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Doshi AB, Sarkar H, Shelke Y, Pothare A, Kulkarni A. Solving a complex, rare, and challenging scenario in a normal pressure hydrocephalus with recurrent shunt dysfunction and multiple revisions - The opposing role of evolving low-pressure hydrocephalus and idiopathic raised intra-abdominal pressure. Surg Neurol Int 2022; 13:546. [PMID: 36600762 PMCID: PMC9805611 DOI: 10.25259/sni_586_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/26/2022] [Indexed: 11/27/2022] Open
Abstract
Background Maintenance of pressure gradient within the intracranial chamber, shunt hardware, and the abdominal cavity plays a significant role in the optimal functioning of the ventriculo peritoneal shunt. We report a rare and a complex scenario in a patient with normal pressure hydrocephalus (NPH) who had recurrent and refractory ventricular peritoneal shunt dysfunction. Following a meticulous analysis, this was attributed to a very rare, and, first to be documented in the literature, a combination of an evolved very low pressure hydrocephalus (VLPH) system and asymptomatic raised intra-abdominal pressure (IAP). Case Description A 72-year-old male presented with NPH syndrome, associated with recurrent shunt dysfunction. A thorough systematic evaluation, which included intracranial pressure monitoring and IAP monitoring, revealed the presence of VLPH and a concomitant elevated IAP that was asymptomatic. This unique situation required changes in surgical strategy, which included correction of VLPH state, insertion of the anti-siphon device, and the placement of the distal end of the shunt into the pleural cavity. This led to solving the "mystery" of recurrent shunt dysfunction in this complex scenario. Conclusion It is imperative to perform the pressure analysis of the intracranial chamber, shunt hardware, and even the abdominal cavity, especially, in every case of refractory shunt revisions. Possibilities of a rare cause such as VLPH or an asymptomatic raised IAP acting alone or in combination must be considered. Only then, the final cerebrospinal fluid diversion strategy should be decided.
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Affiliation(s)
- Anirudha Bharat Doshi
- Corresponding author: Anirudha Bharat Doshi, Department of Neurosurgery, Kokilaben Dhirubhai Ambani Research and Medical Center, Mumbai, Maharashtra, India.
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Kamo M, Kajimoto Y, Ohmura T, Kameda M, Tucker A, Miyake H, Wanibuchi M. Weight and Abdominal Pressure-Induced Shunt Trouble in Patients With Shunted Normal Pressure Hydrocephalus: A Comprehensive Study on Pressure Environment of Shunt System. Front Neurol 2022; 13:882757. [PMID: 35677338 PMCID: PMC9167924 DOI: 10.3389/fneur.2022.882757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives We identified a new type of shunt malfunction (SM) in patients with normal pressure hydrocephalus (NPH). It is induced by weight change and can be treated with valve readjustment. There were two types of SM as follows: Underdrainage induced by the weight gain and overdrainage induced by the weight loss. This study aims to elucidate this mechanism by assessing the shunt pressure environment. Methods The total pressure environment of the shunt system was prospectively studied in patients with shunted NPH at Osaka Medical College Hospital from 1999 to 2005. We measured the pressure environment during the initial pressure setting of the valve by the intracranial pressure (ICP) guide, after setting the valve, and when SM was suspected. We evaluated ICP, intra-abdominal pressure (IAP), and hydrostatic and perfusion pressures of the shunt system in the sitting and supine positions. The target ICP for valve setting was empirically set at the range from −8 to −13 mm Hg in the sitting position, referring to the external auditory meatus. During the study period, we identified five cases of SM induced by weight change and assessed the changes in the pressure environment across pre-SM, SM, and post-SM. Results In four cases of underdrainage, gait disturbance worsened with an average weight gain of 6.8 ± 1.2 kg. With weight gain, IAP and ICP increased by 8.8 ± 1.6 and 4.8 ± 1.0 mm Hg, respectively. Consequently, ICP increased to −6.5 ± 1.9 mm Hg. One overdrainage patient developed an asymptomatic chronic subdural hematoma (CSDH) with a weight loss of 10 kg. With the weight loss, both IAP and ICP decreased by 5 mm Hg, and concomitantly, ICP decreased to −18 mm Hg. In all patients, the valve readjustment restored their ICP to the target pressure. After the valve readjustment, the gait disturbance improved immediately, and the CSDH disappeared after 1 month. Conclusion In patients with shunts, the weight change was linked to ICP via IAP. Due to the weight change, the underdrainage occurred when ICP was above the target pressure, and the overdrainage occurred when ICP was below it. We named this SM as the weight and abdominal pressure-induced shunt trouble. The patients with SM along with weight changes should be the first to be tried for the valve readjustment.
