Evaluation of Ventriculoperitoneal Shunt-Related Complications in Intracranial Meningioma with Hydrocephalus

Ventriculoperitoneal shunt infection and malfunction in adult patients: incidence, risk factors, and long-term follow-up of single institution experience

Ventriculoperitoneal shunt surgery was developed to manage excessive cerebrospinal fluid (CSF) in the brain's ventricles and is considered a mainstream treatment. Despite the development of the shunt device system, various complications still occur. In this study, we reported 307 cases and a long-term follow-up of at least five years of adult patients who underwent VP shunt surgery and analyzed various factors that may affect revision surgery. A retrospective study was conducted at Asan Medical Center, Korea, a tertiary medical center. We reviewed 307 cases from January 2012 to December 2018. The patients' neurological status, predisposing medical conditions, laboratory findings, and other operation-related factors were reviewed using electrical medical records. The normal function group comprised 272 cases (88.6%), and the overall incidence of revision group comprised 35 cases (11.4%). Of the 35 revision surgery cases, 30 (85.71%) were due to shunt malfunctions, such as obstruction, overdrainage, and valve-related errors while 5 (14.29%) were due to shunt infection. Patient demographics, mental status, and operation time did not influence revision as risk factors. Serum laboratory findings showed no statistical difference between the two groups. The white blood cell (WBC) count in the CSF profile differed significantly between the two groups. The Hakim Programmable valve (Codman, USA) is mainly used in our center. In addition, various shunt systems were used, including Strata Regulatory valve (Medtronic, USA), proGAV (Aesculap, USA), and Accu-Flo (Codman, USA). This study analyzed the factors affecting long-term outcomes. Based on these findings, efforts are needed to achieve more favorable outcomes in the future.

Ventriculoperitoneal Shunt Failure and Cerebrospinal Fluid Protein: A Meta-Analysis and Systematic Review

Ventriculoperitoneal shunts (VPS) are used to manage hydrocephalus but suffer from high failure rates. Our objectives were to (1) conduct a meta-analysis to objectively weigh this conflicting evidence, and (2) conduct a systematic review compiling and synthesizing what is known about the association between CSF proteins and shunt failure. A literature search was performed in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Embase, PubMed, and CENTRAL databases were searched from inception to June 2023. The articles were screened based on the inclusion criteria. A meta-analysis was conducted using R statistical software (R Foundation for Statistical Computing, Vienna, Austria); heterogeneity, subgroup, sensitivity, risk of bias, and publication bias analyses were performed. Thirty-one studies were selected for the systematic review, of which eight were selected for the meta-analysis. Perioperative CSF protein level was compared between 351 shunt failures and 1,094 shunt survivals; the mean difference of 24.37 mg/dL favoring shunt failure was significant (95% confidence interval=2.44-46.29 mg/dL). Our systematic review yielded a hypothesized pathogenesis: proteins attached to imperfections in the shunt surface lead to secondary attachment of cells, particularly astrocytes, and tertiary attachment of ependymal cells and the choroid plexus. Owing to the limitations of this meta-analysis, including lack of robustness due to missing data, heterogeneity, and certainty of the evidence, future research is needed to better understand the relationship between perioperative CSF protein levels and shunt failure.

Correlation between cerebrospinal fluid abnormalities before ventriculoperitoneal shunt and postoperative intracranial infection in adult patients with hydrocephalus: A clinical study

Objective

To identify the relationship between preoperative cerebrospinal fluid (CSF) leukocyte, chloride, glucose, aspartate aminotransferase, lactate dehydrogenase, adenosine deaminase, lactic acid and protein levels and ventriculoperitoneal shunt infection.

Methods

Records of 671 consecutive adult patients who underwent ventriculoperitoneal shunt surgery for the treatment of hydrocephalus at Zhujiang Hospital affiliated with Southern Medical University from January 2011 to March 2022 were reviewed. The patients were divided into infection and non-infection groups based on the presence of postoperative infection. For all patients, we analyzed age; sex; primary disease; preoperative CSF leukocyte, chloride, glucose, aspartate aminotransferase, lactate dehydrogenase, adenosine deaminase, lactic acid and protein levels; postoperative temperature; and postoperative infection.

