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Yuri Ferreira M, Oliveira LB, Porto Júnior S, Semione G, Palavani LB, Batista S, Pari Mitre L, Borges PGLB, Abrantes Barros E, Andreão F, Porto Sousa M, Gomez D, Bertani R, Hakim F. Enhancing the quality of evidence, comparability, and reproducibility in ventriculoatrial shunt research for normal pressure hydrocephalus: A systematic review and VAS-NPH reporting guideline. J Clin Neurosci 2024; 126:328-337. [PMID: 39024937 DOI: 10.1016/j.jocn.2024.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 06/03/2024] [Accepted: 06/30/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Ventriculoatrial shunt (VAS) is an important treatment option for normal pressure hydrocephalus (NPH). However, clinical studies reporting the use of VAS for NPH lack sufficient standardization for meta-analytic comparisons that could provide robust evidence regarding its use. This study aims to assess the quality of reporting in these studies and develop a reporting guideline checklist to standardize terminology, concepts, and reporting while reinforcing the essential elements to ensure comparability and reproducibility. METHODS This is a systematic literature review that followed the PRISMA guidelines with the search in Medline, Embase, and Web of Science databases, with no timeframe restriction. The level of evidence of the studies was assessed using the GRADE system, and the rigor used in the publication of the results was assessed concerning adherence to the guidelines indicated by the EQUATOR Network Group. Furthermore, the studies were scrutinized focusing on eight domains: (1) Characteristics of the included studies and baseline characteristics of the patients; (2) Reporting methodology; (3) Pivotal concepts definition; (4) Adverse events assessment; (5) Data writing and reporting; (6) Detailed outcomes reporting; (7) Specific clinical outcomes assessment and reporting; and (8) Complications reporting. RESULTS A total of 14 studies with 734 patients and 753 shunts were included in this review, and the assessment exposes notable deficiencies in reporting, specifically in baseline patient details, methodology, and outcome assessments. Only two studies followed reporting guidelines, prompting concerns about comprehensive reporting of adverse events and intraoperative complications. Varied reporting completeness existed for shunt-related issues. The absence of standardized definitions for key concepts and insufficient intervention details were observed. A VAS-NPH reporting guideline, encompassing 36 items across eight domains, was developed to address these shortcomings. CONCLUSION This systematic review reveals significant deficiencies in methodological rigor and reporting quality. The proposed VAS-NPH Reporting Guideline covers all essential aspects and is a potential solution to rectify these shortcomings and increase transparency, comparability, and reproducibility. This initiative aims to advance the level of evidence and enhance knowledge regarding the use of VAS in NPH.
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Affiliation(s)
- Marcio Yuri Ferreira
- Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
| | - Leonardo B Oliveira
- Department of Neurosurgery, State University of Ponta Grossa, Ponta Grossa, PR, Brazil
| | | | | | | | - Savio Batista
- Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Lucas Pari Mitre
- Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil
| | - Pedro G L B Borges
- Fundação Técnico-Educacional Souza Marques, Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Filipi Andreão
- Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Diego Gomez
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
| | - Raphael Bertani
- Department of Neurosurgery, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Fernando Hakim
- Department of Neurosurgery, Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Cundinamarca, Colombia
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Oliveira LDB, Welling LC, Viegas FAF, Ribas LRC, Junior EOM, Wesselovicz RM, Batista S, Bertani R, Palavani LB, Rabelo NN, Figueiredo EG. Incidence and nature of complications associated with ventriculoatrial shunt placement: A systematic review and single-arm meta-analysis. Clin Neurol Neurosurg 2023; 233:107950. [PMID: 37673013 DOI: 10.1016/j.clineuro.2023.107950] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/22/2023] [Accepted: 08/22/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Ventriculoatrial shunt (VAS) is considered the second option for treating hydrocephalus, but there remains a lack of robust evidence regarding its complications profile. PURPOSE Evaluate the complications associated with VAS. METHODS Adhering to PRISMA guidelines, the authors searched Embase, PubMed, and Web of Science databases to identify articles reporting on the complications of VAS. Eligible articles were required to report whether complications occurred in a cohort of at least four patients. The extraction process focused on various outcome measures, including overall complications, pulmonary complications, cardiac complications, mortality, shunt revisions, glomerulonephritis, intracranial hemorrhage, and hygroma. Complications were defined as any adverse events related to the procedure, including revisions. RESULTS After retrieving a total of 2828 articles, 53 studies met the predefined criteria, involving 2862 patients. The overall complication rate was estimated at 33 % (95 % CI: 25-42 %), while the long-term complications rate was found to be 49 % (95 % CI: 32-67 %). Among the pediatric population, the complication rate was calculated to be 53 % (95 % CI: 39-68 %). The overall revision rate was estimated at 32 % (95 % CI: 23-41 %), with an infection rate of 5 % (95 % CI: 3-7 %). Notably, in the pediatric group, the infection rate was 10 % (95 % CI: 6-13 %). The random analysis indicated an estimated risk of 0 % for glomerulonephritis, intracranial hemorrhage, hygroma, cardiac complications, pulmonary complications, and shunt-related mortality. CONCLUSION VAS is a safe alternative when ventriculoperitoneal shunting is not feasible. Risk of classic severe complications is minimal. Nevertheless, caution is required when shunting critical patients. Further randomized studies are warranted to establish the ideal shunt for different patients.
