An unusual complication of tapping a ventriculoperitoneal shunt

Analysis of the efficacy and related factors of ventriculoperitoneal shunt for AIDS with cryptococcal meningitis

Background

Cryptococcus neoformans is an opportunistic pathogen, which is more common in patients with AIDS. Increased intracranial pressure (ICP) is an important complication of cryptococcal meningitis (CM) and affects the therapeutic effect of CM.

Objective

To evaluate the effect and treatment for the management of ventriculoperitoneal shunt (VPS) in the treatment of AIDS complicated with CM and to analyze the factors associated with VPS and the indices affecting the outcome of CM patients.

Methods

A retrospective case study was conducted on patients with CM treated in the First Affiliated Hospital of Zhejiang University School of Medicine from 2011 to 2019. The Chi-square test was used for categorical variables and the Student’s t-test was used for continuous variables. Multivariable analysis of baseline factors related to VPS placement was performed with stepwise logistic regression analysis, factors associated with the outcome of these patients were studied by Cox regression analysis, and Kaplan–Meier survival curves were constructed to assess the outcome of patients.

Results

There were 96 patients with AIDS complicated with CM. VPS had a great effect on the patients, especially those with ICP > 350 mmH₂O. The outcome, including the mortality rate and modified Rankin scale (MRS) score of these patients, significantly improved after the placement of VPS. The karnofsky performance status (KPS) scores of patients whose ICP > 350 mmH₂O improved from 39.3 ± 21.3 at baseline to 88.7 ± 26.9 at 3 months after VPS, better than those without VPS. Multivariable analysis showed that visual impairment (OR, 0.026; 95% CI, 0.001, 0.567; P = 0.021) and ICP > 350 mmH₂O (OR, 0.026; 95% CI, 0.002, 0.293; P = 0.003) were related elements with the placement of shunt, and KPS score (HR, 0.968; 95% CI, 0.943, 0.993; P = 0.013) and ICP > 350 mmH₂O (HR, 2.801; 95% CI, 1.035, 7.580; P = 0.043) were indices of the outcome of AIDS patients with CM. For patients with ICP > 350 mmHg, Kaplan–Meier analysis showed that the 3-year outcome of patients with VPS was better than that of patients without VPS (P = 0.0067).

Conclusion

VPS was associated with better 3-year survival rates, and postshunt placement complications like infections were rare. The identification of factors related to VPS in the initial diagnosis of CM can contribute to more active management and improve the outcome.

Noninvasive thermal evaluation for shunt failure in the emergency room

Background:

Ventriculoperitoneal shunts (VPSs) have been the mainstay of treating hydrocephalus since the 1950s. However, shunts have a reported complication rate reaching nearly 50%. Devices have been developed that utilize noninvasive thermal transcutaneous diffusion technology. These shunt evaluation devices measure temperature gradients to detect shunt cerebrospinal fluid flow. We assessed the utility using a thermal diffusion technique to work up shunt failure in the emergency room (ER).

Methods:

This was a retrospective case series at a single medical center ER. We included consecutive patients with possible VPS malfunction who were evaluated with a thermal sensor. The time period of data collection included September 2015–April 2018.

Results:

Eight patients were reviewed, including four males and four females. The average age of reviewed patients was 35.1 (+/− ; 16.5). In our case series, three patients had adequate shunt flow as assessed by the shunt evaluation device, and the decision was made to discharge the patient and follow-up in clinic. In two patients, the flow was diminished, but due to other reassuring signs, the patients were still discharged with follow-up. Two patients were noted to have poor flow and were admitted for shunt revision.

Conclusion:

It is important to determine whether a malfunction is present and whether an intervention is necessary for patients who present to the emergency department with possible symptoms of shunt failure. A thermal sensor is a fast and noninvasive tool in the evaluation of shunt flow and helps determine whether it is safe to send a patient home or intervene appropriately.

Critical procedures in pediatric emergency medicine

Children comprise approximately one-quarter of all visits to most emergency departments. Children are generally healthier than adults, yet there are similar priorities in assessment and management of pediatric patients. The initial approach to airway, breathing, and circulation still applies and is first and foremost in the evaluation of young infants and children. There are certain anatomic, physiologic, developmental, and social considerations that are unique to this population and must be taken into account during their evaluation and treatment. In this review, we present and discuss an evidence-based approach to high-yield procedures necessary for all emergency physicians taking care of children.

Thermography - a valuable tool to test hydrocephalus shunt patency

INTRODUCTION

Shunt-function in hydrocephalic patients is verified by clinical examination and repeated cranial computed tomography (CCT) in most cases. Because of the disadvantages of multiple radiation especially in children it was our aim to introduce video-thermography as a simple and non-invasive methodology to evaluate shunt function.

METHODS

54 patients treated with shunts for hydrocephalus were tested. A ventriculo-peritoneal shunt had been implanted in 38 patients, a ventriculo-atrial shunt in 16 patients. Recent CCT-scans were available for all patients and served as control. None of the patients presented with clinical signs of shunt-dysfunction. The temperature of the skin covering the drainage catheter distal to the valve was recorded real-time by a calibrated infrared camera. After cooling the skin area downstream of the valve for exactly 1 min with an ice pack, changes of the skin temperature in the area downstream were registered by a thermocamera. The signals were transferred to a video screen and recorded on videotape. By off-line analysis of the obtained pseudo colour images variations of 0.1 degrees C in skin temperature could be measured.

RESULTS

Temperature distribution of the area under investigation revealed a significant reduction of the skin temperature according to the location of the downstream catheter segment in 48 patients after cooling. In 6 patients skin temperature remained constant, although clinical evaluation and CCT-scan showed no signs of shunt dysfunction. Shunt patency could be verified in more than 85% of the patients by thermal imaging.

CONCLUSION

Infrared-thermography is a valuable and promising tool for replacing CCT-scanning as a screening method to test shunt function in hydrocephalic patients.

Side-effects of risperidone therapy mimicking cerebrospinal fluid shunt malfunction: implications for clinical monitoring and management

Risperidone is an atypical antipsychotic used in the treatment of several psychiatric disorders in both children and adults. We present two patients with hydrocephalus and learning difficulties who were admitted to the neurosurgical unit with a suspected cerebrospinal fluid shunt malfunction and raised intracranial pressure. They had both been commenced on risperidone for the treatment of aggressive outbursts. Twelve days after commencing risperidone, the first patient developed symptoms of headache, nausea, vomiting, drowsiness, lethargy and two episodes of collapse. The second patient presented with similar symptoms 4 days after his risperidone dose was increased. An unnecessary shunt exploration was averted in both cases when it was noted that the side-effect profile of risperidone mimicked exactly those of shunt malfunction. Discontinuation of the drug resulted in complete resolution of all symptoms within 72 h. Many patients with shunted hydrocephalus have associated developmental disorders that may warrant treatment with risperidone. Clinicians should be aware of the potential symptom overlap between shunt malfunction and risperidone side-effects in these patients.