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Affiliation(s)
- Masatsugu Kamo
- Department Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Yoshinaga Kajimoto
- Department Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
- *Correspondence: Yoshinaga Kajimoto
| | - Tomohisa Ohmura
- Department Neurosurgery, Nishinomiya Kyoritsu Neurosurgical Hospital, Nishinomiya, Japan
| | - Masahiro Kameda
- Department Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Adam Tucker
- Department Neurosurgery, Kitami Red Cross Hospital, Kitami, Japan
| | - Hiroji Miyake
- Department Neurosurgery, Nishinomiya Kyoritsu Rehabilitation Hospital, Nishinomiya, Japan
| | - Masahiko Wanibuchi
- Department Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
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Trimmel NE, Podgoršak A, Oertel MF, Jucker S, Arras M, Schmid Daners M, Weisskopf M. The Sheep as a Comprehensive Animal Model to Investigate Interdependent Physiological Pressure Propagation and Multiparameter Influence on Cerebrospinal Fluid Dynamics. Front Neurosci 2022; 16:868567. [PMID: 35431780 PMCID: PMC9008349 DOI: 10.3389/fnins.2022.868567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/09/2022] [Indexed: 11/18/2022] Open
Abstract
The present study aims to develop a suitable animal model for evaluating the physiological interactions between cerebrospinal fluid (CSF) dynamics, hemodynamics, and abdominal compartment pressures. We seek to contribute to the enhanced recognition of the pathophysiology of CSF-dependent neurological disorders like hydrocephalus and the improvement of available treatment options. To date, no comprehensive animal model of CSF dynamics exists, and establishing an accurate model will advance our understanding of complex CSF physiology. Persisting knowledge gaps surrounding the communication and pressure propagation between the cerebrospinal space and adjacent anatomical compartments exacerbate the development of novel therapies for neurological diseases. Hence, the need for further investigation of the interactions of vascular, craniospinal, and abdominal pressures remains beyond dispute. Moreover, the results of this animal study support the optimization of in vitro test benches for medical device development, e.g., ventriculoperitoneal shunts. Six female white alpine sheep were surgically equipped with pressure sensors to investigate the physiological values of intracranial, intrathecal, arterial, central venous, jugular venous, vesical pressure, and four differently located abdominal pressures. These values were measured simultaneously during the acute animal trial with sheep under general anesthesia. Both carotid and femoral arterial blood pressure indicate a reliable and comparable representation of the systematic blood pressure. However, the jugular venous pressure and the central venous pressure in sheep in dorsal recumbency do not correlate well under general anesthesia. Furthermore, there is a trend for possible comparability of lateral intraventricular and lumbar intrathecal pressure. Nevertheless, animal body position during measurements must be considered since different body constitutions can alter the horizontal line between the cerebral ventricles and the lumbar subarachnoid space. While intra-abdominal pressure measurement in the four different abdominal quadrants yielded greater inter-individual variability, intra-vesical pressure measurements in our setting delivered comparable values for all sheep. We established a novel and comprehensive ovine animal model to investigate interdependent physiologic pressure propagation and multiparameter influences on CSF dynamics. The results of this study will contribute to further in vitro bench testing, the derivation of novel quantitative models, and the development of a pathologic ovine hydrocephalus model.
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Affiliation(s)
- Nina Eva Trimmel
- Center for Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Anthony Podgoršak
- Department of Mechanical and Process Engineering, ETH Zürich, Zurich, Switzerland
| | - Markus Florian Oertel
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Simone Jucker
- Center for Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Margarete Arras
- Center for Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | - Miriam Weisskopf
- Center for Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Hagerty V, Galvin C, Maharaj A, Vrionis F. Ventriculoatrial shunts as an alternate therapy in patients with normal pressure hydrocephalus refractory to ventriculoperitoneal shunts: A Case series. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Huang AP, Kuo LT, Lai DM, Yang SH, Kuo MF. Antisiphon device: a review of existing mechanisms and clinical applications to prevent overdrainage in shunted hydrocephalic patients. Biomed J 2021; 45:95-108. [PMID: 34411787 PMCID: PMC9133390 DOI: 10.1016/j.bj.2021.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/01/2021] [Accepted: 08/06/2021] [Indexed: 11/25/2022] Open
Abstract
Overdrainage of cerebrospinal fluid is one of the most notorious complications after ventriculoperitoneal shunt implantation. Siphon effect plays a major role in the development of overdrainage. Various overdrainage-preventing devices have been invented to counteract the siphon effect. Though some of the devices are designed to reduce the flow instead of providing antisiphoning effect, they are generally called antisiphon devices (ASDs). The basics of siphoning, the mechanisms and physical properties of currently available devices are described in this article. The clinical efficacy, shunt survival, and considerations on patient factors are also discussed. There are three kinds of ASD design, diaphragm, gravitational, and flow reducing devices. Flow reducing ASD is always open and the flow it controls is relatively stable. On the other hand, it may not provide sufficient flow in nocturnal intracranial pressure elevations. Diaphragm and gravitational devices are sensitive to the position of the patients. Diaphragm device is sensitive to the external pressure and the relative position of the device to the mastoid process. The gravitational device is sensitive to the angle between the axis of the device and the head. Many studies showed encouraging results with gravitational devices. Studies regarding diaphragm devices either showed better or similar outcomes comparing to differential pressure valves. Clinical studies regarding flow-reducing devices and head-to-head comparison between different mechanisms are warranted. This review aims to provide a useful reference for clinical practice of hydrocephalus.
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Affiliation(s)
- An-Ping Huang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Lu-Ting Kuo
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Dar-Ming Lai
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shih-Hung Yang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Meng-Fai Kuo
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
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How to Choose a Shunt for Patients with Normal Pressure Hydrocephalus: A Short Guide to Selecting the Best Shunt Assembly. J Clin Med 2021; 10:jcm10061210. [PMID: 33803977 PMCID: PMC7999679 DOI: 10.3390/jcm10061210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/06/2021] [Accepted: 03/08/2021] [Indexed: 01/22/2023] Open
Abstract
Most patients with hydrocephalus are still managed with the implantation of a cerebrospinal fluid (CSF) shunt in which the CSF flow is regulated by a differential-pressure valve (DPV). Our aim in this review is to discuss some basic concepts in fluid mechanics that are frequently ignored but that should be understood by neurosurgeons to enable them to choose the most adequate shunt for each patient. We will present data, some of which is not provided by manufacturers, which may help neurosurgeons in selecting the most appropriate shunt. To do so, we focused on the management of patients with idiopathic “normal-pressure hydrocephalus” (iNPH), as one of the most challenging scenarios, in which the combination of optimal technology, patient characteristics, and knowledge of fluid mechanics can significantly modify the surgical results. For a better understanding of the available hardware and its evolution over time, we will have a second look at the design of the first DPV and the reasons why additional devices were incorporated to control for shunt overdrainage and its related complications. We try to persuade the reader that a clear understanding of the physical concepts of the CSF and shunt dynamics is key to understand the pathophysiology of iNPH and to improve its treatment.
