex history of underlying neurogenetic disorder, a hypoxic-ischemic encephalopathy after influenza A infection with septic shock and severe acute respiratory distress syndrome, followed by meningitis at the age of 10 months. In consequence, she developed a severe cerebral atrophy and post-meningitic hydrocephalus requiring placement of a VP shunt. At age 4, she was admitted with community-acquired mycoplasma pneumonia and developed increasing pleural effusions leading to severe respiratory distress and requiring continuous chest tube drainage (up to 1,000-1,400 mL/day) that could not be weaned. β trace protein, in CSF present at concentrations >6 mg/L, was found in the pleural fluid at low concentrations of 2.7 mg/L. An abdomino-thoracic CSF fistula was finally proven by single photon emission computerized tomography combined with low-dose computer tomography. After shunt externalization, the pleural effusion stopped and the chest tube was removed. CSF production rate remains high above 500 mL/24 h. An atrial CSF shunt could not be placed, since a hemodynamically relevant atrial septum defect with frail circulatory balance would not have tolerated the large CSF volumes. Therefore, she underwent a total bilateral endoscopic choroid plexus laser coagulation (CPC) within the lateral ventricles via bi-occipital burr holes. Postoperatively CSF production rate went close to 0 mL and after external ventricular drain removal no signs and symptoms of hydrocephalus developed during a follow-up of now 2.5 years.

CONCLUSION

In summary, pleural effusions in patients with VP shunt can rarely be caused by an abdomino-thoracic fistula, with non-elevated β-trace protein in the pleural fluid. The majority of reported cases in literature were treated by ventriculoatrial shunt. This is the 2nd reported case, which has been successfully treated by radical CPC alone including the temporal horn choroid plexus, making the child shunt independent.

Predictors and Outcome of Ventriculoperitoneal Shunt Infection: A Retrospective Single-Center Study

Background:Shunt infection critically affects approximately 8-10% of all inserted shunts, leading to significant morbidity and mortality. This study aimed to assess the clinical and laboratory factors associated with shunt infection and outcomes in patients treated for hydrocephalus.

Methods: A retrospective study was performed on patients who underwent ventriculoperitoneal shunt (VPS) surgery for hydrocephalus between January 2015 and June 2018. The primary outcome was the development of shunt infection following VPS surgery. Records were reviewed, and variables were analyzed, including patients' demographics, perioperative laboratory and shunt data, and outcomes. The patients had five years of follow-up from surgery, including a minimum of two years from the onset of VPS infection.

Results:A total of 132 shunts were inserted in 103 patients with a mean age of 2 years (range; 2 days to 73 years), and 53.4% were males. Twenty-two patients were suspected of having VPS infection (16.7% per procedure); only six (4.5%) had positive cerebrospinal fluid (CSF) detected organisms. Patients with preoperative hemoglobin, white blood cells, and serum glucose within normal values had a lower shunt infection rate. The pediatric population had an elevated risk of VPS infection, particularly those who underwent surgery at a younger age than 7.5 months, weighed less than 10 Kg, and were associated with myelomeningocele. in addition, a shorter surgery time of less than 82 min, single surgeon, and operating room of fewer than four attendees are associated with lower risk of VPS infection.

Conclusion:We emphasize that early identification and modifications of the risk factors can minimize the probability of developing VPS infection and improve patients outcome.

Intrathecal Injection of Tigecycline and Polymyxin B in the Treatment of Extensively Drug-Resistant Intracranial Acinetobacter baumannii Infection: A Case Report and Review of the Literature

Purpose

Intracranial infection after neurosurgery is one of the most serious complications, especially extensively drug-resistant (XDR) Acinetobacter baumannii (A. baumannii) seriously affects the prognosis of patients. At present, there is little experience in the treatment of this infection and limited effective treatment options, like tigecycline or polymyxin B. Therefore, this report aims to describe the efficacy of tigecycline combined with polymyxin B by intrathecal (ITH) injection in the treatment of XDR intracranial infection with A. baumannii.

Methods

We report a case of intracranial infection with XDR A. baumannii after ventricular drainage, treated by daily ITH and intravenous (IV) tigecycline, combined with polymyxin B ITH route. Moreover, tigecycline and polymyxin B treatments for XDR intracranial infection with A. baumannii that were reported in the literature were also reviewed and summarized.

Results

The white blood cells (WBCs) of the patient’s cerebrospinal fluid dropped to normal, and the symptoms of intracranial infection disappeared. The patient finally obtained good clinical results and transferred to the local hospital.

Conclusion

The polymyxin B ITH route is an ideal treatment strategy for XDR A. baumannii. The IV plus ITH tigecycline may be an effective treatment option. However, more researches should be conducted to confirm our observation.

Development of an In Vitro Hemorrhagic Hydrocephalus Model for Functional Evaluation of Magnetic Microactuators Against Shunt Obstructions

OBJECTIVE

Occlusion of ventriculoperitoneal shunts placed after intraventricular hemorrhage occurs frequently. The objective of this study was to develop a hemorrhagic hydrocephalus model to assess the ability of an oscillating microactuator within the ventricular catheter (VC) to prevent shunt obstruction.

METHODS

An in vitro hydrocephalus model with extreme risk of shunt obstruction was created. Phosphate-buffered saline, blood, and thrombin were driven through ventriculoperitoneal shunts for 8 hours. Five VCs were fitted with a microactuator and compared with 5 control VCs. The microactuator was actuated by an external magnetic field for 30 minutes. Pressure within the imitation lateral ventricle was measured.

