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Kaushal H, Wahane M, Goyal G, Sarna S, Sarna MK. A case of early intraventricular haemorrhage following ventriculoperitoneal shunt: An entity requiring consideration. J R Coll Physicians Edinb 2024; 54:48-54. [PMID: 38462907 DOI: 10.1177/14782715241237579] [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] [Indexed: 03/12/2024] Open
Abstract
The ventriculoperitoneal shunt (VP shunt) is one of the most common neurosurgical procedures performed in daily practice. Various complications following a VP shunt are as follows: post-procedure shunt-related infections, shunt block, shunt displacement or exteriorisation and haemorrhage associated with it. Delayed intraventricular haemorrhage is a relatively uncommon complication following the aforementioned procedure. Here we present an atypical case of a 72-year-old male who presented with subarachnoid haemorrhage with hydrocephalus and underwent a VP shunt, following which the patient had early intraventricular haemorrhage (eIVH) with an unfortunate outcome. Here, we propose pathophysiology and risk factors for eIVH.
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Affiliation(s)
- Himanshu Kaushal
- Department of Neurology, Mahatma Gandhi Medical College and Hospital, Jaipur, RJ, India
| | - Madhugandha Wahane
- Department of Neurology, Mahatma Gandhi Medical College and Hospital, Jaipur, RJ, India
| | - Gourav Goyal
- Department of Neurology, Mahatma Gandhi Medical College and Hospital, Jaipur, RJ, India
| | - Sudha Sarna
- Department of Palliative Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur, RJ, India
| | - Mukesh Kumar Sarna
- Department of General Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur, RJ, India
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2
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Sanker V, Kundu M, El Kassem S, El Nouiri A, Emara M, Maaz ZA, Nazir A, Bekele BK, Uwishema O. Posttraumatic hydrocephalus: Recent advances and new therapeutic strategies. Health Sci Rep 2023; 6:e1713. [PMID: 38028696 PMCID: PMC10652704 DOI: 10.1002/hsr2.1713] [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: 07/02/2023] [Revised: 10/28/2023] [Accepted: 11/01/2023] [Indexed: 12/01/2023] Open
Abstract
Background Hydrocephalus or ventriculomegaly is a condition brought on by an overabundance of cerebrospinal fluid (CSF) in the ventricular system. The major contributor to posttraumatic hydrocephalus (PTH) is traumatic brain injuries (TBIs), especially in individuals with occupations set in industrial settings. A variety of criteria have been employed for the diagnosis of PTH, including the combination of neurological symptoms like nerve deficits and headache, as well as an initial improvement followed by a worsened relapse of altered consciousness and neurological deterioration, which is detected by computed tomography-brain imaging that reveals gradual ventriculomegaly. Aim In this article, we discuss and summarize briefly the current understandings and advancements in the management of PTH. Methods The available literature for this review was searched on various bibliographic databases using an individually verified, prespecified approach. The level of evidence of the included studies was considered as per the Centre for Evidence-Based Medicine recommendations. Results The commonly practiced current treatment modality involves shunting CSF but is often associated with complications and recurrence. The lack of a definitive management strategy for PTH warrants the utilization of novel and innovative modalities such as stem cell transplantations and antioxidative stress therapies. Conclusion One of the worst complications of a TBI is PTH, which has a high morbidity and mortality rate. Even though there hasn't been a successful method in stopping PTH from happening, hemorrhage-derived blood, and its metabolic by-products, like iron, hemoglobin, free radicals, thrombin, and red blood cells, may be potential targets for PTH hindrance and management. Also, using stem cell transplantations in animal models and antioxidative stress therapies in future studies can lower PTH occurrence and improve its outcome. Moreover, the integration of clinical trials and theoretical knowledge should be encouraged in future research projects to establish effective and updated management guidelines for PTH.
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Affiliation(s)
- Vivek Sanker
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Society of Brain Mapping and TherapeuticsLos AngelesCaliforniaUSA
| | - Mrinmoy Kundu
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Institute of Medical Sciences and SUM HospitalBhubaneswarIndia
| | - Sarah El Kassem
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Faculty of MedicineBeirut Arab UniversityBeirutLebanon
| | - Ahmad El Nouiri
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Faculty of MedicineBeirut Arab UniversityBeirutLebanon
| | - Mohamed Emara
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- College of MedicineUniversity of SharjahSharjahUnited Arab Emirates
| | - Zeina Al Maaz
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Faculty of MedicineBeirut Arab UniversityBeirutLebanon
| | - Abubakar Nazir
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
| | - Bezawit Kassahun Bekele
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- School of MedicineAddis Ababa UniversityAddis AbabaEthiopia
- Milken Institute of Public HealthGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Olivier Uwishema
- Oli Health Magazine Organization, Research and EducationKigaliRwanda
- Department of medicineClinton Global Initiative UniversityNew YorkNew YorkUSA
- Faculty of MedicineKaradeniz Technical UniversityTrabzonTurkey
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Dannhoff G, Chibbaro S, Mallereau CH, Ganau M, Agbo-Ponzo M, Santin MDN, Ollivier I, Pop R, Proust F, Todeschi J. Delayed Intracerebral Hematoma after Ventriculoperitoneal Shunt in the Context of Ruptured Brain Arteriovenous Malformation: A Literature Review. Brain Sci 2023; 13:1159. [PMID: 37626515 PMCID: PMC10452536 DOI: 10.3390/brainsci13081159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 07/29/2023] [Accepted: 08/01/2023] [Indexed: 08/27/2023] Open
Abstract
Hemorrhagic complications arising from ventricular drainage procedures are typically asymptomatic and of low volume. A particular subset of these complications, known as delayed intracranial hemorrhage (DICH), is however recognized for its particularly poor prognosis. We primarily aimed to identify epidemiological characteristics associated with DICH, to shed light on its occurrence and potential risk factors. To do so, we performed a retrospective analysis of a series of ten patients who presented with DICH in the context of a ruptured brain arteriovenous malformation (bAVM) and a systematic literature review of all DICH cases reported in the literature. Our ten patients showed delayed neurological deterioration after a ventriculoperitoneal shunt (VPS) procedure, with a computed tomography (CT) scan revealing a DICH surrounding the ventricular catheter, distinct and away from the nidus of their previously ruptured bAVM. Four patients (40%) rapidly declined and passed away, three (30%) required surgical management and the remaining three (30%) demonstrated gradual clinical improvement with conservative management. In the literature, most patients presenting with DICH had hydrocephalus associated with neurovascular disorders (47% of cases), such as bAVM rupture in our present series. These constatations point out the significance of the underlying pathologies potentially being predisposed to these unusual complications.