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Poca MA, Gándara DF, Rosas K, Alcina A, López-Bermeo D, Sahuquillo J. Considerations in the Use of Gravitational Valves in the Management of Hydrocephalus. Some Lessons Learned with the Dual-Switch Valve. J Clin Med 2021; 10:E246. [PMID: 33445418 PMCID: PMC7830811 DOI: 10.3390/jcm10020246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 01/02/2021] [Accepted: 01/07/2021] [Indexed: 11/17/2022] Open
Abstract
In the past decade, there has been a clear trend towards better outcomes in patients with hydrocephalus, especially those with normal pressure hydrocephalus (NPH). This is partly due to the availability of more sophisticated hardware and a better understanding of implants. However, there is little evidence to show the superiority of a specific type of valve over another. The most commonly reported consequence of hydrodynamic mismatch is shunt over-drainage. Simple differential pressure valves, with a fixed opening pressure or even adjustable valves, lead to non-physiologic intraventricular pressure (IVP) as soon as the patient moves into an upright posture. These valves fail to maintain IVP within physiological limits due to the changes in hydrostatic pressure in the drainage system. To solve this problem more complex third-generation hydrostatic valves have been designed. These gravitational devices aim to reduce flow through a shunt system when the patient is upright but there are important technical differences between them. Here we review the main characteristics of the Miethke® Dual-Switch valve, which includes two valve chambers arranged in parallel: a low-opening pressure valve, designed for working in the supine position, and a second high-opening pressure valve, which starts working when the patient assumes the upright position. This paper specifies the main advantages and drawbacks of this device and provide a series of recommendations for its use. The discussion of this specific gravitational valve allows us to emphasize the importance of using gravitational control in implanted shunts and some the caveats neurosurgeons should take into consideration when using gravitational devices in patients with hydrocephalus. The correct function of any gravitational device depends on adequate device implantation along the vertical body axis. Misalignment from the vertical axis equal to or more than 45° might eliminate the beneficial effect of these devices.
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Affiliation(s)
- Maria A. Poca
- Department of Neurosurgery, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.F.G.); (K.R.); (A.A.); (D.L.-B.); (J.S.)
- Neurotrauma and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Dario F. Gándara
- Department of Neurosurgery, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.F.G.); (K.R.); (A.A.); (D.L.-B.); (J.S.)
- Neurotrauma and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Katiuska Rosas
- Department of Neurosurgery, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.F.G.); (K.R.); (A.A.); (D.L.-B.); (J.S.)
- Neurotrauma and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Aloma Alcina
- Department of Neurosurgery, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.F.G.); (K.R.); (A.A.); (D.L.-B.); (J.S.)
| | - Diego López-Bermeo
- Department of Neurosurgery, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.F.G.); (K.R.); (A.A.); (D.L.-B.); (J.S.)
| | - Juan Sahuquillo
- Department of Neurosurgery, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (D.F.G.); (K.R.); (A.A.); (D.L.-B.); (J.S.)
- Neurotrauma and Neurosurgery Research Unit, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
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Depauw PRAM, Groen RJM, Van Loon J, Peul WC, Malbrain MLNG, De Waele JJ. The significance of intra-abdominal pressure in neurosurgery and neurological diseases: a narrative review and a conceptual proposal. Acta Neurochir (Wien) 2019; 161:855-864. [PMID: 30911831 PMCID: PMC6483957 DOI: 10.1007/s00701-019-03868-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 03/03/2019] [Indexed: 11/24/2022]
Abstract
Intra-abdominal pressure (IAP) is a physiological parameter that has gained considerable attention during the last few decades. The incidence of complications arising from increased IAP, known as intra-abdominal hypertension (IAH) or abdominal compartment syndrome in critically ill patients, is high and its impact is significant. The effects of IAP in neurological conditions and during surgical procedures are largely unexplored. IAP also appears to be relevant during neurosurgical procedures (spine and brain) in the prone position, and in selected cases, IAH may affect cerebrospinal fluid drainage after a ventriculoperitoneal shunt operation. Furthermore, raised IAP is one of the contributors to intracranial hypertension in patients with morbid obesity. In traumatic brain injury, case reports described how abdominal decompression lowers intracerebral pressure. The anatomical substrate for transmission of the IAP to the brain and venous system of the spine is the extradural neural axis compartment; the first reports of this phenomenon can be found in anatomical studies of the sixteenth century. In this review, we summarize the available knowledge on how IAP impacts the cerebrospinal venous system and the jugular venous system via two pathways, and we discuss the implications for neurosurgical procedures as well as the relevance of IAH in neurological disorders.
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Affiliation(s)
- Paul R A M Depauw
- Department of Neurosurgery, Elisabeth Tweesteden Hospital (ETZ), Tilburg, The Netherlands.