RESULTS

In the 5 control shunts, 6 obstructions developed (3 VC, 3 valve-distal catheter) compared with 1 obstruction (VC) in the 5 microactuator shunts. In the control and microactuator groups, the median volume exiting the shunts in 8 hours was 30 mL versus 256 mL. Median time to reach an intraventricular pressure of 40 mm Hg (13.8 minutes vs. >8 hours), median total time >40 mm Hg (6.2 hours vs. 0.0 hours), and median maximum pressure (192 mm Hg vs. 36 mm Hg) were significantly improved in the microactuator group (P < 0.01).

CONCLUSIONS

In addition to protecting the VC, the microactuator appeared to prevent hematoma obstructing the valve or distal catheter, resulting in a much longer duration of low intraventricular pressures. A microactuator activated by placing the patient's head in an external magnetic field could reduce shunt obstructions in hemorrhagic hydrocephalus.

Idiopathic Intracranial Hypertension following Ventriculoperitoneal Shunt Malfunction in Infant Hydrocephalus

<p>Idiopathic intracranial hypertension (IIH) is a syndrome defined by elevated intracranial pressure without any abnormal findings. In the present study, we report a rare case of IIH in a patient after ventriculoperitoneal shunt (VPS) due to infant hydrocephalus. A 13-year-old girl with a history of VPS due to infant hydrocephalus was admitted to emergency room with the complaint of severe headache and visual disturbance. Brain computed tomography showed normal findings. However, based on the measurement by lumbar puncture, her cerebrospinal fluid (CSF) pressure was observed to be very high. The shunt function test revealed a VPS malfunction. Thus, we conducted VPS revision in this patient. All symptoms improved immediately after the revision. Thus, it is proposed that IIH should be considered for patients with visual disturbance and severe headache after VPS due to infant hydrocephalus without ventriculomegaly.

Fatal ventriculoperitoneal shunt occlusions diagnosed at autopsy

The placement of a ventriculoperitoneal (VP) shunt is frequently used in the management of chronic hydrocephalus. Failure of the shunt may occur due to physical obstruction, which is a recognized complication. Autopsy examination of deceased individuals with chronic disability is often not performed, which contributes to the difficulty in determining the frequency of mortality from VP shunts. Examination, when it does occur, should focus on the patency and positioning of the shunt, and this evaluation is especially important when the cause of death is poorly defined. In this report, we describe two cases of death caused by obstruction of VP shunts documented at autopsy. The first death was determined to be secondary to cerebellar edema with uncal and tonsillar herniation after posterior left VP shunt occlusion. The second was due to VP shunt occlusion resulting in diffuse cerebral edema and ventricular enlargement with compression and hemorrhage of the cerebellar tonsils and medulla.

Abdominal pseudocysts, an unusual complication of ventriculoperitoneal shunt systems: Literature systematic review

Since the first report in 1954, abdominal pseudocysts have been recognized as a particularly uncommon complication of ventriculoperitoneal shunts of CSF, so their etiology, diagnosis, and therapeutic management remain very controversial. Our objective is to offer a critical and updated systematic review of those controversial points, using a thorough search and review of the most relevant literature available. The clinical presentation of pseudocysts is normally through non-specific abdominal symptoms. The most validated etiology consists on the existence of a concomitant infection of the CSF shunt system, and so, treatment needs of antibiotherapy and total or partial substitution of the system. However, the pseudocyst itself doesn't need an active treatment, except for some specific cases. This management, algorithmically presented in the present work, achieves a lower recurrence rate than other options, but this one is still important, and is also associated with other complications of those shunts related with several other factors which need to be taken in account.

Survival and failure trends of cerebrospinal fluid shunts with distal slit valves: comparative study and literature review

OBJECTIVE

The malfunction rates of and trends in various cerebrospinal fluid (CSF) shunt designs have been widely studied, but one area that has received little attention is the comparison of the peritoneal distal slit valve (DSV) shunt to other conventional valve (CV) type shunts. The literature that does exist comes from older case series that provide only indirect comparisons, and the conclusions are mixed. Here, the authors provide a direct comparison of the overall survival and failure trends of DSV shunts to those of other valve type shunts.

METHODS

Three hundred seventy-two new CSF shunts were placed in pediatric patients at the authors' institution between January 2011 and December 2015. Only ventriculoperitoneal (VP) shunts were eligible for study inclusion. Ventriculoatrial, lumboperitoneal, cystoperitoneal, subdural-peritoneal, and spinal shunts were all excluded. Rates and patterns of shunt malfunction were compared, and survival curves were generated. Patterns of failure were categorized as proximal failure, distal failure, simultaneous proximal and distal (proximal+distal) failure, removal for infection, externalization for abdominal pseudocyst, and addition of a ventricular catheter for loculated hydrocephalus.