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Affiliation(s)
- Guillaume Dannhoff
- Department of Neurosurgery, Strasbourg University Hospital, 67000 Strasbourg, France
| | - Salvatore Chibbaro
- Department of Neurosurgery, Strasbourg University Hospital, 67000 Strasbourg, France
| | | | - Mario Ganau
- Department of Neurosurgery, Strasbourg University Hospital, 67000 Strasbourg, France
| | - Martial Agbo-Ponzo
- Department of Neurosurgery, Strasbourg University Hospital, 67000 Strasbourg, France
| | | | - Irène Ollivier
- Department of Neurosurgery, Strasbourg University Hospital, 67000 Strasbourg, France
| | - Raoul Pop
- Department of Interventional Radiology, Strasbourg University Hospital, 67000 Strasbourg, France
| | - François Proust
- Department of Neurosurgery, Strasbourg University Hospital, 67000 Strasbourg, France
| | - Julien Todeschi
- Department of Neurosurgery, Strasbourg University Hospital, 67000 Strasbourg, France
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4
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Intracranial thrombosis after ventriculoperitoneal shunting. Childs Nerv Syst 2022; 38:1205-1208. [PMID: 34390380 DOI: 10.1007/s00381-021-05319-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
We report a case of intracranial thrombosis (IT) after ventriculoperitoneal shunting (VPS). We reviewed the literature to highlight the importance of considering the possibility of cerebral venous thrombosis following VPS, even though it is a rarely reported complication. A 14-year-old boy underwent distal catheter replacement due to its short size that was detected during a routine consultation. Five days postoperatively, he experienced nausea, vomiting, seizures, and headache. Although a diagnosis of meningitis was considered, diagnosis of IT was eventually confirmed through computed tomography venography and gadolinium magnetic angioresonance. The patient subsequently underwent anticoagulant therapy, which led to complete resolution of symptoms. In this report, we suggest a possible association between VPS and IT, which is a complication that is not commonly reported. The literature suggests that decreased blood flow due to over-drainage of CSF after VPS causes decreased head pressure, culminating in venous stasis and consequent thrombosis. In addition, the literature describes associations between IT and lumbar puncture (LP); therefore, it is important to consider the possibility of IT following these procedures.
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5
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Cizmeci MN, de Vries LS, Tataranno ML, Zecic A, van de Pol LA, Alarcon A, Groenendaal F, Woerdeman PA. Intraparenchymal hemorrhage after serial ventricular reservoir taps in neonates with hydrocephalus and association with neurodevelopmental outcome at 2 years of age. J Neurosurg Pediatr 2021; 28:695-702. [PMID: 34534961 DOI: 10.3171/2021.6.peds21120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Decompressing the ventricles with a temporary device is often the initial neurosurgical intervention for preterm infants with hydrocephalus. The authors observed a subgroup of infants who developed intraparenchymal hemorrhage (IPH) after serial ventricular reservoir taps and sought to describe the characteristics of IPH and its association with neurodevelopmental outcome. METHODS In this multicenter, case-control study, for each neonate with periventricular and/or subcortical IPH, a gestational age-matched control with reservoir who did not develop IPH was selected. Digital cranial ultrasound (cUS) scans and term-equivalent age (TEA)-MRI (TEA-MRI) studies were assessed. Ventricular measurements were recorded prior to and 3 days and 7 days after reservoir insertion. Changes in ventricular volumes were calculated. Neurodevelopmental outcome was assessed at 2 years corrected age using standardized tests. RESULTS Eighteen infants with IPH (mean gestational age 30.0 ± 4.3 weeks) and 18 matched controls were included. Reduction of the ventricular volumes relative to occipitofrontal head circumference after 7 days of reservoir taps was greater in infants with IPH (mean difference -0.19 [95% CI -0.37 to -0.004], p = 0.04). Cognitive and motor Z-scores were similar in infants with and those without IPH (mean difference 0.42 [95% CI -0.17 to 1.01] and 0.58 [95% CI -0.03 to 1.2]; p = 0.2 and 0.06, respectively). Multifocal IPH was negatively associated with cognitive score (coefficient -0.51 [95% CI -0.88 to -0.14], p = 0.009) and ventriculoperitoneal shunt with motor score (coefficient -0.50 [95% CI -1.6 to -0.14], p = 0.02) after adjusting for age at the time of assessment. CONCLUSIONS This study reports for the first time that IPH can occur after a rapid reduction of the ventricular volume during the 1st week after the initiation of serial reservoir taps in neonates with hydrocephalus. Further studies on the use of cUS to guide the amount of cerebrospinal fluid removal are warranted.