- Elisabeth Tweesteden Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands.
| | - Rob J M Groen
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Johannes Van Loon
- Department of Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center (LUMC) and The Hague Medical Center (HMC+), Leiden, The Netherlands
| | - Manu L N G Malbrain
- Intensive Care Unit, University Hospital Brussels (UZB), Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
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Frybova B, Drabek J, Lochmannova J, Douda L, Hlava S, Zemkova D, Mixa V, Kyncl M, Zeman L, Rygl M, Keil R. Cholelithiasis and choledocholithiasis in children; risk factors for development. PLoS One 2018; 13:e0196475. [PMID: 29763444 PMCID: PMC5953441 DOI: 10.1371/journal.pone.0196475] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/13/2018] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To compare anthropometric data (body mass index [BMI]) in patients without lithiasis to patients with symptomatic simple cholelithiasis or choledocholithiasis. METHODS We retrospectively reviewed data from 147 patients undergoing laparoscopic cholecystectomy between 2001-2015. Complete growth data from 98 patients was compared with anthropometric data from the population of the Czech Republic and a control group (BMI of 100 consecutive patients without biliary stones in abdominal ultrasound who were admitted to a surgical department for suspected appendicitis). RESULTS The BMI of 75 children with simple cholelithiasis and 23 with choledocholithiasis was compared to the standard Czech pediatric population and to the control group. The median age (simple cholelithiasis and choledocholithiasis) was 16 years, and 35 patients (24%) had a family history of gallstones. Types of lithiasis included multiple (n = 120), solitary (n = 11), and sludge (n = 10). Five cases had polyps and one had gallbladder dysplasia. Patients with simple cholelithiasis had significantly higher BMI compared to the control group without cholelithiasis (p<0.0001) and the standard Czech population (p = 0.03). Patients with choledocholithiasis had a mean BMI significantly higher than that of the general population (p = 0.001) and the control group (p = 0.0001). Patients with choledocholithiasis had significantly higher BMI than those with simple cholelithiasis (p = 0.03). CONCLUSION Patients with cholelithiasis had significantly higher BMI than the general population, and patients with choledocholithiasis had significantly higher BMI than patients with simple lithiasis. Elevated BMI is a risk factor for developing choledocholithiasis. ERCP and early laparoscopic cholecystectomy in patients with choledocholithiasis offer equivalent outcomes in patients with simple cholelithiasis.
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Affiliation(s)
- Barbora Frybova
- Department of Pediatric Surgery, Charles University in Prague, 2 Faculty of Medicine, University Hospital Motol in Prague, Prague, Czech Republic
| | - Jiri Drabek
- Department of Internal Medicine, Charles University in Prague, 2 Faculty of Medicine, University Hospital Motol in Prague, Prague, Czech Republic
| | - Jindra Lochmannova
- Department of Internal Medicine, Charles University in Prague, 2 Faculty of Medicine, University Hospital Motol in Prague, Prague, Czech Republic
| | - Ladislav Douda
- 2 Department of Internal Medicine–Gastroenterology, Charles University in Prague, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Stepan Hlava
- Department of Internal Medicine, Charles University in Prague, 2 Faculty of Medicine, University Hospital Motol in Prague, Prague, Czech Republic
| | - Daniela Zemkova
- Department of Pediatrics, Charles University in Prague, 2 Faculty of Medicine, University Hospital Motol in Prague, Prague, Czech Republic
| | - Vladimir Mixa
- Department of Anaesthesiology and Intensive Care Medicine, Charles University in Prague, 2 Faculty of Medicine, University Hospital in Motol in Prague, Prague, Czech Republic
| | - Martin Kyncl
- Department of Radiology, Charles University in Prague, 2 Faculty of Medicine, University Hospital Motol in Prague, Prague, Czech Republic
| | - Lubos Zeman
- Department of Pediatric Surgery, Charles University in Prague, 2 Faculty of Medicine, University Hospital Motol in Prague, Prague, Czech Republic
| | - Michal Rygl
- Department of Pediatric Surgery, Charles University in Prague, 2 Faculty of Medicine, University Hospital Motol in Prague, Prague, Czech Republic
| | - Radan Keil
- Department of Internal Medicine, Charles University in Prague, 2 Faculty of Medicine, University Hospital Motol in Prague, Prague, Czech Republic
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A counterforce to diversion of cerebrospinal fluid during ventriculoperitoneal shunting: the intraperitoneal pressure. An observational study. Acta Neurochir (Wien) 2018; 160:519-524. [PMID: 29288392 DOI: 10.1007/s00701-017-3439-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 12/14/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Intraperitoneal pressure (IPP) counteracts the diversion of cerebrospinal fluid (CSF) from the cranial to the peritoneal compartment during ventriculoperitoneal shunting. Animal studies suggest that the intrinsic IPP exceeds the intraperitoneal hydrostatic pressure. The intrinsic IPP in mobile patients is relevant for shunt therapy, but data about it is not available. METHODS The IPP was measured indirectly in 25 mobile subjects (13 female) by applying a standard intravesical pressure measurement technique. Measurements were carried out in reference to the navel (supine position) and the xiphoid (upright position). Results were adjusted for the intraperitoneal hydrostatic pressure and correlated afterward with general body measures. RESULTS The corrected mean (SD) IPP measured in the supine position was 4.4 (4.5) cm H2O, and the mean (SD) upright IPP was 1.6 (7.8) cm H2O (p = 0.02). A positive correlation was found between the body mass index (BMI) and the IPP in the upright (r = 0.51) and supine (r = 0.65) body positions, and between the abdominal circumference and the IPP in the supine position (r = 0.63). CONCLUSIONS The intrinsic IPP in mobile subjects exceeds the intraperitoneal hydrostatic pressure. Thus, the intrinsic IPP counteracts the diversion of CSF into the peritoneal compartment. The intrinsic IPP is correlated with mobile patients' general body measures.