RESULTS

A total of 232 VP shunts were included in the final analysis, 115 DSV shunts and 117 CV shunts. There was no difference in the overall failure rate or time to failure between the two groups, and the follow-up period was statistically similar between the groups. The DSV group had a failure rate of 54% and a mean time to failure of 17.8 months. The CV group had a failure rate of 50% (p = 0.50) and a mean time to failure of 18.5 months (p = 0.56). The overall shunt survival curves for these two groups were similar; however, the location of failure was significantly different between the two groups. Shunts with DSVs had proportionately more distal failures than the CV group (34% vs 14%, respectively, p = 0.009). DSV shunts were also found to have proximal+distal catheter occlusions more frequently than CV shunts (23% vs 5%, respectively, p = 0.005). CV shunts were found to have significantly more proximal failures than the DSV shunts (53% vs 27%, p = 0.028). However, the only failure type that carried a statistically significant adjusted hazard ratio in a multivariate analysis was proximal+distal catheter obstruction (CV vs DSV shunt: HR 0.21, 95% CI 0.05-0.81).

CONCLUSIONS

There appears to be a difference in the location of catheter obstruction leading to the malfunction of shunts with DSVs compared to shunts with CVs; however, overall shunt survival is similar between the two. These failure types are also affected by other factors such etiology of hydrocephalus and endoscope use. The implications of these findings are unclear, and this topic warrants further investigation.

Evaluation of an in vivo model for ventricular shunt infection: a pilot study using a novel antimicrobial-loaded polymer

OBJECTIVE

Ventricular shunt infection remains an issue leading to high patient morbidity and cost, warranting further investigation. The authors sought to create an animal model of shunt infection that could be used to evaluate possible catheter modifications and innovations.

METHODS

Three dogs underwent bilateral ventricular catheter implantation and inoculation with methicillin-sensitive Staphylococcus aureus (S. aureus). In 2 experimental animals, the catheters were modified with a polymer containing chemical "pockets" loaded with vancomycin. In 1 control animal, the catheters were polymer coated but without antibiotics. Animals were monitored for 9 to 11 days, after which the shunts were explanted. MRI was performed after shunt implantation and prior to catheter harvest. The catheters were sonicated prior to microbiological culture and also evaluated by electron microscopy. The animals' brains were evaluated for histopathology.

RESULTS

All animals underwent successful catheter implantation. The animals developed superficial wound infections, but no neurological deficits. Imaging demonstrated ventriculitis and cerebral edema. Harvested catheters from the control animal demonstrated > 104 colony-forming units (CFUs) of S. aureus. In the first experimental animal, one shunt demonstrated > 104 CFUs of S. aureus, but the other demonstrated no growth. In the second experimental animal, one catheter demonstrated no growth, and the other grew trace S. aureus. Brain histopathology revealed acute inflammation and ventriculitis in all animals, which was more severe in the control.

CONCLUSIONS

The authors evaluated an animal model of ventricular shunting and reliably induced features of shunt infection that could be microbiologically quantified. With this model, investigation of pathophysiological and imaging correlates of infection and potentially beneficial shunt catheter modifications is possible.

Infection risk for Bactiseal Universal Shunts versus Chhabra shunts in Ugandan infants: a randomized controlled trial

OBJECTIVE Clinical and economic repercussions of ventricular shunt infections are magnified in low-resource countries. The efficacy of antibiotic-impregnated shunts in this setting is unclear. A previous retrospective cohort study comparing the Bactiseal Universal Shunt (BUS) and the Chhabra shunt provided clinical equipoise; thus, the authors conducted this larger randomized controlled trial in Ugandan children requiring shunt placement for hydrocephalus to determine whether there was, in fact, any advantage of one shunt over the other. METHODS Between April 2013 and September 2016, the authors randomly assigned children younger than 16 years of age without evidence of ventriculitis to either BUS or Chhabra shunt implantation in this single-blind randomized controlled trial. The primary outcome was shunt infection, and secondary outcomes included reoperation and death. The minimum follow-up was 6 months. Time to outcome was assessed using the Kaplan-Meier method. The significance of differences was tested using Wilcoxon rank-sum, chi-square, Fisher’s exact, and t-tests. RESULTS Of the 248 patients randomized, the BUS was implanted in 124 and the Chhabra shunt in 124. There were no differences between the groups in terms of age, sex, or hydrocephalus etiology. Within 6 months of follow-up, there were 14 infections (5.6%): 6 BUS (4.8%) and 8 Chhabra (6.5%; p = 0.58). There were 14 deaths (5.6%; 5 BUS [4.0%] vs 9 Chhabra [7.3%], p = 0.27) and 30 reoperations (12.1%; 15 BUS vs 15 Chhabra, p = 1.00). There were no significant differences in the time to primary or secondary outcomes at 6 months’ follow-up (p = 0.29 and 0.17, respectively, Wilcoxon rank-sum test). CONCLUSIONS Among Ugandan infants, BUS implantation did not result in a lower incidence of shunt infection or other complications. Any recommendation for a more costly standard of care in low-resource countries must have contextually relevant, evidence-based support. Clinical trial registration no.: PACTR201804003240177 (http://www.pactr.org/)

Risk Factors of Delayed Intracranial Hemorrhage Following Ventriculoperitoneal Shunt

Objective

Placement of a ventriculoperitoneal (VP) shunt is a common neurosurgical procedure for cerebrospinal fluid diversion. A rare complication is delayed intracranial hemorrhage (ICH) secondary to VP shunting, and only a few patients with this complication have been reported. We investigate the incidence and risk factors of delayed ICH development following VP shunt placement.

Methods

Over an 11-year period, 167 patients received a VP shunt for hydrocephalus, and of these, 138 patients were eligible for this study. All medical records and computed tomography scans obtained within 48 h after the operation and at postoperative day 7 were reviewed. The risk factors of developing delayed ICH (≥48 hr after VP shunt placement) were analyzed according to the demographic data, including sex and age, original intracranial lesions, co-morbid diseases, and laboratory findings.