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Affiliation(s)
- Mehmet N Cizmeci
- 1Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University, Utrecht
- 2University Medical Center Utrecht, Utrecht Brain Center, Utrecht, The Netherlands
- 3Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Linda S de Vries
- 1Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University, Utrecht
- 2University Medical Center Utrecht, Utrecht Brain Center, Utrecht, The Netherlands
| | - Maria Luisa Tataranno
- 1Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University, Utrecht
- 2University Medical Center Utrecht, Utrecht Brain Center, Utrecht, The Netherlands
| | - Alexandra Zecic
- 4Department of Neonatology, University Hospital Ghent, Ghent, Belgium
| | - Laura A van de Pol
- 5Department of Child Neurology, Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Ana Alarcon
- 6Department of Neonatology, Hospital Sant Joan de Déu, Barcelona, Spain; and
| | - Floris Groenendaal
- 1Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University, Utrecht
- 2University Medical Center Utrecht, Utrecht Brain Center, Utrecht, The Netherlands
| | - Peter A Woerdeman
- 7Division of Neuroscience, Department of Neurosurgery, University Medical Center Utrecht, and Utrecht University, Utrecht, The Netherlands
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Cole TS, Graham DT, Wakim AA, Bohl MA, Morgan CD, Catapano JS, Smith KA, Sanai N, Lawton MT. Local 3-Dimensional Printing of a Calvarium-Anchored Ventricular Catheter Occlusion Device. NEUROSURGERY OPEN 2021. [DOI: 10.1093/neuopn/okab024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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7
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Khan B, Hamayun S, Haqqani U, Khanzada K, Ullah S, Khattak R, Zadran N, Bibi Z, Khan AW. Early Complications of Ventriculoperitoneal Shunt in Pediatric Patients With Hydrocephalus. Cureus 2021; 13:e13506. [PMID: 33786215 PMCID: PMC7993285 DOI: 10.7759/cureus.13506] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective Ventriculoperitoneal shunt (VPS) is the most commonly used procedure for the treatment of hydrocephalus (HDC), especially in children. However, this is prone to many complications, and requires repeated surgeries, which as such increases the morbidity of the patients. It is estimated that majority of the complications occurs in the immediate post-operative period and the rate of complications decreases over the time, with no impunity to these, though. We conducted this study to know about the complications of VPS in the early post-operative period, in pediatric patients with hydrocephalus. Materials and methods This descriptive study was conducted in the Department of Neurosurgery, Lady Reading Hospital, Peshawar, between June 2019 and January 2020 (seven months). All patients with hydrocephalus below 12 years of age, operated for the first time were included after taking an informed consent, while those with repeated shunt procedures and elderly patients requiring shunt were excluded from the study. Patients’ details like age, gender, location, contact number, cause of hydrocephalus, date of shunt placement, type of surgery (elective or emergency) and any follow-up complications like failure, erosion, infections, ileus were noted on a predesigned proforma. After the surgery, patients were followed for a period of one month, and contacted either through the telephone or asked to visit in the outpatients on the specified days, and were evaluated for any shunt-related complications, and any of these complications suspected were further evaluated and noted. The data was analyzed using the statistical program SPSS version 19 (IBM Corp., Armonk, NY). Results are presented in the form of charts, tables and graph. Results During the study period, we evaluated a total of 151 patients; there were 78 (51.65%) males and 73 (48.34%) females with a male to female ratio approaching 1.1:1. The age range was from 22 days to 12 years. The mean age was 38.46 ± 7.53 months. The primary indications for the insertion of VP shunt were: congenital hydrocephalus in 70 (46.4%), post infectious hydrocephalus in 57 (37.7%), hydrocephalus due to tumor in 22 (14.6%), and post traumatic hydrocephalus in two (1.4%) patients. Among the total number of patients, 85 patients (55.6%) were done as elective cases and 66 patients (44.4%) were done as emergency cases. Complications were encountered in 30 patients (19.87%) during the follow-up of 30 days. Complications occurred between day 1 and day 20 of follow-up with a mean of 9.10 ± 1.69 2SD days. Conclusion VP shunt is the most widely used treatment for HDC, but is predisposed to complications and almost every fifth case of VP shunt comes across with complications. Shunt blockage, infections and abdominal wound-related complications are common earlier complications in pediatric patients with hydrocephalus.
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Affiliation(s)
- Bilal Khan
- Neurosurgery, Lady Reading Hospital-Medical Teaching Institutions (MTI), Peshawar, PAK
| | | | - Usman Haqqani
- Neurosurgery, Qazi Hussain Ahmed Medical Complex, Nowshera, PAK
| | | | - Sajjad Ullah
- Neurosurgery, Khyber Teaching Hospital-Medical Teaching Institutions (MTI), Peshawar, PAK
| | - Rizwanullah Khattak
- Neurosurgery, Hayatabad Medical Complex-Medical Teaching Institutions (MTI), Peshawar, PAK
| | | | - Zohra Bibi
- Psychiatry, Lady Reading Hospital-Medical Teaching Institutions (MTI), Peshawar, PAK
| | - Abdul Wali Khan
- Internal Medicine, College of Physicians and Surgeons Pakistan, Peshawar, PAK.,Internal Medicine, Hayatabad Medical Complex Peshawar, Peshawar, PAK
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8
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Musali SR, Manne S, Beniwal HK, Butkuri N, Gollapudi PR, Nandigama PK. Delayed Intracerebral Hemorrhage after Placement of a Ventriculoperitoneal Shunt in a Case of Hydrocephalus: A Rare Case Report and Review of Literature. J Neurosci Rural Pract 2019; 10:533-536. [PMID: 31595129 PMCID: PMC6779545 DOI: 10.1055/s-0039-1697769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Ventriculoperitoneal (VP) shunt is a frequently performed operation to achieve cerebrospinal fluid (CSF) diversion but is associated with many complications. Postoperative delayed intracerebral hemorrhage is a kind of rare but catastrophic complication of a VP shunt which questions the survival of a seemingly recovered patient. Here, we present one such case where the patient presented to casualty in altered sensorium and with a history of vomiting. On examination, the Glasgow Coma Scale (GCS) score was E2V1M3; pupils were middilated but reactive. Computerized tomography of the brain showed ventriculomegaly and hydrocephalus, and an emergency VP shunt was done. There was an initial phase of good recovery followed by sudden loss consciousness, vomiting, and a fall in the GCS scores on postoperative day 7. Computed tomography showed an intracerebral hematoma along the shunt track and an intraventricular bleed. The presumed cause for this occurrence is a deranged coagulation profile.