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Progressive Functional Underdrainage in Cerebrospinal Fluid Shunt-Dependent Women During Pregnancy: Case Report and Review of the Literature. World Neurosurg 2018; 109:372-376. [DOI: 10.1016/j.wneu.2017.09.108] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/15/2017] [Accepted: 09/16/2017] [Indexed: 11/20/2022]
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12
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Carnevale JA, Ahmedli N, Morrison JF, Asaad WF, Klinge P, Telfeian A. T-Connector Modification for Reducing Recurrent Distal Shunt Failure: Report of 2 Cases. Oper Neurosurg (Hagerstown) 2017; 13:E33-E36. [PMID: 29186599 DOI: 10.1093/ons/opx050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 02/17/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Cerebrospinal fluid shunt placement is used to treat the various causes of hydrocephalus by redirecting the cerebrospinal fluid to the body, most commonly from the ventricle to the peritoneum. Distal catheter displacement from the peritoneal cavity can occur as a complication, necessitating reoperation. CLINICAL PRESENTATION We report 2 such cases in obese patients involving retropulsion of the distal tubing. To address this complication, we implanted a T-connector to the distal catheter construct. CONCLUSION This study supports the use of a T-connector catheter construct to decrease and prevent the possibility of distal peritoneal catheter retropulsion in cases of elevated intra-abdominal pressure, both prophylactically and in revisions.
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Affiliation(s)
- Joseph A Carnevale
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Nigar Ahmedli
- Department of Otolaryngology, Albert Einstein College of Medicine, Bronx, New York
| | - John F Morrison
- Department of Neurosurgery, University at Buffalo, Buffalo, New York
| | - Wael F Asaad
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Petra Klinge
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Albert Telfeian
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Castle-Kirszbaum MD, Tee JW, Chan P, Hunn MK. Obesity in Neurosurgery: A Narrative Review of the Literature. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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14
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Martín-Láez R, Vázquez-Barquero A. [Long-term prognosis of idiopathic chronic adult hydrocephalus: I. The University Hospital Marqués de Valdecilla diagnostic and therapeutic protocol]. Neurocirugia (Astur) 2016; 28:141-156. [PMID: 27255166 DOI: 10.1016/j.neucir.2016.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 04/19/2016] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Despite the existence of published guidelines for more than a decade, there is still a substantial variation in the management of idiopathic normal pressure hydrocephalus due to its diagnostic and therapeutic complexity. DEVELOPMENT The diagnostic and therapeutic protocol for the management of idiopathic normal pressure hydrocephalus in use at the Department of Neurosurgery of the University Hospital Marqués de Valdecilla is presented. The diagnostic process includes neuropsychological testing, phase contrast cine MRI, urodynamic evaluation, continuous intracranial pressure monitoring, cerebrospinal fluid hydrodynamics by means of lumbar infusion testing, and intra-abdominal pressure measurement. A patient is considered a surgical candidate if any of the following criteria is met: mean intracranial pressure >15mmHg, or B-waves present in >10% of overnight recording; pressure-volume index <15ml, or resistance to cerebrospinal fluid outflow (ROUT) >4.5mmHg/ml/min in bolus infusion test; ROUT >12mmHg/ml/min, intracranial pressure >22mmHg, or high amplitude B-waves in the steady-state of the continuous rate infusion test; or a clinical response to high-volume cerebrospinal fluid withdrawal. CONCLUSIONS The implementation of a diagnostic and therapeutic protocol for idiopathic normal pressure hydrocephalus management could improve various aspects of patient care. It could reduce variability in clinical practice, optimise the use of health resources, and help in identifying scientific uncertainty areas, in order to direct research efforts in a more appropriate way.
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Affiliation(s)
- Rubén Martín-Láez
- Servicio de Neurocirugía-Unidad de Raquis Quirúrgico, Servicio de Neurocirugía, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander, Cantabria; Instituto de Investigación Sanitaria Marqués de Valdecilla (IDIVAL), Santander, Cantabria; Observatorio de Salud Pública de Cantabria, Fundación Marqués de Valdecilla, Santander, Cantabria.
| | - Alfonso Vázquez-Barquero
- Servicio de Neurocirugía-Unidad de Raquis Quirúrgico, Servicio de Neurocirugía, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander, Cantabria; Instituto de Investigación Sanitaria Marqués de Valdecilla (IDIVAL), Santander, Cantabria; Observatorio de Salud Pública de Cantabria, Fundación Marqués de Valdecilla, Santander, Cantabria
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Bolster F, Fardanesh R, Morgan T, Katz DS, Daly B. Cross-sectional imaging of thoracic and abdominal complications of cerebrospinal fluid shunt catheters. Emerg Radiol 2015; 23:117-25. [PMID: 26610766 DOI: 10.1007/s10140-015-1368-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 11/17/2015] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Ferdia Bolster
- Department of Radiology, University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201, USA.