Results

Delayed ICH following VP shunt placement developed in 34 (24.6%) of the 138 patients. Risk factors for developing delayed ICH were age (p=0.037) and the partial thromboplastin time (PTT) (p=0.032). Intraventricular hemorrhage after VP shunting was the most common complication, occurring in 16 cases. Hemorrhagic volume was <1 mL in 28 cases and >1 mL in 6 cases.

Conclusion

This study suggests that old age and delayed PTT are major risk factors for developing delayed ICH following VP shunting. Additionally, delayed ICH after VP shunting commonly occurs even when most patients are asymptomatic. Therefore, extra care should be taken to observe and follow-up with patients who have undergone VP shunt placement.

Relationship between the location of the ventricular catheter tip and the ventriculoperitoneal shunt malfunction

OBJECTIVE

Ventriculoperitoneal (VP) shunt is the most common neurosurgical procedure to treat obstructive and communicating hydrocephalus, but failures are frequent. The most common causes of shunt failure are malpositioning and obstruction of the ventricular catheter by debris or blood clothes. The knowledge of the relationship between ventricular catheter tip position, etiology of hydrocephalus and patient's age with shunt malfunction may be useful to avoid shunt failure.

PATIENTS AND METHODS

We retrospectively analyze 89 adult patients affected by obstructive and communicating hydrocephalus operated with Ventriculoperitoneal shunt at our Institute. Patients with evident abdominal shunt malfunction were excluded from this study. Statistical analysis was performed in the group of patients with intracranial catheter malfunction in order to correlate shunt malfunction with the position of the catheter tip in brain ventricles, etiology of hydrocephalus and patient's age.

RESULTS

Shunt revision was performed in 26 patients out of 89 and cranial catheter malfunction was documented in 11 patients out of 26. Tip position in Monro foramen, lateral ventricles and third ventricle ("good position") had a lower rate of surgical shunt revision compared to septum pellucidum and wall of lateral ventricle ("bad position") p value = 0,049. No statistical significant association was observed between shunt malfunction and etiology of the hydrocephalus or patient's age.

CONCLUSIONS

Ventricular catheter tip position is one the most important factor for shunt function.

Shunt Devices for Neurointensivists: Complications and Management

Cerebrospinal fluid diversion has become the mainstay treatment in hydrocephalus for over 50 years. As the number of patients with ventricular shunt systems increases, neurointensivists are becoming the first-line physicians for many of these patients. When symptoms of a shunt malfunction are suspected and access to a neurosurgeon is limited or delayed, workup and temporizing measures must be initiated. The article highlights the functional nuances, complications, and management of current programmable shunt valves and their MRI sensitivity.

Use of CSF infusion studies to unblock occluded hydrocephalus ventricular shunt catheters: a preliminary report of two patients

Two patients with ventriculoperitoneal shunts presented with symptoms of raised intracranial pressure indicative of possible shunt malfunction. During investigation, to eliminate this possibility, cerebral spinal fluid infusion studies were performed, which indicated proximal occlusion of the shunts in both cases. Retrograde flush of the ventricular catheter was performed during temporary compression of the siphon-control device, a manoeuvre which blocks distal flow. After the use of this technique, both patients' symptoms improved and they have remained symptom-free for over 2 years. This case report validates the role that infusion studies can play in clearing a blocked ventricular catheter shunt.

Controversy about Management of Hydrocephalus - Shunt vs. Endoscopic Third Ventriculostomy

The best management of hydrocephalus is still controversial in the twenty-first century. Shunt treatment for hydrocephalus is the most common procedure performed in neurosurgical practice and is associated with the highest complications rate. But during the last 2 decades, the treatment of hydrocephalus has improved with better shunt devices available today, increased facilities for investigations and newer approaches like endoscopic third ventriculostomy. The recent advances in development of better endoscopes have provided the patient and treating doctor with an option for an alternative surgery for treatment of hydrocephalus.

Intracranial Perishunt Catheter Fluid Collections with Edema, a Sign of Shunt Malfunction: Correlation of CT/MRI and Nuclear Medicine Findings

Fluid collections with edema along the intracranial tract of ventriculoperitoneal shunt catheters in adults are rare and are more frequently seen in children. The imaging appearance of these fluid collections is frequently confusing and presents a diagnostic dilemma. We present 6 cases of adult patients noted to have collections with edema along the tract of ventriculoperitoneal shunt catheters. To our knowledge, there are no previous studies correlating the CT/MR imaging findings with nuclear medicine scans in this entity. We hypothesized that when seen in adults, the imaging findings of a CSF-like fluid collection around the intracranial ventriculoperitoneal shunt catheter on CT/MR imaging may suggest areas of CSF accumulation with interstitial edema. It is important to recognize this rare ventriculoperitoneal shunt complication in adults to prevent misdiagnosis of an abscess or cystic tumor.

Vaginal Extrusion of a Ventriculoperitoneal Shunt: A Case Report and Review of Literature

BACKGROUND

Ventriculoperitoneal shunting is the most common treatment for hydrocephalus (excessive cerebrospinal fluid accumulation in the brain), but has the potential for serious complications such as shunt migration. Potential migration sites include the lateral ventricle mediastinum, gastrointestinal tract, abdominal wall, bladder, vagina, and scrotum.