Results

A total of 397 patients were included, 28 (7.05%) of whom had an infection within 6 months of the operation and the remaining had no infection. There was no significant difference in age, sex, primary disease, leukocyte, chloride ion, aspartate aminotransferase, lactate dehydrogenase, adenosine deaminase and protein levels in CSF between infection group and non-infection group (p > 0.05). The postoperative infection rate of patients with CSF glucose < 2.8 mmol/L (x ² = 11.650, p = 0.001) and CSF lactic acid >2.8 mmol/L (x ² = 12.455, p < 0.001) was higher than that of patients with CSF glucose level ≥2.8 mmol/L and CSF lactic acid level in the range of (1-2.8) mmol/L, respectively, with statistical difference. Compared with the non-infection group, the level of CSF glucose (t = 4.113, p < 0.001) was significantly lower, and the level of CSF lactic acid (t = 6.651, p < 0.001) was significantly higher in the infection group. Multivariate logistic regression analysis showed that preoperative cerebrospinal fluid glucose < 2.8 mmol/L (OR = 3.911, 95% CI: 1.653~9.253, p = 0.002) and cerebrospinal fluid lactate >2.8 mmol/L (OR = 4.712, 95% CI: 1.892~11.734, p = 0.001) are risk factors for infection after ventriculoperitoneal shunt. ROC analysis revealed that the area under the curve (AUC) for CSF glucose and lactic acid level were 0.602 (95% CI: 0.492-0.713) and 0.818 (95% CI: 0.738-0.898), respectively. The infection group had higher rates of fever and body temperature on postoperative day 3-7 (p < 0.05).

Conclusions

For adult hydrocephalus patients without clinical manifestations of intracranial infection but only with simple abnormality of cerebrospinal fluid, when the content of glucose in cerebrospinal fluid is < 2.8 mmol/L, and the content of lactic acid is >2.8 mmol/L, it is recommended to perform ventriculoperitoneal shunt after further improvement of cerebrospinal fluid indicators, otherwise, hasty operation will increase the postoperative infection rate. The postoperative fever rate of ventriculoperitoneal shunt surgery is high and the body temperature drops rapidly. If there is still fever after day 3 after surgery, whether there is intracranial infection should be considered.

Outcome After Protontherapy for Progression or Recurrence of Surgically Treated Meningioma

Background

To assess the outcome after meningioma surgery and protontherapy (PT).

Methods

We processed the French Système National des Données de Santé database to retrieve appropriate cases of meningiomas operated and irradiated between 2008 and 2017. Survival methods were implemented.

Results

One hundred ninety-three patients who received PT after meningioma surgery over a 10-year period were identified. Of the 193 patients, 75.6% were female. Median age at surgery was 50 years (interquartile range [IQR] 41–62). The median number of PT fractions was 31 (IQR 30–39) given over a median duration of 52 days (IQR 44–69). Fourteen patients (7.3%) also received photon radiotherapy and six patients (3.1%) stereotactic radiosurgery. Median follow-up was 4.4 years (IQR 3.86–4.71). Five-year progression-free survival (PFS) rate was 69% (95% confidence interval [CI] 62.1–76.6). For benign, atypical, and malignant meningioma, 5-year PFS rates were 71.5% (95% CI 64.4–79.4), 55.6% (95% CI 32.5–95), and 35.6% (95% CI 12.8–98.9), respectively (p<0.01). In the adjusted regression, tumour location (hazard ratio [HR]=0.1, 95% CI 0.05–0.22, p<0.001), aggressive meningioma (HR=2.26, 95% CI 1.1–4.66, p=0.027), and the need of cerebrospinal fluid (CSF) insertion for hydrocephalus (HR=3.51, 95% CI 1.32–9.31, p=0.012) remained significantly associated to the PFS. All grades considered, 5-year overall survival (OS) rates was 89.7% (95% CI 84.6–95.1). For benign, atypical, and malignant meningioma, 5-year OS rates were 93% (95% CI 88.7–97.4), 76.4% (95% CI 51.4–100), and 44.4% (95% CI 16.7–100), respectively (p<0.01). In the multivariable regression, an older age above 70 years (HR=5.95, 95% CI 2.09–16.89, p<0.001) associated to a high level of comorbidities (HR=5.31, 95% CI 1.43–19.78, p=0.013) and a malignant meningioma (HR=5.68, 95% CI 1.54–20.94, p=0.009) remained significantly associated to a reduced OS.