| | - Reza Fardanesh
- Department of Radiology, University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201, USA
| | - Tara Morgan
- Department of Radiology, University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201, USA
| | - Douglas S Katz
- Department of Radiology, Winthrop-University Hospital, Mineola, NY, 11501, USA
| | - Barry Daly
- Department of Radiology, University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201, USA
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Meier U, Stengel D, Müller C, Fritsch MJ, Kehler U, Langer N, Kiefer M, Eymann R, Schuhmann MU, Speil A, Weber F, Remenez V, Rohde V, Ludwig HC, Lemcke J. Predictors of subsequent overdrainage and clinical outcomes after ventriculoperitoneal shunting for idiopathic normal pressure hydrocephalus. Neurosurgery 2014; 73:1054-60. [PMID: 24257332 DOI: 10.1227/neu.0000000000000155] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Little is known about variables associated with overdrainage complications and neurofunctional and health-related quality of life outcomes in idiopathic normal-pressure hydrocephalus (iNPH) patients after shunt surgery. OBJECTIVE To identify candidate demographic and disease-specific predictors of overdrainage and patient-related outcomes, allowing for more personalized care of patients with iNPH. METHODS This was a secondary analysis of the dataset of the SVASONA study, a multicenter randomized trial comparing gravitational and conventional gravitational valves for treating iNPH. We evaluated the association between baseline items and the incidence of overdrainage, using different endpoint definitions. RESULTS We identified only a few variables associated with a possible increased risk of overdrainage. Apart from using conventional rather than gravitational valves, longer duration of surgery and female sex were associated with a higher risk of clinical signs and symptoms suggestive of overdrainage (hazard ratio: 1.02, 95% confidence interval: 1.01-1.04 and 1.84, 95% confidence interval: 0.81-4.16). The occurrence of clinical symptoms of overdrainage, and the need for exchanging a programmable by a gravitational valve may adversely affect disease-specific outcomes like the Kiefer score. CONCLUSION Few, if any, baseline and treatment characteristics may be helpful in estimating the individual risk of complications and clinical outcomes after shunt surgery for iNPH. Patients should be informed that longer surgery for any reason may increase the risk of later overdrainage. Also, women should be counseled about a sex-associated increased risk of the development of clinical symptoms of overdrainage, although the latter cannot be distinguished from a generally higher prevalence of headaches in the female population.
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Affiliation(s)
- Ullrich Meier
- ‡Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany; §Centre for Clinical Research, Department of Trauma and Orthopaedic Surgery, Unfallkrankenhaus Berlin, Germany; ¶Julius Wolff Institute, Charité Medical University Centre, Germany; ‖Department of Neurosurgery, Ernst-Moritz-Arndt-University of Greifswald, Germany; #Department of Neurosurgery, Asklepios Hospital Altona, Hamburg, Germany; **Department of Neurosurgery, Saarland Medical University, Homburg/Saar, Germany; ‡‡Department of Neurosurgery, Eberhard-Karls-University of Tübingen, Germany; §§Department of Neurosurgery, Hospital Cologne-Merheim, Germany; ¶¶Department of Neurosurgery, Georg-August-University of Göttingen, Germany
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17
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Analysis of intra-abdominal hypertension in severe burned patients: The Vall d’Hebron experience. Burns 2014; 40:719-24. [DOI: 10.1016/j.burns.2013.09.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 07/29/2013] [Accepted: 09/20/2013] [Indexed: 01/12/2023]
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Freimann FB, Ötvös J, Chopra SS, Vajkoczy P, Wolf S, Sprung C. Differential pressure in shunt therapy: investigation of position-dependent intraperitoneal pressure in a porcine model. J Neurosurg Pediatr 2013; 12:575-81. [PMID: 24093588 DOI: 10.3171/2013.8.peds13205] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECT The differential pressure between the intracranial and intraperitoneal cavities is essential for ventriculoperitoneal shunting. A determination of the pressure in both cavities is decisive for selecting the appropriate valve type and opening pressure. The intraperitoneal pressure (IPP)-in contrast to the intracranial pressure-still remains controversial with regard to its normal level and position dependency. METHODS The authors used 6 female pigs for the experiments. Two transdermal telemetric pressure sensors (cranial and caudal) were implanted intraperitoneally with a craniocaudal distance of 30 cm. Direct IPP measurements were supplemented with noninvasive IPP measurements (intragastral and intravesical). The IPP was measured with the pigs in the supine (0°), 30°, 60°, and vertical (90°) body positions. After the pigs were euthanized, CT was used to determine the intraperitoneal probe position. RESULTS With pigs in the supine position, the mean (± SD) IPP was 10.0 ± 3.5 cm H2O in a mean vertical distance of 4.5 ± 2.8 cm to the highest level of the peritoneum. The difference between the mean IPP of the cranially and the caudally implanted probes (Δ IPP) increased according to position, from 5.5 cm H2O in the 0° position to 11.5 cm H2O in the 30° position, 18.3 cm H2O in the 60° position, and 25.6 cm H2O in the vertical body position. The vertical distance between the probe tips (cranially implanted over caudally implanted) increased 3.4, 11.2, 19.3, and 22.3 cm for each of the 4 body positions, respectively. The mean difference between the Δ IPP and the vertical distance between both probe tips over all body positions was 1.7 cm H2O. CONCLUSIONS The IPP is subject to the position-dependent hydrostatic force. Normal IPP is able to reduce the differential pressure in patients with ventriculoperitoneal shunts.
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Abstract
Abdominal compartment syndrome is defined as sustained intra-abdominal pressure greater than 20 mm Hg (with or without abdominal perfusion pressure <60 mm Hg) associated with new organ failure or dysfunction. The syndrome is associated with 90% to 100% mortality if not recognized and treated in a timely manner. Nurses are responsible for accurately measuring intra-abdominal pressure in children with abdominal compartment syndrome and for alerting physicians about important changes. This article provides relevant definitions, outlines risk factors for abdominal compartment syndrome developing in children, and discusses an instructive case involving an adolescent with abdominal compartment syndrome. Techniques for measuring intra-abdominal pressure, normal ranges, and the importance of monitoring in the critical care setting for timely identification of intra-abdominal hypertension and abdominal compartment syndrome also are discussed.
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Affiliation(s)
- Jennifer Newcombe
- Pediatric Cardiothoracic Surgery, School of Nursing, Loma Linda University, Loma Linda, California, USA.