CASE

Here, we present a rare case of vaginal extrusion of a ventriculoperitoneal shunt.

SUMMARY AND CONCLUSION

Neurosurgeons and gynecologists should be aware of the potential occurrence of this rare complication.

Ventriculostomy-related infections in subarachnoid hemorrhage patients-a retrospective study of incidence, etiology, and antimicrobial therapy

BACKGROUND

This study was performed to investigate the incidence and etiology of ventriculostomy-related infections (VRIs) in patients with subarachnoid hemorrhage (SAH) and to assess adherence to local clinical guidelines regarding empirical antimicrobial therapy and diagnostic routines.

METHODS

A total of 191 consecutive SAH patients treated in the neuro-intensive care unit of Uppsala University Hospital between 2010 and 2013 were included retrospectively. Information regarding cerebrospinal fluid samples, bacterial cultures, ventriculostomy treatment, patient characteristics, and antibiotic treatment were collected from electronic patient records.

RESULTS

Eleven patients developed VRI, resulting in an incidence of 5.8% per patient, 5.4% per ventriculostomy catheter, and 4.1 per 1000 catheter days. Coagulase-negative staphylococci caused nine cases of VRI and Klebsiella pneumoniae and Staphylococcus aureus caused one each. Empirical VRI therapy was initiated on 97 occasions in 81 subjects (42.4%). Out of the 11 patients with VRI, four did not receive empirical antibiotic therapy before the positive culture result. The clinical actions performed after analysis of CSF samples were in line with the action suggested by the local guidelines in 307 out of 592 cases (51.9%).

CONCLUSIONS

The incidence of VRI in our cohort was comparable to what has previously been reported. Coagulase-negative staphylococci was the most common agent. Our study demonstrates the difficulty in diagnosing VRI in SAH patients. Improved adherence to clinical guidelines could to some extent reduce the use of empirical antibiotic treatment, but better diagnostic methods and routines are needed.

Ventriculoatrial Shunts in Adults, Incidence of Infection, and Significant Risk Factors: A Single-Center Experience

BACKGROUND

In recent years, the number of ventriculoatrial (VA) shunt insertions has decreased worldwide, the major cause being the risk of shunt infection. VA shunts remain as an alternative option to ventriculoperitoneal shunts. We describe our 10-year experience with VA shunts by analyzing the incidence of shunt infections and predisposing cofactors.

METHODS

During a median follow-up of 15.3 months, 259 shunt insertions, performed on 255 patients, were analyzed. The infection rate was calculated and the predisposing cofactors age, gender, cause of the hydrocephalus, previous external ventricle drainage, antibiotic-impregnated catheters, the number of revisions, the educational level of the surgeons, and the duration of the operations were analyzed. Two observation times were stratified.

RESULTS

We found overall infections in 18 patients (7.1%), 16 deep infections (6.3%) including 1 shunt nephritis (0.4%) and 2 superficial infections (0.8%). Wound dehiscence occurred in 17 patients (6. 6%). Analyzing follow-up time, the infection rate was 3.65% (95% confidence interval, 0.9%-5.9%) at survival time 1, 3.38% (95% confidence interval, 1.1%-6.2%) at survival time 2. In the first 6 months, 95% of patients were free of infection. Only the number of revision procedures was associated with the number of infections (P value < 0.0005).

CONCLUSIONS

In our patient cohort, the infection rate related to VA shunt insertion is low; the only statistically significant risk factor was the number of revisions. If the VA shunt is applied following a standardized protocol, the infection risk does not represent an argument for reluctance towards the VA draining concept.

Outcomes in meningitis/ventriculitis treated with intravenous or intraventricular plus intravenous colistin

BACKGROUND

The aim of this work is to evaluate the outcome of patients treated with intrathecal colistin for meningitis/ventriculitis.

METHODS

This retrospective case series study included patients presenting with nosocomial meningitis/ventriculitis following neurosurgical interventions and having intravenous (IVC group) or intravenous and intrathecal/intraventricular colistin (ITC group) treatment between 2006 and 2014.

RESULTS

Thirty-four patients presented nosocomial meningitis/ventriculitis; 11 (32.5 %) were included in the IVC group and 23 (67.6 %) in the ITC group. The most frequent isolated bacteria were Acinetobacter baumannii. The mean dose was 170,000 (±400) IU and the duration of intraventricular treatment was 16.0 (±8.3) days. The duration of intravenous treatment was 16.0 (±8.3) days in the ITC group and 15.3 ± 7.6 days in IVC group. Hospital mortality was significantly lower in the ITC group compared with the IVC group (13 vs. 72.7 %, p = 0.001).

CONCLUSIONS

The combination of intravenous plus intraventricular (IV-IVT) colistin therapy may improve outcomes in patients attending with meningitis/ventriculitis due to multi-drug resistance infections.

A case of breast cancer involving a ventriculoperitoneal shunt

An 84-year-old woman was examined for an enlargement of an induration in the left breast. A ventriculoperitoneal shunt had been placed for postoperative normal pressure hydrocephalus of a cerebral hemorrhage, and it had penetrated the mass according to the computed tomography findings. Breast cancer was diagnosed after a close examination; however, close observation was selected because her family rejected treatment. She developed somnolence 7 months after the initial examination, and ventricular dilatation and expansion of the low-density region around the ventricle were noted on computed tomography, suggesting that the enlarged tumor had excluded the shunt and caused obstruction. The growth of breast carcinoma involving a shunt tube can be the cause of obstruction of a ventriculoperitoneal shunt. Our findings suggest that a breast lesion should be evaluated at both pre- and postoperation.