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Affiliation(s)
| | | | | | | | | | | | - Savio Batista
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Raphael Bertani
- Department of Neurosurgery, University of São Paulo, São Paulo, Brazil
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Lele AV, Theard MA, Vavilala MS. Cerebrospinal fluid diversion devices and shunting procedures: a narrative review for the anesthesiologist. Int Anesthesiol Clin 2023; 61:29-36. [PMID: 37249174 DOI: 10.1097/aia.0000000000000399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Abhijit Vijay Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
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Muram S, Isaacs AM, Sader N, Holubkov R, Fong A, Conly J, Hamilton MG. A standardized infection prevention bundle for reduction of CSF shunt infections in adult ventriculoperitoneal shunt surgery performed without antibiotic-impregnated catheters. J Neurosurg 2023; 138:494-502. [PMID: 35916085 DOI: 10.3171/2022.5.jns22430] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Ventriculoperitoneal (VP) shunt insertion and revision surgeries are some of the most common procedures that are performed by neurosurgeons. Shunt infections within the adult population are associated with significant morbidity and mortality and rates remain high. The objective of the current study was to use quality improvement (QI) methodology to create a standardized infection prevention bundle aimed at reducing the rate of shunt infections. METHODS A prospective, single-center, single-surgeon QI study was undertaken. Patients were included if they were 18 years of age or older and were undergoing a VP shunt insertion or revision. The primary outcome of the study was the development of a shunt-related surgical site infection, within 1 year of surgery, as defined according to the Canadian Nosocomial Infection Surveillance Program guidelines. There was no standardized protocol prior to July 2013. A bundle coined as the Calgary Adult Shunt Infection Prevention Protocol (CASIPP) was implemented on July 1, 2013, and updated on July 1, 2015, when 2% chlorhexidine gluconate in 70% isopropyl alcohol replaced povidone-iodine for preoperative skin antisepsis. Protocol compliance was regularly monitored using a standardized process. No antibiotic-impregnated catheters were used. RESULTS A total of 621 consecutive VP shunt insertions and revisions were included in the study. The rate of shunt infection was 5.8% during the period in which there was no standardized shunt protocol. After the implementation of the CASIPP the infection rate decreased to 4.0%, and after introduction of the chlorhexidine/alcohol skin antisepsis, the infection rate was 0% in 379 consecutive procedures (p < 0.0001). Multivariable logistic regression analysis demonstrated that the use of chlorhexidine/alcohol with CASIPP was associated with a significant reduction in the odds of developing a shunt infection (OR 0.032, 95% CI 0-0.19, p = 0.0005). CONCLUSIONS The implementation of a standardized shunt infection prevention bundle within the adult population, without the use of antibiotic-impregnated catheters, significantly reduced the rate of shunt infections which was sustained over many years. The use of 2% chlorhexidine gluconate in 70% isopropyl alcohol for preoperative antisepsis may have played a significant role. Multicenter studies should be completed to verify the effectiveness of the authors' protocol.
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Affiliation(s)
- Sandeep Muram
- 1Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Alberta.,2Alberta Health Services, Calgary, Alberta, Canada
| | - Albert M Isaacs
- 1Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Alberta.,2Alberta Health Services, Calgary, Alberta, Canada
| | - Nicholas Sader
- 1Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Alberta.,2Alberta Health Services, Calgary, Alberta, Canada
| | | | - Annie Fong
- 2Alberta Health Services, Calgary, Alberta, Canada.,4Infection Prevention and Control, Alberta Health Services, Calgary
| | - John Conly
- 4Infection Prevention and Control, Alberta Health Services, Calgary.,8O'Brien Institute for Public Health; and
| | - Mark G Hamilton
- 1Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Alberta.,2Alberta Health Services, Calgary, Alberta, Canada.,9The Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
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Bakhaidar M, Wilcox JT, Sinclair DS, Diaz RJ. Ventriculoatrial Shunts: Review of Technical Aspects and Complications. World Neurosurg 2021; 158:158-164. [PMID: 34775091 DOI: 10.1016/j.wneu.2021.11.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022]
Abstract
Diversion of cerebrospinal fluid is required in many neurosurgical conditions. When a standard ventriculoperitoneal shunt and endoscopic third ventriculostomy are not appropriate options, placement of a ventriculoatrial shunt is a safe, relatively familiar second-line shunting procedure. Herein we reviewed the technical aspects of ventriculoatrial shunt placement using an illustrative case. We focused on the different modalities for inserting and confirming the location of the distal catheter tip. We discussed how to overcome typical difficulties and significant concerns, such as cardiac arrhythmias and venous thrombosis. In addition, we reviewed the current literature for the different complications associated with ventriculoatrial shunt placement.