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Affiliation(s)
- Siddartha Reddy Musali
- Department Of Neurosurgery, Gandhi Medical College and Hospital, Secunderabad, Telangana, India
| | - Srikrishnaditya Manne
- Department Of Neurosurgery, Gandhi Medical College and Hospital, Secunderabad, Telangana, India
| | - Hemant K Beniwal
- Department Of Neurosurgery, Gandhi Medical College and Hospital, Secunderabad, Telangana, India
| | - Nagarjuna Butkuri
- Department Of Neurosurgery, Gandhi Medical College and Hospital, Secunderabad, Telangana, India
| | - Prakash Rao Gollapudi
- Department Of Neurosurgery, Gandhi Medical College and Hospital, Secunderabad, Telangana, India
| | - Pratap Kumar Nandigama
- Department Of Neurosurgery, Gandhi Medical College and Hospital, Secunderabad, Telangana, India
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Jang SY, Kim CH, Cheong JH, Kim JM. Risk Factors of Delayed Intracranial Hemorrhage Following Ventriculoperitoneal Shunt. Korean J Neurotrauma 2018; 14:112-117. [PMID: 30402428 PMCID: PMC6218347 DOI: 10.13004/kjnt.2018.14.2.112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 10/05/2018] [Accepted: 10/10/2018] [Indexed: 12/20/2022] Open
Abstract
Objective Placement of a ventriculoperitoneal (VP) shunt is a common neurosurgical procedure for cerebrospinal fluid diversion. A rare complication is delayed intracranial hemorrhage (ICH) secondary to VP shunting, and only a few patients with this complication have been reported. We investigate the incidence and risk factors of delayed ICH development following VP shunt placement. Methods Over an 11-year period, 167 patients received a VP shunt for hydrocephalus, and of these, 138 patients were eligible for this study. All medical records and computed tomography scans obtained within 48 h after the operation and at postoperative day 7 were reviewed. The risk factors of developing delayed ICH (≥48 hr after VP shunt placement) were analyzed according to the demographic data, including sex and age, original intracranial lesions, co-morbid diseases, and laboratory findings. Results Delayed ICH following VP shunt placement developed in 34 (24.6%) of the 138 patients. Risk factors for developing delayed ICH were age (p=0.037) and the partial thromboplastin time (PTT) (p=0.032). Intraventricular hemorrhage after VP shunting was the most common complication, occurring in 16 cases. Hemorrhagic volume was <1 mL in 28 cases and >1 mL in 6 cases. Conclusion This study suggests that old age and delayed PTT are major risk factors for developing delayed ICH following VP shunting. Additionally, delayed ICH after VP shunting commonly occurs even when most patients are asymptomatic. Therefore, extra care should be taken to observe and follow-up with patients who have undergone VP shunt placement.
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Affiliation(s)
- Se Youn Jang
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
| | - Choong Hyun Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Jin Hwan Cheong
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Jae Min Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
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Vinas Rios JM, Sanchez-Aguilar M, Kretschmer T, Heinen C, Medina Govea FA, Jose Juan SR, Schmidt T. Predictors of hydrocephalus as a complication of non-traumatic subarachnoid hemorrhage: a retrospective observational cohort study in 107 patients. Patient Saf Surg 2018; 12:13. [PMID: 29796090 PMCID: PMC5964876 DOI: 10.1186/s13037-018-0160-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 05/08/2018] [Indexed: 01/03/2023] Open
Abstract
Background The predictors of shunt dependency such as amount of subarachnoid blood, acute hydrocephalus (HC), mode of aneurysm repair, clinical grade at admission and cerebro spinal fluid (CSF) drainage in excess of 1500 ml during the 1st week after the subarachnoid hemorrhage (SAH) have been identified as predictors of shunt dependency. Therefore our main objective is to identify predictors of CSF shunt dependency following non-traumatic subarachnoid hemorrhage. Methods We performed a retrospective study including patients from January 1st 2012 to September 30th 2014 between 16 and 89 years old and had a non-traumatic subarachnoid hemorrhage in cranial computed tomography (CCT). We excluded patients with the following characteristics: Patients who died 3 days after admittance, lesions in brainstem, previous surgical treatment in another clinic, traumatic brain injury, pregnancy and disability prior to SAH. We performed a descriptive and comparative analysis as well as a logistic regression with the variables that showed a significant difference (p < 0.05). Hence we identified the variables concerning HC after non traumatic SAH and its correlation. Results One hundred and seven clinical files of patients with non-traumatic SAH were analyzed. Twenty one (48%) later underwent shunt treatment. Shunt patients had significantly clinical and corroborated with doppler ultrasonography vasospasmus (p = 0.015), OR = 5.2. The amount of subarachnoidal blood according to modified Fisher grade was (p = 0.008) OR = 10.9. Endovascularly treated patients were less often shunted as compared with those undergoing surgical aneurysm repair (p = 0.004). Conclusion Vasospasmus and a large amount of ventricular blood seem to be a predictor concerning hydrocephalus after non-traumatic SAH. Hence according to our results the presence of these two variables could alert the treating physician in the decision whether an early shunt implantation < 7 days after SAH should be necessary.