Cross-sectional imaging of thoracic and abdominal complications of cerebrospinal fluid shunt catheters

This study aims to review the imaging findings of distal (thoracic and abdominal) complications related to ventriculo-peritoneal (VP), ventriculo-pleural (VPL), and ventriculo-atrial (VA) cerebrospinal fluid (CSF) shunt catheter placement. Institution review board-approved single-center study of patients with thoracic and abdominal CSF catheter-related complications on cross-sectional imaging examinations over a 14-year period was performed. Clinical presentation, patient demographics, prior medical history, and subsequent surgical treatment were recorded. The presence or absence of CSF catheter-related infection and/or acute hydrocephalus on cross-sectional imaging was also recorded. There were 81 distal CSF catheter-related complications identified on 47 thoracic or abdominal imaging examinations in 30 patients (age 5-80 years, mean 39.3 years), most often on CT (CT = 42, MRI = 1, US = 4). Complications included 38 intraperitoneal and 11 extraperitoneal fluid collections. Extraperitoneal collections included nine abdominal wall subcutaneous (SC) pseudocysts associated with shunt migration and obesity, an intrapleural pseudocyst, and a breast pseudocyst. There were also two large VPL-related pleural effusions, a fractured catheter in the SC tissues, and a large VA shunt thrombus within the right atrium. Ten patients (33.3 %) had culture-positive infection from CSF or shunt catheter samples. Ten patients (33.3 %) had features of temporally related acute or worsening hydrocephalus on neuroimaging. In four of these patients, the detection of thoracic and abdominal complications on CT preceded and predicted the findings of acute hydrocephalus on cranial imaging. Thoracic and abdominal complications of CSF shunts, as can be identified on CT, include shunt infection and/or obstruction, may be both multiple and recurrent, and may be predictive of concurrent acute intracranial problems.

Fabrication of three-dimensional hydrogel scaffolds for modeling shunt failure by tissue obstruction in hydrocephalus

Background

Shunt obstruction in the treatment of hydrocephalus is poorly understood, is multi-factorial, and in many cases is modeled ineffectively. Several mechanisms may be responsible, one of which involves shunt infiltration by reactive cells from the brain parenchyma. This has not been modeled in culture and cannot be consistently examined in vivo without a large sample size.

Methods

We have developed and tested a three-dimensional in vitro model of astrocyte migration and proliferation around clinical grade ventricular catheters and into catheter holes that mimics the development of cellular outgrowth from the parenchyma that may contribute to shunt obstruction.

Results

Cell attachment and growth was observed on shunt catheters for as long as 80 days with at least 77 % viability until 51 days. The model can be used to study cellular attachment to ventricular catheters under both static and pulsatile flow conditions, which better mimic physiological cerebrospinal fluid dynamics and shunt system flow rates (0.25 mL/min, 100 pulses/min). Pulsatile flow through the ventricular catheter decreased cell attachment/growth by 63 % after 18 h. Under both conditions it was possible to observe cells accumulating around and in shunt catheter holes.

Conclusions

Alone or in combination with previously-published culture models of shunt obstruction, this model serves as a relevant test bed to analyze mechanisms of shunt failure and to test catheter modifications that will prevent cell attachment and growth.

Comparative effectiveness of antibiotic-impregnated shunt catheters in the treatment of adult and pediatric hydrocephalus: analysis of 12,589 consecutive cases from 287 US hospital systems

OBJECT

The real-world effectiveness of antibiotic-impregnated shunt catheters to reduce the incidence of shunt infections is still debated. The literature to date consists mostly of small, single-institution studies. The aim of this study was to assess the incidence of infection for antibiotic-impregnated catheters (AICs) versus standard shunt catheters in a large nationwide administrative database.

METHODS

The authors retrospectively reviewed hospital discharge and billing records from the Premier Perspective Database from April 2003 to July 2009 to identify all adult and pediatric patients undergoing de novo ventricular shunt placement. The primary end point was the incidence of shunt infection within 1 year of implantation. Multivariate logistical regression was performed to determine factors associated with increased incidence of infection.

RESULTS

A total of 10,819 adult (AIC, 963; standard catheter, 9856) and 1770 pediatric (AIC, 229; standard catheter, 1541) patients underwent ventricular shunt placement in 287 US hospitals. Overall, the incidence of infection was 3.5% in adults (n=380) and 6.6% in pediatric patients (n=116). AICs were associated with significant reduction in infection for both adult (2.2% vs 3.6%, p=0.02) and pediatric (2.6% vs 7.1%, p<0.01) patients. AIC use was associated with reduced infection regardless of hospital size, annual shunt volume, hospital location, or patient risk factors and remained associated with a reduced infection in multivariate analysis for both adult (p=0.02) and pediatric (p=0.02) patients.

CONCLUSIONS

The use of antibiotic-impregnated shunt catheters was associated with a reduction in shunt infections for both adult and pediatric patients. This provides further support that AICs may represent a reliable means of reducing shunt infections for both adult and pediatric patients.

