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Wilson TJ, McCoy KE, Al-Holou WN, Molina SL, Smyth MD, Sullivan SE. Comparison of the accuracy and proximal shunt failure rate of freehand placement versus intraoperative guidance in parietooccipital ventricular catheter placement. Neurosurg Focus 2017; 41:E10. [PMID: 27581306 DOI: 10.3171/2016.5.focus16159] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this paper is to compare the accuracy of the freehand technique versus the use of intraoperative guidance (either ultrasound guidance or frameless stereotaxy) for placement of parietooccipital ventricular catheters and to determine factors associated with reduced proximal shunt failure. METHODS This retrospective cohort study included all patients from 2 institutions who underwent a ventricular cerebrospinal fluid (CSF) shunting procedure in which a new parietooccipital ventricular catheter was placed between January 2005 and December 2013. Data abstracted for each patient included age, sex, method of ventricular catheter placement, side of ventricular catheter placement, Evans ratio, and bifrontal ventricular span. Postoperative radiographic studies were reviewed for accuracy of ventricular catheter placement. Medical records were also reviewed for evidence of shunt failure requiring revision. Standard statistical methods were used for analysis. RESULTS A total of 257 patients were included in the study: 134 from the University of Michigan and 123 from Washington University in St. Louis. Accurate ventricular catheter placement was achieved in 81.2% of cases in which intraoperative guidance was used versus 67.3% when the freehand technique was used. Increasing age reduced the likelihood of accurate catheter placement (OR 0.983, 95% CI 0.971-0.995; p = 0.005), while the use of intraoperative guidance significantly increased the likelihood (OR 2.809, 95% CI 1.406-5.618; p = 0.016). During the study period, 108 patients (42.0%) experienced shunt failure, 79 patients (30.7%) had failure involving the proximal catheter, and 53 patients (20.6%) had distal failure (valve or distal catheter). Increasing age reduced the likelihood of being free from proximal shunt failure (OR 0.983, 95% CI 0.970-0.995; p = 0.008), while both the use of intraoperative guidance (OR 2.385, 95% CI 1.227-5.032; p = 0.011), and accurate ventricular catheter placement (OR 3.424, 95% CI 1.796-6.524; p = 0.009) increased the likelihood. CONCLUSIONS The use of intraoperative guidance during parietooccipital ventricular catheter placement as part of a CSF shunt system significantly increases the likelihood of accurate catheter placement and subsequently reduces the rate of proximal shunt failure.
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Affiliation(s)
- Thomas J Wilson
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and
| | - Kathleen E McCoy
- Department of Neurosurgery, Washington University in St. Louis, Missouri
| | - Wajd N Al-Holou
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and
| | - Sergio L Molina
- Department of Neurosurgery, Washington University in St. Louis, Missouri
| | - Matthew D Smyth
- Department of Neurosurgery, Washington University in St. Louis, Missouri
| | - Stephen E Sullivan
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and
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Coulson NK, Chiarelli PA, Su DK, Chang JJ, MacConaghy B, Murthy R, Toms P, Robb TL, Ellenbogen RG, Browd SR, Mourad PD. Ultrasound stylet for non-image-guided ventricular catheterization. J Neurosurg Pediatr 2015; 16:393-401. [PMID: 26140670 DOI: 10.3171/2015.2.peds14387] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Urgent ventriculostomy placement can be a lifesaving procedure in the setting of hydrocephalus or elevated intracranial pressure. While external ventricular drain (EVD) insertion is common, there remains a high rate of suboptimal drain placement. Here, the authors seek to demonstrate the feasibility of an ultrasound-based guidance system that can be inserted into an existing EVD catheter to provide a linear ultrasound trace that guides the user toward the ventricle. METHODS The ultrasound stylet was constructed as a thin metal tube, with dimensions equivalent to standard catheter stylets, bearing a single-element, ceramic ultrasound transducer at the tip. Ultrasound backscatter signals from the porcine ventricle were processed by custom electronics to offer real-time information about ventricular location relative to the catheter. Data collected from the prototype device were compared with reference measurements obtained using standard clinical ultrasound imaging. RESULTS A study of porcine ventricular catheterization using the experimental device yielded a high rate of successful catheter placement after a single pass (10 of 12 trials), despite the small size of pig ventricles and the lack of prior instruction on porcine ventricular architecture. A characteristic double-peak signal was identified, which originated from ultrasound reflections off of the near and far ventricular walls. Ventricular dimensions, as obtained from the width between peaks, were in agreement with standard ultrasound reference measurements (p < 0.05). Furthermore, linear ultrasound backscatter data permitted in situ measurement of the stylet distance to the ventricular wall (p < 0.05), which assisted in catheter guidance. CONCLUSIONS The authors have demonstrated the ability of the prototype ultrasound stylet to guide ventricular access in the porcine brain. The alternative design of the device makes it potentially easy to integrate into the standard workflow for bedside EVD placement. The availability of a fast, easy-to-use, inexpensive guidance system can play a role in reducing the complication rate for EVD placement.