Conclusion

Five-year PFS and OS after meningioma surgery and PT is favourable but impaired for older patients with high level of morbidities, tumour of the convexity, malignant histopathology and for those requiring CSF shunting. Further inclusion and prolonged follow-up is required to assess other predictors such as sex, tumour volume, or given dose.

Predicting Discharge Disposition Following Meningioma Resection Using a Multi-Institutional Natural Language Processing Model

BACKGROUND

Machine learning (ML)-based predictive models are increasingly common in neurosurgery, but typically require large databases of discrete variables for training. Natural language processing (NLP) can extract meaningful data from unstructured text.

OBJECTIVE

To present an NLP model that predicts nonhome discharge and a point-of-care implementation.

METHODS

We retrospectively collected age, preoperative notes, and radiology reports from 595 adults who underwent meningioma resection in an academic center from 1995 to 2015. A total of 32 algorithms were trained with the data; the 3 best performing algorithms were combined to form an ensemble. Predictive ability, assessed by area under the receiver operating characteristic curve (AUC) and calibration, was compared to a previously published model utilizing 52 neurosurgeon-selected variables. We then built a multi-institutional model by incorporating notes from 693 patients at another center into algorithm training. Permutation importance was used to analyze the relative importance of each input to model performance. Word clouds and non-negative matrix factorization were used to analyze predictive features of text.

RESULTS

The single-institution NLP model predicted nonhome discharge with AUC of 0.80 (95% CI = 0.74-0.86) on internal and 0.76 on holdout validation compared to AUC of 0.77 (95% CI = 0.73-0.81) and 0.74 for the 52-variable ensemble. The multi-institutional model performed similarly well with AUC = 0.78 (95% CI = 0.74-0.81) on internal and 0.76 on holdout validation. Preoperative notes most influenced predictions. The model is available at http://nlp-home.insds.org.

CONCLUSION

ML and NLP are underutilized in neurosurgery. Here, we construct a multi-institutional NLP model that predicts nonhome discharge.

Methods and Devices for Posterior Ventriculoperitoneal Shunt Placement Surgery: 25 Years of Iterative Refinement

BACKGROUND

The posterior ventriculoperitoneal shunt (VPS) placement procedure is technically efficient and cosmetically appealing. The main limitations of the posterior approach relate to the technical challenges associated with accurately placing the ventricular catheter. In this report, we describe methods and simple devices used for posterior VPS surgery that have evolved over a >25-year period to enhance catheter placement accuracy and reduce complication rates.

OBJECTIVE

We describe the combination of methods and customized devices used at a single institution to perform posterior VPS surgery. Results are presented for the most recent 11-year epoch, along with a description of sources of technical errors and plans for further methodologic refinements.

MATERIALS AND METHODS

The medical records and imaging studies of 468 patients undergoing posterior VPS, from 2007 to 2018 were reviewed. Ventricular catheter placement accuracy data were collected and complications were identified and recorded.

RESULTS

Optimal ventricular catheter placement was achieved in 98.29%. Of the remaining 1.71%, one half (0.85%) required acute revision surgery. Four patients (0.85%) developed new neurologic deficits following surgery; 2 were related to intraparenchymal hemorrhages and 2 (0.43%) as a result of a misplaced catheter. The deficits resulting from poor catheter placement were transient. The complication rates due to causes other than catheter placement accuracy compared favorably with those reported previously in the literature.

CONCLUSIONS

Using the methods and devices described in this series, posterior VPS operations can be performed safely with a high degree of ventricular catheter placement accuracy.