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20
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Newcombe J, Mathur M, Bahjri K, Ejike JC. Pediatric critical care nurses' experience with abdominal compartment syndrome. Ann Intensive Care 2012; 2 Suppl 1:S6. [PMID: 22873422 PMCID: PMC3390293 DOI: 10.1186/2110-5820-2-s1-s6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Abdominal compartment syndrome (ACS) is a syndrome associated with multi-system effects of elevated intra-abdominal pressure (IAP) in critically ill children. It has a 90-100% mortality rate if not recognized and treated promptly. Measuring IAP helps identify patients developing intra-abdominal hypertension (IAH) which allows for timely intervention before progression to ACS. IAP helps identify ACS and guides its medical and surgical management. IAP is often measured by the bedside nurse in the intensive care unit. Pediatric critical care nurses (PCCN) play a key role in managing critically ill patients and recognizing potential causes for clinical deterioration such as ACS therefore should be knowledgeable about this entity. OBJECTIVE The aim of this study was to assess the awareness and current knowledge of ACS among PCCN. METHODS A ten-item written questionnaire was distributed at a National Critical Care Conference in 2006 and again in 2010. Participants of the conference voluntarily completed and immediately returned the survey. Results from the two questionnaires were compared. RESULTS Sixty-two percent of 691 questionnaires were completed. The awareness of ACS improved from 69.3% in 2006 to 87.8% in 2010 (p < 0.001) among PCCN. "Years in practice" influenced awareness of ACS. Nurses working for 5-10 and > 10 years were, respectively, 2.34 and 1.89 times more likely to be aware of ACS than those working for < 5 years. Hands-on experience managing a child with ACS by PCCN also improved from 49.1% to 67.9% (p < 0.001) but remains low. The number of participants who never measured IAP fell from 27.3% to 19.1% (p = 0.101). The most common method being used to measure IAP is the bladder method. Knowledge of the definition of ACS remains poor with only 13.2% associating the definition of ACS with organ dysfunction in 2010 which was even lower than in 2006. CONCLUSIONS There is increasing awareness of ACS and experience in its management among PCCN. However, few PCCN correctly understand the definition of ACS. Since recognition of IAH and early intervention can reduce morbidity and mortality in critically ill patients, further educational efforts should be directed toward improving the knowledge and recognition of ACS by PCCN.
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Affiliation(s)
| | - Mudit Mathur
- Division of Pediatric Critical Care, Department of Pediatrics, School of Medicine, Loma Linda University, 11175 Campus Street, Suite A1117, Loma Linda, CA 92354, USA
| | - Khaled Bahjri
- Department of Epidemiology and Biostatistics, School of Public Health, Loma Linda University, Loma Linda, CA, USA
| | - J Chiaka Ejike
- Division of Pediatric Critical Care, Department of Pediatrics, School of Medicine, Loma Linda University, 11175 Campus Street, Suite A1117, Loma Linda, CA 92354, USA
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Schulz M, Goelz L, Spors B, Haberl H, Thomale UW. Endoscopic Treatment of Isolated Fourth Ventricle. Neurosurgery 2011; 70:847-58; discussion 858-9. [PMID: 21937936 DOI: 10.1227/neu.0b013e318236717f] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Treatment of an isolated fourth ventricle should be considered when clinical symptoms or a significant mass effect occur.
OBJECTIVE:
To report clinical and radiographic outcomes after endoscopic transaqueductal or transcisternal stent placement into the fourth ventricle.
METHODS:
In 19 patients (age, 34th week of gestation-20 years; median age, 17.5 months), 22 endoscopic procedures were performed. Either an aqueductoplasty or, in cases with a supratentorially extended fourth ventricular component, an interventricular fenestration was performed. In all patients, a stent connected to the cerebrospinal fluid--diverting shunt was placed through the fenestration. Surgical complications and radiological and clinical outcomes are reported.
RESULTS:
All 19 patients had a mean follow-up of 26.9 ± 18.2 months. No persisting neurological complications were observed; 27.3% of patients experienced complete resolution of presenting symptoms, whereas 68.3% demonstrated partial resolution. Symptoms with short duration (< 4 weeks) resolved completely, whereas long-standing symptoms partially improved. Short-term shunt complications (n = 2; insufficient catheter placement and subdural hygroma) and a need for long-term stent revisions (n = 3; stent retraction and shunt revision for other causes) were observed. The mean fourth ventricular volume was reduced after surgery (44.2 ± 25.8 to 23.1 ± 21.9 mL; P < .01). Pontine diameter increased from 0.9 ± 0.3 to 1.2 ± 0.3 cm (P < .01) after surgery. Both effects were still demonstrated on later radiological follow-up of 24.4 ± 14.2 months (fourth ventricular size, 24.7 ± 28.1 mL; P < .01; pontine diameter, 1.3 ± 0.3 cm; P < .01).
CONCLUSION:
The clinical and radiological outcomes after endoscopic aqueductoplasty and interventriculostomy in children with an isolated fourth ventricle indicate that this procedure is feasible, effective, and safe.