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Pierre D Mourad
- Departments of 1 Bioengineering and.,Applied Physics Laboratory, University of Washington;,Division of Engineering and Mathematics, University of Washington, Bothell, Washington
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Chung SD, Sheu JJ, Kao LT, Lin HC, Kang JH. Dementia is associated with iron-deficiency anemia in females: A population-based study. J Neurol Sci 2014; 346:90-3. [DOI: 10.1016/j.jns.2014.07.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Revised: 07/28/2014] [Accepted: 07/29/2014] [Indexed: 11/25/2022]
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Whitehead WE, Riva-Cambrin J, Wellons JC, Kulkarni AV, Holubkov R, Illner A, Oakes WJ, Luerssen TG, Walker ML, Drake JM, Kestle JRW. No significant improvement in the rate of accurate ventricular catheter location using ultrasound-guided CSF shunt insertion: a prospective, controlled study by the Hydrocephalus Clinical Research Network. J Neurosurg Pediatr 2013; 12:565-74. [PMID: 24116981 DOI: 10.3171/2013.9.peds1346] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Cerebrospinal fluid shunt ventricular catheters inserted into the frontal horn or trigone are associated with prolonged shunt survival. Developing surgical techniques for accurate catheter insertion could, therefore, be beneficial to patients. This study was conducted to determine if the rate of accurate catheter location with intraoperative ultrasound guidance could exceed 80%. METHODS The authors conducted a prospective, multicenter study of children (< 18 years) requiring first-time treatment for hydrocephalus with a ventriculoperitoneal shunt. Using intraoperative ultrasound, surgeons were required to target the frontal horn or trigone for catheter tip placement. An intraoperative ultrasound image was obtained at the time of catheter insertion. Ventricular catheter location, the primary outcome measure, was determined from the first postoperative image. A control group of patients treated by nonultrasound surgeons (conventional surgeons) were enrolled using the same study criteria. Conventional shunt surgeons also agreed to target the frontal horn or trigone for all catheter insertions. Patients were triaged to participating surgeons based on call schedules at each center. A pediatric neuroradiologist blinded to method of insertion, center, and surgeon determined ventricular catheter tip location. RESULTS Eleven surgeons enrolled as ultrasound surgeons and 6 as conventional surgeons. Between February 2009 and February 2010, 121 patients were enrolled at 4 Hydrocephalus Clinical Research Network centers. Experienced ultrasound surgeons (> 15 cases prior to study) operated on 67 patients; conventional surgeons operated on 52 patients. Experienced ultrasound surgeons achieved accurate catheter location in 39 (59%) of 66 patients, 95% CI (46%-71%). Intraoperative ultrasound images were compared with postoperative scans. In 32.7% of cases, the catheter tip moved from an accurate location on the intraoperative ultrasound image to an inaccurate location on the postoperative study. This was the most significant factor affecting accuracy. In comparison, conventional surgeons achieved accurate location in 24 (49.0%) of 49 cases (95% CI [34%-64%]). The shunt survival rate at 1 year was 70.8% in the experienced ultrasound group and 66.9% in the conventional group (p = 0.66). Ultrasound surgeons had more catheters surrounded by CSF (30.8% vs 6.1%, p = 0.0012) and away from the choroid plexus (72.3% vs 58.3%, p = 0.12), and fewer catheters in the brain (3% vs 22.4%, p = 0.0011) and crossing the midline (4.5% vs 34.7%, p < 0.001), but they had a higher proportion of postoperative pseudomeningocele (10.1% vs 3.8%, p = 0.30), wound dehiscence (5.8% vs 0%, p = 0.13), CSF leak (10.1% vs 1.9%, p = 0.14), and shunt infection (11.6% vs 5.8%, p = 0.35). CONCLUSIONS Ultrasound-guided shunt insertion as performed in this study was unable to consistently place catheters into the frontal horn or trigone. The technique is safe and achieves outcomes similar to other conventional shunt insertion techniques. Further efforts to improve accurate catheter location should focus on prevention of catheter migration that occurs between intraoperative placement and postoperative imaging. Clinical trial registration no.: NCT01007786 ( ClinicalTrials.gov ).