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Affiliation(s)
| | | | - Thomas Kretschmer
- 3Department of neurosurgery, Klinikum Klagenfurt, Klagefurt, Austria
| | - Christian Heinen
- Department of neurosurgery, University clinic Evangelical Hospital Oldenburg, Oldenburg, Germany
| | | | | | - Thomas Schmidt
- Department of neurosurgery, University clinic Evangelical Hospital Oldenburg, Oldenburg, Germany
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Delayed Intraventricular Hemorrhage following a Ventriculoperitoneal Shunt Placement: Exploring the Surgical Anatomy of a Rare Complication. Case Rep Med 2018; 2017:3953248. [PMID: 29312454 PMCID: PMC5698782 DOI: 10.1155/2017/3953248] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 10/18/2017] [Indexed: 12/20/2022] Open
Abstract
Ventriculoperitoneal shunt (VPS) placement is one of the commoner neurosurgical procedures worldwide. The purpose of this article is to report a case of delayed intraventricular hemorrhage (IVH) following a VPS and to review the literature regarding anatomic factors that could potentially explain this rare complication. A 78-year-old man with normal pressure hydrocephalus, who underwent an uneventful right VPS placement, suffered from a catastrophic isolated IVH five days later. The reported cases of delayed intracerebral hemorrhage (ICH) following VPS are rare and those with IVH are even rarer. Potential factors of surgical anatomy that could cause delayed ICH/IVH following a VPS procedure include erosion of vasculature by catheter cannulation, multiple attempts at perforation, puncture of the choroid plexus, improper placement of the tubing within the brain parenchyma, VPS system revision, venous infarction, vascular malformations, head trauma, and brain tumors. Other causes include generalized convulsion, VPS system malfunction, increased intracranial or blood pressure, sudden intracranial hypotension, and bleeding disorders. According to the current literature, our case is the first reported delayed isolated IVH after a VPS placement so far. Neurosurgeons should be aware of the delayed ICH/IVH as a rare, potentially fatal complication of VPS, as well as of its risk factors.
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12
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Oushy S, Parker JJ, Campbell K, Palmer C, Wilkinson C, Stence NV, Handler MH, Mirsky DM. Frontal and occipital horn ratio is associated with multifocal intraparenchymal hemorrhages in neonatal shunted hydrocephalus. J Neurosurg Pediatr 2017; 20:432-438. [PMID: 28885094 DOI: 10.3171/2017.6.peds16481] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Placement of a cerebrospinal fluid diversion device (i.e., shunt) is a routine pediatric neurosurgical procedure, often performed in the first weeks of life for treatment of congenital hydrocephalus. In the postoperative period, shunt placement may be complicated by subdural, catheter tract, parenchymal, and intraventricular hemorrhages. The authors observed a subset of infants and neonates who developed multifocal intraparenchymal hemorrhages (MIPH) following shunt placement and sought to determine any predisposing perioperative variables. METHODS A retrospective review of the electronic medical record at a tertiary-care children's hospital was performed for the period 1998-2015. Inclusion criteria consisted of shunt placement, age < 30 days, and available pre- and postoperative brain imaging. The following data were collected and analyzed for each case: ventricular size ratios, laboratory values, clinical presentation, shunt and valve type, and operative timing and approach. RESULTS A total of 121 neonates met the inclusion criteria for the study, and 11 patients (9.1%) had MIPH following shunt placement. The preoperative frontal and occipital horn ratio (FOR) was significantly higher in the patients with MIPH than in those without (0.65 vs 0.57, p < 0.001). The change in FOR (∆FOR) after shunt placement was significantly greater in the MIPH group (0.14 vs 0.08, p = 0.04). Among neonates who developed MIPH, aqueductal stenosis was the most common etiology (45%). The type of shunt valve was associated with incidence of MIPH (p < 0.001). Preoperative clinical parameters, including head circumference, bulging fontanelle, and coagulopathy, were not significantly associated with development of MIPH. CONCLUSIONS MIPH represents an underrecognized complication of neonatal shunted hydrocephalus. Markers of severity of ventriculomegaly (FOR) and ventricular response to CSF diversion (∆FOR) were significantly associated with occurrence of MIPH. Choice of shunt and etiology of hydrocephalus were also significantly associated with MIPH. After adjusting for corrected age, etiology of hydrocephalus, and shunt setting, the authors found that ∆FOR after shunting was still associated with MIPH. A prospective study of MIPH prevention strategies and assessment of possible implications for patient outcomes is needed.
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Affiliation(s)
| | - Jonathon J Parker
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Kristen Campbell
- Child Health Research Biostatistical Core, Children's Hospital Colorado; and.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado; and
| | - Claire Palmer
- Pediatrics, University of Colorado School of Medicine.,Child Health Research Biostatistical Core, Children's Hospital Colorado; and
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Qian Z, Gao L, Wang K, Pandey S. Delayed Catheter-Related Intracranial Hemorrhage After a Ventriculoperitoneal or Ventriculoatrial Shunt in Hydrocephalus. World Neurosurg 2017; 107:846-851. [PMID: 28847553 DOI: 10.1016/j.wneu.2017.08.098] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 08/13/2017] [Accepted: 08/14/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Delayed catheter-related intracranial hemorrhage is not rare after a ventriculoperitoneal (VP) or ventriculoatrial (VA) shunt for the treatment of hydrocephalus. Immediate postoperative catheter-related intracranial hemorrhage is possibly due to the procedure itself; however, delayed intracranial hemorrhage may have other underlying mechanisms. This study aimed to investigate the clinical characteristics and reveal the risk factors of delayed catheter-related intracranial hemorrhage after a VP or VA shunt. METHODS We did a retrospective study to review patients with hydrocephalus and underwent VP or VA shunt in our department from September 2011 to December 2015. We reviewed the clinical characteristics of the patients with delayed catheter-related intracranial hemorrhage, and its risk factors were analyzed with SPSS 16.0. RESULTS Of the 218 patients enrolled in the study (145 male, 73 female), 17 (7.8%) patients experienced delayed catheter-related intracranial hemorrhage, including 11 of 151 (7.3%) patients with a VP shunt and 6 of 67 (9.0%) patients with a VA shunt. Additionally, 4 of the 16 patients with postoperative low-molecular-weight heparin (LMWH) therapy and 13 of the 202 patients without LMWH experienced bleeding, showing a significant difference (25% vs. 6.4%, P = 0.026). The relative risk was 4.8 (95% confidence interval: 1.4-17.1). CONCLUSION Delayed catheter-related intracranial hemorrhage is not rare after a VP or VA shunt. However, most patients can be cured after appropriate treatment. Postoperative anticoagulation therapy with enoxaparin may be associated with an increased risk of bleeding.