Cost savings associated with antibiotic-impregnated shunt catheters in the treatment of adult and pediatric hydrocephalus

BACKGROUND

Cerebrospinal fluid (CSF) shunt infection is a major cause of morbidity and mortality in the treatment of hydrocephalus and is associated with significant medical cost. Several studies have demonstrated the efficacy of antibiotic-impregnated (AI) shunt catheters in reducing CSF shunt infection; however, providers remain reluctant to adopt AI catheters into practice because of the increased upfront cost. The objective of this study was to determine if the use of AI catheters provided cost savings in a large nationwide database.

METHODS

Hospital discharge and billing records from the Premier Perspective Database from 2003-2009 were retrospectively reviewed to identify all adult and pediatric patients undergoing de novo ventricular shunt placement. The incidence of shunt infection within 1 year of implantation was determined. Shunt infection-related cost was defined as all inpatient billing costs incurred during hospitalization for treatment of shunt infection.

RESULTS

In 287 U.S. hospitals, 10,819 adult (AI catheters, 963; standard catheters, 9856) and 1770 pediatric (AI catheters, 229; standard catheters, 1541) patients underwent ventricular shunt placement. AI catheters were associated with significant reduction in infection for both adult (2.2% vs. 3.6%, P = 0.02) and pediatric (2.6% vs. 7.1%, P < 0.01) patients. Total infection-related costs were $17,371,320 ($45,714 ± $49,745 per shunt infection) for adult patients and $6,508,064 ($56,104 ± $65,746 per shunt infection) for pediatric patients. Infection-related cost per 100 de novo shunts placed was $120,534 for AI catheters and $162,659 for standard catheters in adult patients and $165,087 for AI catheters and $395,477 for standard catheters in pediatric patients.

CONCLUSIONS

In analysis of this large, nationwide database, AI catheters were found to be associated with a significant reduction in infection incidence, resulting in tremendous cost savings. AI catheters were associated with a cost savings of $42,125 and $230,390 per 100 de novo shunts placed in adult and pediatric patients, respectively.

Effect of antibiotic-impregnated shunts on infection rate in adult hydrocephalus: a single institution's experience

BACKGROUND

Cerebrospinal fluid (CSF) shunt infection remains a major cause of morbidity and mortality in the treatment of hydrocephalus. Studies have demonstrated the efficacy of antibiotic-impregnated shunt (AIS) systems in reducing CSF shunt infections in pediatric patients. Fewer studies evaluate the efficacy of AIS systems in adult hydrocephalus.

OBJECTIVE

: To determine whether categorical conversion to AIS shunt systems reduced the incidence of shunt infection in adults.

METHODS

All adult patients undergoing CSF shunt insertion over a 7-year period were retrospectively reviewed (2004-2009). In 2006, a categorical switch to AIS catheters was made. Before 2006, standard nonimpregnated shunt catheters were used. We retrospectively reviewed the first 250 cases of AIS catheter implantation and compared them with the immediately preceding 250 non-AIS cases to assess 1-year incidence of CSF shunt infection.

RESULTS

Five hundred shunt surgeries were performed for normal-pressure hydrocephalus in 378 patients (76%), pseudotumor cerebri in 83 patients (17%), and various obstructive/communicating hydrocephalus etiologies in 40 patients (8%). All patients were followed for 12 months. The mean age was 60 ± 18 years. Baseline characteristics were similar between AIS (n = 250) and non-AIS (n = 250) cohorts. Overall, 13 patients (2.6%) experienced CSF shunt infection, occurring a mean of 2 ± 2 months postoperatively. Shunt infection incidence was decreased in AIS (1.2%) vs non-AIS (4.0%) cohorts (P = .0492). Staphylococcus epidermidis was the most common pathogen in AIS and non-AIS cohorts. Oxacillin resistance was not increased in the AIS cohort.

CONCLUSION

Categorical conversion to AIS catheters was associated with a reduced incidence of shunt infection. AIS catheters may be a reliable instrument for decreasing perioperative shunt colonization and subsequent infection in adults with hydrocephalus.

Imaging diagnosis--Ventriculo-peritoneal shunt associated infection in a dog

Ventriculo-peritoneal shunting is a surgical treatment for hydrocephalus. Complications of this procedure are not well described in dogs. The most common complication in humans is infection, which can be fatal if not diagnosed and treated quickly. We describe the magnetic resonance (MR) imaging characteristics of a shunt-associated cerebral infection in a dog. The MR features of the infection included hyperintensity of the lining of the ventricular system visible on a T2-weighted FLAIR sequence and marked linear contrast enhancement of the ependymal layer on T1-weighted sequences, similar to that described in people.

Antibiotic-impregnated catheters for the prevention of CSF shunt infections: a systematic review and meta-analysis

CSF infections are a serious complication of CSF shunts and external ventricular drains (EVDs). Antibiotic-impregnated catheters (AIC) have been tried in order to minimise the risk of such infections.

OBJECTIVES

To conduct a systematic review and a meta-analysis comparing AICs versus non-AICs used as ventriculo-peritoneal (VP) shunts or external ventricular drains (EVDs) in the neonatal population. The secondary aim was to include data from a paediatric and adult population if insufficient information was available from neonatal studies.

DATA SOURCES

PubMed (March 2011), EMBASE (March 2011), CENTRAL (1980-March 2011), and CINAHL (March 2011) were searched. Study selection. Both randomised controlled trials (RCTs) and observational studies were included.