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Wilson TJ, Stetler WR, Al-Holou WN, Sullivan SE. Comparison of the accuracy of ventricular catheter placement using freehand placement, ultrasonic guidance, and stereotactic neuronavigation. J Neurosurg 2013; 119:66-70. [DOI: 10.3171/2012.11.jns111384] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The objective of this study was to compare the accuracy of 3 methods of ventricular catheter placement during CSF shunt operations: the freehand technique using surface anatomy, ultrasonic guidance, and stereotactic neuronavigation.
Methods
This retrospective cohort study included all patients from a single institution who underwent a ventricular CSF shunting procedure in which a new ventricular catheter was placed between January 2005 and March 2010. Data abstracted for each patient included age, sex, diagnosis, method of ventricular catheter placement, site and side of ventricular catheter placement, Evans ratio, and bifrontal ventricular span. Postoperative radiographic studies were reviewed for accuracy of ventricular catheter placement. Medical records were also reviewed for evidence of shunt failure requiring revision through December 2011. Statistical analysis was then performed comparing the 3 methods of ventricular catheter placement and to determine risk factors for inaccurate placement.
Results
There were 249 patients included in the study; 170 ventricular catheters were freehand passed, 51 were placed using stereotactic neuronavigation, and 28 were placed under intraoperative ultrasonic guidance. There was a statistically significant difference between freehand catheters and stereotactic-guided catheters (p < 0.001), as well as between freehand catheters and ultrasound-guided catheters (p < 0.001). The only risk factor for inaccurate placement identified in this study was use of the freehand technique. The use of stereotactic neuronavigation and ultrasonic guidance reduced proximal shunt failure rates (p < 0.05) in comparison with a freehand technique.
Conclusions
Stereotactic- and ultrasound-guided ventricular catheter placements are significantly more accurate than freehand placement, and the use of these intraoperative guidance techniques reduced proximal shunt failure in this study.
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Phillips SB, Gates M, Krishnamurthy S. Strategic placement of bedside ventriculostomies using ultrasound image guidance: report of three cases. Neurocrit Care 2013; 17:255-9. [PMID: 21691896 DOI: 10.1007/s12028-011-9571-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The blind free-hand technique for external ventricular drain (EVD) placement sometimes requires multiple attempts, and catheter location is often less than ideal. Our institution has adapted an intraoperative ultrasound-guided ventriculostomy technique for the placement of EVDs at the bedside. Our experience with ultrasound at the bedside has proven to be invaluable in certain circumstances. We present three cases of strategic EVD catheter trajectories that were made possible at the bedside with the use of ultrasound. METHODS Illustrative cases were chosen from a larger prospective study investigating the ultrasound-guided EVD technique. A portable ultrasound with a "burr hole" probe was used with modification of the standard surgical technique for placement of EVDs at the bedside. RESULTS Case 1 describes an unexpected re-hemorrhage that was first realized by the ultrasound image obtained during the bedside EVD placement procedure. The catheter was purposefully directed across midline to the more prominent ventricle on the contralateral side based on this real-time finding. Case 2 describes how ultrasound was used to salvage the failed free-hand procedure and cannulate an extremely small ventricular space at the bedside. Case 3 describes an unconventionally placed burr hole that provided a customized trajectory in which the EVD catheter was placed just laterally and inferior to a large frontal hematoma. CONCLUSION Ultrasound-guided bedside EVD placement allows EVD trajectories to be customized based on real-time information to accommodate for distorted and dynamic anatomy of the brain and its ventricles.