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Affiliation(s)
- Zhouqi Qian
- Neurosurgical Department, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Liang Gao
- Neurosurgical Department, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Ke Wang
- Neurosurgical Department, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China.
| | - Sajan Pandey
- Neurosurgical Department, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
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14
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Delayed Intracerebral Hemorrhage Secondary to Ventriculoperitoneal Shunt: A Retrospective Study. World Neurosurg 2017; 107:160-167. [PMID: 28765020 DOI: 10.1016/j.wneu.2017.07.133] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 07/20/2017] [Accepted: 07/22/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative delayed intracerebral hemorrhage (DICH) secondary to ventriculoperitoneal (VP) shunt is a rare but severe event. The present study aimed to investigate the incidence and risk factors related to DICH after placement of the VP shunt. METHODS The clinical data from 532 patients with VP shunt were collected retrospectively. All clinical variables were examined by univariate analysis, and a binary logistic regression analysis was performed to identify the risk factors related to DICH. RESULTS DICH occurred in 20 patients, from 3 to 10 days after placement of the VP shunt. Univariate analysis showed significant differences between the patients with DICH and without DICH with respect to age, history of hypertension, history of craniotomy, and features of the first computed tomography (CT) scans after placement of the VP shunt (all P < 0.05). The binary logistic regression analysis showed that age, history of craniotomy, and features of first CT scans after placement of the VP shunt were independent risk factors for DICH (all P < 0.05). The prognosis for patients with DICH was consistent with the hematoma volume and the neurologic status at the time of hospital admission (all P < 0.05). CONCLUSIONS DICH is a rare and potentially severe complication secondary to VP shunt, and a repeat of cranial CT scans after placement of the VP shunt is recommended. Advanced age, craniotomy history, and brain edema around the catheter on the first cranial CT scan after placement of the VP shunt served as independent risk factors for DICH. The patients with DICH with poor neurologic status at the time of hospital admission or large hematoma volume were associated with poor outcome.
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15
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Hou K, Suo S, Gao X, Zhu X, Zhang Y, Li G. Symptomatic Intracerebral Hemorrhage Secondary to Ventriculoperitoneal Shunt in Adults without Bleeding Tendency. World Neurosurg 2017; 106:368-373. [PMID: 28711542 DOI: 10.1016/j.wneu.2017.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 07/01/2017] [Accepted: 07/05/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Ventriculoperitoneal shunt (VPS) is a common procedure in daily neurosurgical practice. According to some reports, the rate of intracerebral hemorrhage secondary to VPS in patients with no bleeding tendency can be 43.1%; however, symptomatic intracerebral hemorrhage (SICH) secondary to VPS is rare with only sporadic cases reported in adults. To further elucidate the characteristics, mechanism, management, and prognosis of SICH secondary to VPS, we performed a retrospective study in our institution and a systematic review of the literature. METHODS A retrospective review of the medical records of patients admitted for VPS was performed. We also performed a systematic PubMed search of published studies. RESULTS Of 5 patients identified at our institution, 3 experienced a favorable recovery. Including our case series, there were 16 (8 female) patients. The time interval from the termination of VPS procedure to SICH was 4 hours to 15 days. All but 1 patient experienced intracerebral hemorrhage adjacent to cannulation. Of 11 patients in whom a Glasgow Outcome Scale score could be obtained, the score was 5 in 4 patients, 4 in 1 patient, 3 in 1 patient, and 1 in 5 patients. CONCLUSIONS SICH is a rare complication after VPS in adults without bleeding tendency. The mechanism is obscure, management is challenging, and prognosis is dismal. Future prospective study is anticipated.
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Affiliation(s)
- Kun Hou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Shihuan Suo
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Xianfeng Gao
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Xiaobo Zhu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yang Zhang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Guichen Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin, China.
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16
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Gong W, Xu L, Yang P, Yu Z, Wang Z, Chen G, Zhang S, Wu J. Characteristics of delayed intracerebral hemorrhage after ventriculoperitoneal shunt insertion. Oncotarget 2017; 8:42693-42699. [PMID: 28496010 PMCID: PMC5522098 DOI: 10.18632/oncotarget.17444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 03/21/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Delayed intracerebral hemorrhage after ventriculoperitoneal (VP) shunt insertion is rare and has not been well investigated previously. Its characteristics is still unknown. OBJECTIVE We reported 12 patients with delayed intracerebral hemorrhage after VP shunt to investigate the potential risk factors and the outcome. RESULTS 12 patients (1.59%) of all the 754 hydrocephalus had delayed intracerebral hemorrhage after VP shunt insertion. 4 patients were women and 8 patients were men, ranging in age from 50 to 76 years. The delayed cerebral hemorrhage from day 3 to day 7 post operation was diagnosed by repeated CT. The delayed intracerebral hemorrhage was significantly related to age, prior craniotomy operation history and manipulation of valve system (3-7 days). Neither gender sexuality nor potential risk factors for postoperative hemorrhage (including anticoagulation/antiplatelet status, liver disease, diabetes, hypertension), time of shunt attempt affected the happen of delayed intracerebral hemorrhage. MATERIALS AND METHODS The clinical characteristics including sex, age, anticoagulation/antiplatelet status, liver disease, diabetes, hypertension, craniotomy operation history, manipulation of valve system and time of shunt attempt of 754 patients who were surgically treated of VP shunt at the first affiliated hospital of Soochow University between 2007 and 2013 were reviewed retrospectively. The potential risk factors of the delayed intracerebral hemorrhage were statistically analyzed. CONCLUSIONS This study summarizes the presentation and outcome of a series of 12 patients with delayed intracerebral hemorrhage after VP shunt. Age ≥ 60 years, prior craniotomy operation and manipulation of the valve system are statistically significant to the delayed hematoma secondary to VP shunt.