RESULTS

Only three observational studies reported on the use of AI-VP shunt catheters in the neonatal population. Meta-analysis found a statistically significant difference favouring AI shunts (RR: 0.37; CI: 0.16, 0.86; p = 0.02). Twelve studies (one RCT, 11 observational; n = 3284) compared AI versus non-AI VP shunts in a paediatric and adult population. The RCT showed a trend towards benefit using the AICs (RR: 0.38; 95% CI: 0.11, 1.30; p = 0.12). A meta-analysis of the 11 observational studies showed a significant benefit in the AI group (RR: 0.37; CI: 0.23, 0.60; p = 0.0001; n = 3149). Similar benefits were noted for AI-EVDs in RCTs (RR: 0.19; 95% CI: 0.05, 0.64; p = 0.01; n = 472, two studies) and observational studies (RR: 0.31; 95 CI: 0.13, 0.74; p = 0.009; n = 2415, five studies).

CONCLUSIONS

A meta-analysis of mainly observational studies suggests that AICs may be an effective way of reducing the incidence of shunt and EVD infections. Well-designed multi-centre RCTs are urgently needed.

Benign external hydrocephalus: a review, with emphasis on management

Benign external hydrocephalus in infants, characterized by macrocephaly and typical neuroimaging findings, is considered as a self-limiting condition and is therefore rarely treated. This review concerns all aspects of this condition: etiology, neuroimaging, symptoms and clinical findings, treatment, and outcome, with emphasis on management. The review is based on a systematic search in the Pubmed and Web of Science databases. The search covered various forms of hydrocephalus, extracerebral fluid, and macrocephaly. Studies reporting small children with idiopathic external hydrocephalus were included, mostly focusing on the studies reporting a long-term outcome. A total of 147 studies are included, the majority however with a limited methodological quality. Several theories regarding pathophysiology and various symptoms, signs, and clinical findings underscore the heterogeneity of the condition. Neuroimaging is important in the differentiation between external hydrocephalus and similar conditions. A transient delay of psychomotor development is commonly seen during childhood. A long-term outcome is scarcely reported, and the results are varying. Although most children with external hydrocephalus seem to do well both initially and in the long term, a substantial number of patients show temporary or permanent psychomotor delay. To verify that this truly is a benign condition, we suggest that future research on external hydrocephalus should focus on the long-term effects of surgical treatment as opposed to conservative management.

Delayed bilateral thalamic bleeding post-ventriculoperitoneal shunt

Ventriculoperitoneal shunt is one of the most common procedure done by neurosurgeon worldwide. We present a rare case of delayed intracerebral bleed post VP shunt and discuss the possible causes of intracerebral hemorrhage post ventriculoperitoneal shunt and bilateral thalamic bleed. The presumed cause in our case was shunt induced disseminated coagulation profile.

Cost analysis of antibiotic-impregnated catheters in the treatment of hydrocephalus in adult patients

OBJECTIVE

To determine if use of antibiotic-impregnated shunt (AIS) systems to reduce cerebrospinal fluid (CSF) shunt infections in adult patients with hydrocephalus has been cost-effective at one institution.

METHODS

All adult patients undergoing CSF shunt insertion over a 7-year period at the Johns Hopkins Hospital were retrospectively reviewed (2004-2009). In 2006, a categorical switch to AIS catheters was made. Before 2006, standard nonimpregnated shunt catheters were used. The 1-year incidence of shunt infection was retrospectively assessed and accounting and billing records were reviewed to determine shunt infection-related medical costs for patients undergoing AIS vs non-AIS shunt surgery.

RESULTS

A total of 500 (250 AIS, 250 non-AIS) shunt surgeries were performed for normal-pressure hydrocephalus (NPH) (n = 378 [76%]), pseudotumor cerebri (n = 83 [17%]), and various obstructive and communicating hydrocephalus etiologies (n = 40 [8%]). The incidence of shunt infection was decreased in the AIS (1.2%) vs non-AIS (4.0%) cohorts (P = .0492. Overall, the mean cost per shunt infection was $40,371. Per 250 shunts placed, the total infection-related cost was reduced from $321,407 to $203,424 after the conversion to AIS catheters. AIS catheters were associated with direct cost savings of $47,193 per 100 shunt surgeries performed.

CONCLUSIONS

In a retrospective cohort study of 500 CSF shunt surgeries performed in adult patients with hydrocephalus, this institution's categorical conversion to AIS catheters was associated with a significant reduction in infection-related medical costs within the first year after surgery. Although prospective randomized cost-utility studies are needed to confirm these observations, these results suggest that AIS catheters are cost-effective in the treatment of hydrocephalus in adult patients.

Cerebrospinal fluid hydrothorax without ventriculoperitoneal shunt migration in an infant

Cerebrospinal fluid (CSF) hydrothorax is a rare complication of a ventriculoperitoneal shunt (VPS), and even rarer in the absence of shunt migration into the thoracic compartment. Because of the limited volume within the thoracic cavity, hydrothorax in infants can rapidly cause severe respiratory distress. The case of an infant with recurrent CSF hydrothorax despite a well-positioned VPS is presented. A ventriculoatrial shunt was successfully performed as the definitive treatment. The absence of ascites or predisposing factors for decreased peritoneal absorption and a false-negative β(2)-transferrin CSF marker are some of the factors that can add to the diagnostic challenge in these patients. This is a potentially life-threatening condition in infants, which should be closely considered in patients with VPS who develop hydrothorax, although diagnosis is not always straight forward. The etiology and pathophysiology of this very rare disease continue to be elusive, and treatment with ventriculoatrial shunt provides good results.