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Affiliation(s)
- Scott B Phillips
- Department of Neurosurgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, 48202 MI, USA.
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Abstract
Alzheimer’s disease (AD), considered the commonest neurodegenerative cause of dementia, is associated with hallmark pathologies including extracellular amyloid-β protein (Aβ) deposition in extracellular senile plaques and vessels, and intraneuronal tau deposition as neurofibrillary tangles. Although AD is usually categorized as neurodegeneration distinct from cerebrovascular disease (CVD), studies have shown strong links between AD and CVD. There is evidence that vascular risk factors and CVD may accelerate Aβ 40-42 production/ aggregation/deposition and contribute to the pathology and symptomatology of AD. Aβ deposited along vessels also causes cerebral amyloid angiopathy. Amyloid imaging allows in vivo detection of AD pathology, opening the way for prevention and early treatment, if disease-modifying therapies in the pipeline show safety and efficacy. In this review, we review the role of vascular factors and Aβ, underlining that vascular risk factor management may be important for AD prevention and treatment.
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Selective use of intra-catheter endoscopic-assisted ventricular catheter placement: indications and outcome. Childs Nerv Syst 2012; 28:1163-9. [PMID: 22729626 DOI: 10.1007/s00381-012-1838-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 06/05/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE In a previous well-controlled study, routine endoscopic-guided placement of ventricular catheters did not seem to decrease the rate of shunt failure or proximal shunt malfunction. Since this study was published, this technique does not seem to gain much acceptance. However, in selected cases, it may assist in accuracy and safety. We therefore have analyzed our experience with selective intra-catheter endoscopic use for ventricular hardware placement. METHODS We retrospectively collected clinical and radiological data on all children undergoing intra-catheter endoscopic-assisted ventricular catheter placement. RESULTS During 25 months, 16 children (ages 3 months-18 years) underwent 18 procedures using the above technique. Indications for surgery were: proximal shunt malfunction with relatively small ventricles (ten children), proximal shunt malfunction with intraventricular membranes (one child), proximal shunt malfunction with distorted ventricles (one child), new shunt with small to medium sized ventricles (two children), or large ventricles and a loculated fourth ventricle secondary to an aqueductal web (two children). Fourteen procedures were technically successful. The catheter was properly located on postoperative imaging in 13 procedures. Frameless navigation was used in three cases. CONCLUSIONS Selective use of intra-catheter endoscopic-assisted proximal shunt placement is useful and may be indicated in small or distorted ventricles and in cases when fenestration of an intraventricular membrane or aqueductal web is indicated. The main value of such a technique is the ability to accurately place the catheter tip within distorted or small ventricles. Larger series are needed to refine these indications.
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Frisoni GB, Fox NC, Jack CR, Scheltens P, Thompson PM. The clinical use of structural MRI in Alzheimer disease. Nat Rev Neurol 2010; 6:67-77. [PMID: 20139996 PMCID: PMC2938772 DOI: 10.1038/nrneurol.2009.215] [Citation(s) in RCA: 1132] [Impact Index Per Article: 80.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Structural imaging based on magnetic resonance is an integral part of the clinical assessment of patients with suspected Alzheimer dementia. Prospective data on the natural history of change in structural markers from preclinical to overt stages of Alzheimer disease are radically changing how the disease is conceptualized, and will influence its future diagnosis and treatment. Atrophy of medial temporal structures is now considered to be a valid diagnostic marker at the mild cognitive impairment stage. Structural imaging is also included in diagnostic criteria for the most prevalent non-Alzheimer dementias, reflecting its value in differential diagnosis. In addition, rates of whole-brain and hippocampal atrophy are sensitive markers of neurodegeneration, and are increasingly used as outcome measures in trials of potentially disease-modifying therapies. Large multicenter studies are currently investigating the value of other imaging and nonimaging markers as adjuncts to clinical assessment in diagnosis and monitoring of progression. The utility of structural imaging and other markers will be increased by standardization of acquisition and analysis methods, and by development of robust algorithms for automated assessment.