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Affiliation(s)
- Matthias Schulz
- Department of Pediatric Neurosurgery, Charite University Hospital Berlin, Berlin, Germany
- Department of Neurosurgery, Waikato Hospital, Hamilton, New Zealand
| | - Leonie Goelz
- Department of Pediatric Neurosurgery, Charite University Hospital Berlin, Berlin, Germany
| | - Birgit Spors
- Department of Pediatric Radiology, Charite University Hospital Berlin, Berlin, Germany
| | - Hannes Haberl
- Department of Pediatric Neurosurgery, Charite University Hospital Berlin, Berlin, Germany
| | - Ulrich-Wilhelm Thomale
- Department of Pediatric Neurosurgery, Charite University Hospital Berlin, Berlin, Germany
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Morrison JF, Sung KE, Bergman AM, Rosenblatt MS, Arle JE. A novel solution to reduce the complications of distal shunt catheter displacement associated with obesity. J Neurosurg 2010; 113:1314-6. [PMID: 20617878 DOI: 10.3171/2010.6.jns10300] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Despite the varied sources of hydrocephalus, all shunt-treated conditions involve redirection of CSF to the body, commonly the peritoneum. Migration of the distal catheter tip out of the peritoneal space can occur, leading to the need for reoperation. Although uncommon, the authors have recently had 3 such cases in obese patients involving distal tubing retropulsion in otherwise uncomplicated surgeries. In addressing this issue, the authors performed anchoring of the distal catheter tubing through a small abdominal mesh, which is commonly used for hernia repair to increase catheter tube friction without compromising CSF flow. The results suggest this method may mitigate the chance of peritoneal catheter displacement in patients with higher than normal intraabdominal pressure.
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Affiliation(s)
- John F Morrison
- Department of Neurosurgery, Lahey Clinic, Burlington, MA 01805, USA.
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23
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Perforation holes in ventricular catheters--is less more? Childs Nerv Syst 2010; 26:781-9. [PMID: 20024658 DOI: 10.1007/s00381-009-1055-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Accepted: 11/16/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Obstruction is a common cause of cerebrospinal fluid (CSF) shunt failure. Risk factors for proximal obstructive malfunction are suboptimal ventricular catheter positioning and slit-like ventricles. A new ventricular catheter design to decrease risk of obstruction was evaluated. METHODS A review of histopathological tissue investigation from occluded ventricular catheters (n = 70) was performed. A new ventricular catheter design was realized with six perforation holes. These catheters were compared to regular catheters (16 holes, Miethke, Aesculap) for flow characteristics using ink studies and flow velocity at hydrostatic pressure levels from 14 to 2 cmH(2)O in an experimental setup. The six-hole catheters were implanted in hydrocephalic patients with slit-like ventricles (n = 55). A follow-up was performed to evaluate the need of catheter revisions. RESULTS Histological evaluation showed that obstructive tissue involved 43-60% extraventricular tissue, including gliosis, connective and inflammatory cells. In flow characteristic studies, the 16-hole catheters showed that only proximal perforations are of functional relevance. For six-hole catheters, all perforations were shown to be relevant with remaining reserve capacity. Flow velocity however showed no significant differences between six and 16 perforations. The six-hole catheter was implanted in 55 patients with a mean follow-up period of 15 +/- 9 months. A total of 12 catheters were explanted, revealing an overall survival proportion of 77.4%. CONCLUSION In narrow ventricles, we assume that catheter perforations that are located also in the tissue might be a risk for CSF shunt obstruction. Fewer amounts of perforations in the catheters with equal flow features might decrease this risk when catheters can be implanted with adequate precision.
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Ejike JC, Kadry J, Bahjri K, Mathur M. Semi-recumbent position and body mass percentiles: effects on intra-abdominal pressure measurements in critically ill children. Intensive Care Med 2009; 36:329-35. [PMID: 19898835 DOI: 10.1007/s00134-009-1708-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Accepted: 09/09/2009] [Indexed: 12/16/2022]
Abstract
PURPOSE Patient position and body mass index (BMI) affect intra-abdominal pressure (IAP) measured by the intra-vesical method in adults. We sought to determine effects of patient position and BMI on IAP in children because accurate measurement and interpretation of IAP are important for patient management. METHODS Seventy-seven mechanically ventilated children (<18 years) admitted to a PICU were prospectively studied. IAP was taken with the head of the bed at 0 degrees and 30 degrees every 6 h over a 24-h period. Statistical methods included descriptives, univariate statistics to identify potential confounding variables and multivariable analysis to assess the impact of position on IAP after adjusting for the significant covariates. RESULTS Seventy-seven patients had 290-paired IAP measurements. Mean IAP at 30 degrees was 10.6 +/- 4.0 compared to 8.4 +/- 4.0 at 0 degrees , which was significantly higher (p = 0.026) even after adjusting for age, gender and length. There was no correlation between IAP and actual BMI or BMI percentiles. CONCLUSION Patient position should be considered when interpreting IAP. BMI did not influence IAP measurements in children.
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Affiliation(s)
- Janeth Chiaka Ejike
- Department of Pediatrics, School of Medicine, Loma Linda University, 11175 Campus Street, Suite A1117, Loma Linda, CA 92354, USA.
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Abstract
Normal Pressure Hydrocephalus first became recognized as a treatable, reversible disorder in the 1960s. The classic triad of magnetic apraxia, urinary incontinence, and dementia remain relevant into the 21(st) century as being the basis for symptomatic diagnosis and predicting potential benefit from ventriculoperitoneal shunting, though they have been greatly augmented by the addition of modern neuroimaging, particularly MRI. Modern criteria recognize a wider range of diagnostic criteria, and new positive and negative prognostic indicators for treatment benefit have been discovered, though the mainstay remains initial drainage of a large volume of cerebrospinal fluid and monitoring for clinical improvement. Even with our advances in understanding both primary and secondary normal pressure hydrocephalus, diagnosis, management, and counseling remain challenging in this disorder.
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Affiliation(s)
- Glen R Finney
- Memory and Cognitive Disorders Program, University of Florida Department of Neurology, Gainesville, Florida 32610-0236, USA
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