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Affiliation(s)
- Weiyi Gong
- Department of Neurosurgery, The First People's Hospital of Kunshan, Suzhou, Jiangsu Province, 215300, China
| | - Li Xu
- Department of Intensive Care Unit, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Peng Yang
- Department of Emergency, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Zhengquan Yu
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Zhong Wang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Gang Chen
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Shiming Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
| | - Jiang Wu
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006, China
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Abstract
BACKGROUND Advancements in cancer treatment have led to more cases of leptomeningeal disease, which requires a multimodal approach. METHODS Treatment modalities are reviewed from a neurosurgical standpoint, focusing on intrathecal chemotherapy and shunting devices. Potential complications and how to avoid them are discussed. RESULTS The Ommaya reservoir and the chemoport are used for administering intrathecal chemotherapy. Use of ventriculo-lumbar perfusion can efficiently deliver chemotherapeutic agents and improve intracerebral pressure. Shunting systems, in conjunction with all of their variations, address the challenge of hydrocephalus in leptomeningeal carcinomatosis. Misplaced catheters, malfunction of the system, and shunt-related infections are known complications of treatment. CONCLUSIONS From an oncological perspective, the surgical treatment for leptomeningeal disease is limited; however, neurosurgery can be used to aid in the administration of chemotherapy and address the issue of hydrocephalus. Minimizing surgical complications is important in this sensitive patient population.
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Affiliation(s)
| | | | - Frank D Vrionis
- Marcus Neuroscience Institute, Boca Raton Regional Hospital and the Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL.
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18
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Johansson E, Ambarki K, Birgander R, Bahrami N, Eklund A, Malm J. Cerebral microbleeds in idiopathic normal pressure hydrocephalus. Fluids Barriers CNS 2016; 13:4. [PMID: 26860218 PMCID: PMC4748449 DOI: 10.1186/s12987-016-0028-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/03/2016] [Indexed: 11/25/2022] Open
Abstract
Background A vascular disease could be involved in pathophysiology of normal pressure hydrocephalus (INPH). If so, there should be an association between INPH and cerebral microbleeds (CMB). This study aims to analyze if CMB are associated with INPH. Methods In this case-control study we included 14 patients with INPH (mean age 76 years, 60 % female) and 41 healthy controls (HeCo; mean age 71 years, 60 % female). All were investigated with magnetic resonance imaging (MRI) using a T2*-sequence. The MRI exams were reviewed by two neuroradiologists for the presence of CMBs; the prevalence of findings of two or more CMBs was compared between INPH group and control group. After investigation, INPH patients underwent shunt surgery. Results Two or more CMB were detected more frequently in the INPH group compared to HeCo (n = 6, 43 % vs. n = 4, 10 %; p = 0.01). Among the participants where MRI revealed CMB, the number of CMB was higher among the INPH patients than the HeCo (median 8; IQR 2-34 vs. median 1; IQR 1–2; p = 0.005). Conclusions This study supports a vascular component to the pathophysiology of INPH.
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Affiliation(s)
- Elias Johansson
- Department of Pharmacology and Clinical Neuroscience, Norrlands Universitetssjukhus, Umeå University, S-901 85, Umeå, Sweden.
| | - Khalid Ambarki
- Department of Radiation Sciences, Umeå University, Umeå, Sweden. .,Centre for Biomedical Engineering and Physics, Umeå University, Umeå, Sweden.
| | | | - Nazila Bahrami
- Department of Radiation Sciences, Umeå University, Umeå, Sweden.
| | - Anders Eklund
- Department of Radiation Sciences, Umeå University, Umeå, Sweden. .,Centre for Biomedical Engineering and Physics, Umeå University, Umeå, Sweden.
| | - Jan Malm
- Department of Pharmacology and Clinical Neuroscience, Norrlands Universitetssjukhus, Umeå University, S-901 85, Umeå, Sweden.
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Lubnin AY, Karnaukhov VV, Moshkin AV, Rylova AV, Shimansky VN. [Neurosurgery in a patient on dual antiplatelet therapy. Case report and the review of the literature]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2016. [PMID: 28635845 DOI: 10.17116/neiro201680391-98] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION A neurosurgical intervention in a patient on dual antiplatelet therapy is a serious challenge for both the neurosurgeon and anesthesiologist.. MATERIAL AND METHODS The article describes a clinical case of a successful urgent neurosurgical intervention (ventriculoperitoneostomy for obstructive hydrocephalus caused by a large meningioma of the posterior surface of the petrous pyramid) in a patient on dual antiplatelet therapy (DAT) due to a recently placed coronary stent.. CONCLUSION Given a high risk of coronary stent thrombosis, the surgery was performed in the presence of ongoing DAT. There were no intracranial hemorrhagic complications, but subcutaneous hemorrhagic complications developed. The article discusses the features of managing similar patients whose number is growing.