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Strowitzki M, Komenda Y, Eymann R, Steudel WI. Accuracy of ultrasound-guided puncture of the ventricular system. Childs Nerv Syst 2008; 24:65-9. [PMID: 17609966 DOI: 10.1007/s00381-007-0410-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2007] [Indexed: 11/25/2022]
Abstract
OBJECTS Puncture of the ventricular system as one of the most frequently performed operative procedures in neurosurgery is usually done in a freehand way without guiding devices. The objective of this study is to examine whether ultrasonic guidance is able to heighten the accuracy of ventricular tapping. METHODS Real-time imaging via a single burr hole approach is achieved by aid of a bajonet-like shaped transducer with a footprint of 8x8 mm only (EUP-NS32, Hitachi Medical Systems). The needle is advanced towards the frontal horn along a displayed guideline. 51 punctures in 48 patients were performed with ultrasonic guidance and compared to 85 punctures in 67 patients without a guiding device. CONCLUSION The presented ultrasound method was not able to heighten the access rate of ventricular tapping, but it improved correct positioning of the catheter tip inside the frontal horn of the ventricular system significantly.
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Affiliation(s)
- M Strowitzki
- Department of Neurosurgery, Saarland University Medical School, Kirrberger Str., 66421, Homburg, Saarland, Germany.
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Patterson C, Feightner J, Garcia A, MacKnight C. Primary prevention of dementia. Alzheimers Dement 2007; 3:348-54. [DOI: 10.1016/j.jalz.2007.07.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Accepted: 07/12/2007] [Indexed: 11/29/2022]
Affiliation(s)
- Christopher Patterson
- Division of Geriatric MedicineDepartment of MedicineFaculty of Health SciencesMcMaster UniversityHamiltonOntarioCanada
| | - John Feightner
- Department of Family MedicineFaculty of MedicineUniversity of Western OntarioLondonOntarioCanada
| | - Angeles Garcia
- Department of Medicine (Geriatrics)Queen's UniversityKingstonOntarioCanada
| | - Chris MacKnight
- Division of Geriatric MedicineDalhousie UniversityHalifaxNova ScotiaCanada
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Patterson C, Feightner J, Garcia A, MacKnight C. General risk factors for dementia: A systematic evidence review. Alzheimers Dement 2007; 3:341-7. [DOI: 10.1016/j.jalz.2007.07.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Accepted: 07/12/2007] [Indexed: 10/22/2022]
Affiliation(s)
- Christopher Patterson
- Division of Geriatric MedicineDepartment of MedicineFaculty of Health SciencesMcMaster UniversityHamiltonOntarioCanada
| | - John Feightner
- Department of Family MedicineFaculty of MedicineUniversity of Western OntarioLondonOntarioCanada
| | - Angeles Garcia
- Department of Medicine (Geriatrics)Queen's UniversityKingstonOntarioCanada
| | - Chris MacKnight
- Division of Geriatric MedicineDalhousie UniversityHalifaxNova ScotiaCanada
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Abstract
A variety of acute neurologic disorders present with visual signs and symptoms. In this review the authors focus on those disorders in which the clinical outcome is dependent on timely and accurate diagnosis. The first section deals with acute visual loss, specifically optic neuritis, ischemic optic neuropathy (ION), retinal artery occlusion, and homonymous hemianopia. The authors include a discussion of those clinical features that are helpful in distinguishing between inflammatory and ischemic optic nerve disease and between arteritic and nonarteritic ION. The second section concerns disc edema with an emphasis on the prevention of visual loss in patients with increased intracranial pressure. The third section deals with abnormal ocular motility, and includes orbital inflammatory disease, carotid-cavernous fistulas, painful ophthalmoplegia, conjugate gaze palsies, and neuromuscular junction disorders. The final section concerns pupillary abnormalities, with a particular emphasis on the dilated pupil and on carotid artery dissection. Throughout there are specific guidelines for the management of these disorders, and areas are highlighted in which there is ongoing controversy.
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Affiliation(s)
- Valerie Purvin
- Indiana University Medical Center, Department of Ophthalmology, Indianapolis, IN 46280, USA.