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Affiliation(s)
- Mohamad Bakhaidar
- Department of Neurology and Neurosurgery, Montreal Neurological Hospital and Institute, McGill University, Montreal, Quebec, Canada; Division of Neurosurgery, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Jared T Wilcox
- Department of Neurology and Neurosurgery, Montreal Neurological Hospital and Institute, McGill University, Montreal, Quebec, Canada
| | - David S Sinclair
- Department of Neurology and Neurosurgery, Montreal Neurological Hospital and Institute, McGill University, Montreal, Quebec, Canada
| | - Roberto Jose Diaz
- Department of Neurology and Neurosurgery, Montreal Neurological Hospital and Institute, McGill University, Montreal, Quebec, Canada.
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Hamilton M, Isaacs A. Natural History, Treatment Outcomes and Quality of Life in Idiopathic Normal Pressure Hydrocephalus (iNPH). Neurol India 2021; 69:S561-S568. [DOI: 10.4103/0028-3886.332281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Della Pepa GM, Sturiale CL, Stifano V. Letter: Transesophageal Echocardiography-Guided Ventriculoatrial Shunt Insertion. Oper Neurosurg (Hagerstown) 2020; 20:E73. [PMID: 33074316 DOI: 10.1093/ons/opaa344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 08/19/2020] [Indexed: 11/13/2022] Open
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Hamilton MG, Krahn D, Walker AM, Isaacs AM, Hurdle H. In Reply: Transesophageal Echocardiography-Guided Ventriculoatrial Shunt Insertion. Oper Neurosurg (Hagerstown) 2020; 20:E74. [PMID: 33074307 DOI: 10.1093/ons/opaa345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Mark G Hamilton
- Division of Neurosurgery Department of Clinical Neuroscience University of Calgary Calgary Alberta, Canada.,Adult Hydrocephalus Program Department of Clinical Neuroscience University of Calgary Calgary Alberta, Canada
| | - Danae Krahn
- Department of Anesthesia University of Calgary Calgary Alberta, Canada
| | - Andrew M Walker
- Department of Anesthesia University of Calgary Calgary Alberta, Canada
| | - Albert M Isaacs
- Division of Neurosurgery Department of Clinical Neuroscience University of Calgary Calgary Alberta, Canada.,Department of Neuroscience Washington University School of Medicine St. Louis, Missouri
| | - Heather Hurdle
- Department of Anesthesia University of Calgary Calgary Alberta, Canada
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Hamilton MG, Krahn D, Walker AM, Hurdle H, Isaacs AM. In Reply: Transesophageal Echocardiography-Guided Ventriculoatrial Shunt Insertion. Oper Neurosurg (Hagerstown) 2020; 19:E334. [PMID: 32615594 DOI: 10.1093/ons/opaa185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mark G Hamilton
- Division of Neurosurgery Department of Clinical Neuroscience University of Calgary Cumming School of Medicine Calgary, AB, Canada.,Adult Hydrocephalus Program Department of Clinical Neuroscience University of Calgary Cumming School of Medicine Calgary, AB, Canada
| | - Danae Krahn
- Department of Anesthesia University of Calgary Cumming School of Medicine Calgary, AB, Canada
| | - Andrew M Walker
- Department of Anesthesia University of Calgary Cumming School of Medicine Calgary, AB, Canada
| | - Heather Hurdle
- Department of Anesthesia University of Calgary Cumming School of Medicine Calgary, AB, Canada
| | - Albert M Isaacs
- Division of Neurosurgery Department of Clinical Neuroscience University of Calgary Cumming School of Medicine Calgary, AB, Canada.,Department of Neuroscience Washington University School of Medicine St. Louis, Missouri
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García-Ballestas E, Martinez-Perez R, Agrawal A, Moscote-Salazar LR. Letter: Transesophageal Echocardiography-Guided Ventriculoatrial Shunt Insertion. Oper Neurosurg (Hagerstown) 2020; 19:E333. [PMID: 32585690 DOI: 10.1093/ons/opaa182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ezequiel García-Ballestas
- Consejo Latinoamericano de Neurointensivismo- CLaNi Cartagena, Colombia.,Centro De Investigaciones Biomédicas (CIB) Faculty of Medicine - University of Cartagena Cartagena, Colombia
| | - Rafael Martinez-Perez
- Department of Neurosurgery Wexner Medical Center The Ohio State University Columbus, Ohio.,Institute of Neurosciences Division of Neurosurgery Universidad Austral de Chile Valdivia, Chile
| | - Amit Agrawal
- Department of Neurosurgery All India Institute of Medical Sciences Saket Nagar, Bhopal Madhya Pradesh, India
| | - Luis-Rafael Moscote-Salazar
- Consejo Latinoamericano de Neurointensivismo- CLaNi Cartagena, Colombia.,Centro De Investigaciones Biomédicas (CIB) Faculty of Medicine - University of Cartagena Cartagena, Colombia
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