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Kestle JRW, Drake JM, Cochrane DD, Milner R, Walker ML, Abbott R, Boop FA. Lack of benefit of endoscopic ventriculoperitoneal shunt insertion: a multicenter randomized trial. J Neurosurg 2003; 98:284-90. [PMID: 12593612 DOI: 10.3171/jns.2003.98.2.0284] [Citation(s) in RCA: 171] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Endoscopically assisted ventricular catheter placement has been reported to reduce shunt failure in uncontrolled series. The authors investigated the efficacy of this procedure in a prospective multicenter randomized trial. METHODS Children younger than 18 years old who were scheduled for their first ventriculoperitoneal (VP) shunt placement were randomized to undergo endoscopic or nonendoscopic insertion of a ventricular catheter. Eligibility and primary outcome (shunt failure) were decided in a blinded fashion. An intention-to-treat analysis was performed. The sample size offered 80% power to detect a 10 to 15% absolute reduction in the 1-year shunt failure rate. The authors studied 393 patients from 16 pediatric neurosurgery centers between May 1996 and November 1999. Median patient age at shunt insertion was 89 days. The baseline characteristics of patients within each group were similar: 54% of patients treated with endoscopy were male and 55% of patients treated without endoscopy were male; 30% of patients treated with and 26% of those without endoscopy had myelomeningocele; a differential pressure valve was used in 51% of patients with and 49% of those treated without endoscopy; a Delta valve was inserted in 38% of patients in each group; and a Sigma valve was placed in 9% of patients treated with and 12% of those treated without endoscopy. Median surgical time lasted 40 minutes in the group treated with and 35 minutes in the group treated without endoscopy. Ventricular catheters, which during surgery were thought to be situated away from the choroid plexus, were demonstrated to be in it on postoperative imaging in 67% of patients who had undergone endoscopic insertion and 61% of those who had undergone nonendoscopic shunt placements. The incidence of shunt failure at 1 year was 42% in the endoscopic insertion group and 34% in the nonendoscopic group. The time to first shunt failure was not different between the two groups (log rank = 2.92, p = 0.09). CONCLUSIONS Endoscopic insertion of the initial VP shunt in children suffering from hydrocephalus did not reduce the incidence of shunt failure.
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Affiliation(s)
- John R W Kestle
- Division of Pediatric Neurosurgery, University of Utah, Primary Children's Medical Center, Salt Lake City, Utah 84113, USA.
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Doraiswamy PM, Leon J, Cummings JL, Marin D, Neumann PJ. Prevalence and impact of medical comorbidity in Alzheimer's disease. J Gerontol A Biol Sci Med Sci 2002; 57:M173-7. [PMID: 11867654 DOI: 10.1093/gerona/57.3.m173] [Citation(s) in RCA: 167] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We examined the prevalence of comorbid medical illnesses in Alzheimer's disease (AD) patients at different severity levels. We also examined the effect of cumulative medical comorbidity on cognition and function. METHODS Analyses of data from 679 AD patients (Mini-Mental State Exam score range 0-30, mean +/- SD = 11.8 +/- 8) from 13 sites (four dementia centers assessing outpatients, four managed care organizations, two assisted living facilities, and three nursing homes) prospectively recruited using a stratification approach including dementia severity and care setting. Medical comorbidity was quantified using the Cumulative Illness Rating Scale-Geriatric. RESULTS Across patients, 61% had three or more comorbid medical illnesses. Adjusting for age, gender, race, and care setting, medical comorbidity increased with dementia severity (mild to moderate, p <.01; moderate to severe, p <.001). Adjusting for age, educational level, gender, race, and care setting, higher medical comorbidity was associated with greater impairment in cognition (p <.001) and in self-care (p <.001). CONCLUSIONS Despite the limitation of a cross-sectional design, our initial findings suggest that there is a strong association between medical comorbidity and cognitive status in AD. Optimal management of medical illnesses may offer potential to improve cognition in AD.
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Affiliation(s)
- P Murali Doraiswamy
- Department of Psychiatry, Duke University Medical Center, Durham, North Carolina 27710, USA.
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