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Affiliation(s)
- A Yu Lubnin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - A V Moshkin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A V Rylova
- Burdenko Neurosurgical Institute, Moscow, Russia
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Sæhle T, Eide PK. Characteristics of intracranial pressure (ICP) waves and ICP in children with treatment-responsive hydrocephalus. Acta Neurochir (Wien) 2015; 157:1003-14. [PMID: 25870129 DOI: 10.1007/s00701-015-2410-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 03/23/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND One important goal of modern treatment of pediatric hydrocephalus is to normalize the intracranial pressure (ICP) and ICP volume reserve capacity to optimize normal brain development. Better knowledge of the characteristics of ICP waves/ICP in pediatric hydrocephalus may provide new insight into the mechanisms behind modern hydrocephalus treatment. The aim of the present work was to characterize the ICP waves/ICP in children with either communicating or non-communicating hydrocephalus who improved clinically after surgery. The hydrocephalic children not treated surgically following ICP monitoring served as reference patients. METHODS The patient material includes all children with hydrocephalus and no previous surgical treatment who underwent diagnostic ICP wave/ICP monitoring during the period 2002-2011. We retrieved the information about the patients from the patient records and the digitally stored ICP waveforms. The ICP wave characteristics amplitude, rise time and rise time coefficient and the mean ICP were determined in the patients treated surgically for their hydrocephalus. The findings were compared with findings in children not treated surgically after ICP monitoring who served as reference patients. RESULTS The patient material includes 58 patients. Thirty-one (53%) were treated surgically after ICP monitoring, of whom all improved clinically. As compared to the reference patients, patients treated surgically presented with increased ICP wave amplitudes (MWA) and mean ICP. Alterations were comparable in communicating and non-communicating hydrocephalus. We found no apparent association between the ICP wave/ICP scores and presence of symptoms, indices of ventricular size or age. CONCLUSIONS Children with either communicating or non-communicating hydrocephalus improving clinically after surgery presented with elevated MWA and mean ICP. In particular, the levels of MWA were raised to a magnitude seen when intracranial compliance is impaired. Hence, the present observations may support the idea that improvement of intracranial compliance can be an important mechanism by which shunts work in pediatric hydrocephalus.
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21
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Sæhle T, Eide PK. Intracranial pressure monitoring in pediatric and adult patients with hydrocephalus and tentative shunt failure: a single-center experience over 10 years in 146 patients. J Neurosurg 2015; 122:1076-86. [PMID: 25679270 DOI: 10.3171/2014.12.jns141029] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In patients with hydrocephalus and shunts, lasting symptoms such as headache and dizziness may be indicative of shunt failure, which may necessitate shunt revision. In cases of doubt, the authors monitor intracranial pressure (ICP) to determine the presence of over- or underdrainage of CSF to tailor management. In this study, the authors reviewed their experience of ICP monitoring in shunt failure. The aims of the study were to identify the complications and impact of ICP monitoring, as well as to determine the mean ICP and characteristics of the cardiac-induced ICP waves in pediatric versus adult over- and underdrainage. METHODS The study population included all pediatric and adult patients with hydrocephalus and shunts undergoing diagnostic ICP monitoring for tentative shunt failure during the 10-year period from 2002 to 2011. The patients were allocated into 3 groups depending on how they were managed following ICP monitoring: no drainage failure, overdrainage, or underdrainage. While patients with no drainage failure were managed conservatively without further actions, over- or underdrainage cases were managed with shunt revision or shunt valve adjustment. The ICP and ICP wave scores were determined from the continuous ICP waveforms. RESULTS The study population included 71 pediatric and 75 adult patients. There were no major complications related to ICP monitoring, but 1 patient was treated for a postoperative superficial wound infection and another experienced a minor bleed at the tip of the ICP sensor. Following ICP monitoring, shunt revision was performed in 74 (51%) of 146 patients, while valve adjustment was conducted in 17 (12%) and conservative measures without any actions in 55 (38%). Overdrainage was characterized by a higher percentage of episodes with negative mean ICP less than -5 to -10 mm Hg. The ICP wave scores, in particular the mean ICP wave amplitude (MWA), best differentiated underdrainage. Neither mean ICP nor MWA levels showed any significant association with age. CONCLUSIONS In this cohort of pediatric and adult patients with hydrocephalus and tentative shunt failure, the risk of ICP monitoring was very low, and helped the authors avoid shunt revision in 49% of the patients. Mean ICP best differentiated overdrainage, which was characterized by a higher percentage of episodes with negative mean ICP less than -5 to -10 mm Hg. Underdrainage was best characterized by elevated MWA values, indicative of impaired intracranial compliance.
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Affiliation(s)
- Terje Sæhle
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet; and
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22
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Choudhri O, Gupta M, Feroze AH, Heit JJ, Do HM. Endovascular management of external ventricular drain-associated cerebrovascular injuries. Surg Neurol Int 2015; 5:167. [PMID: 25558425 PMCID: PMC4278086 DOI: 10.4103/2152-7806.145930] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 09/27/2014] [Indexed: 11/09/2022] Open
Abstract
Background: Placement of external ventricular drains (EVDs) is a common, life-saving neurosurgical procedure indicated across a variety of settings. While advances have made the procedure quite safe, the potential for iatrogenic morbidity and mortality continues. We document our experience with the endovascular management of three pseudoaneurysms associated with EVD placement and discuss the endovascular treatment options for EVD-associated cerebrovascular injury. Methods: We performed a retrospective analysis to identify all EVDs placed from 2008 through 2013 at our institution. In instances of EVD-associated cerebrovascular injury, all admission and subsequent radiographic studies were reviewed, including cerebral angiograms and computed tomography (CT) scans where available. Angiograms were reviewed to record the extent of vascular injury and outcomes after treatment. Results: One female and two male patients (age range, 40-75 years) were found to have developed vascular injuries associated with EVD placement. Three pseudoaneurysms, of the posterior communicating artery (PCOM), pericallosal artery branch, and the middle meningeal artery, respectively, were treated by coil and/or glue embolization. Conclusions: Although EVD-associated cerebrovascular injury remains a rare phenomenon, such procedures are not entirely benign. Endovascular repair for such lesions proves a viable, effective option.
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Affiliation(s)
- Omar Choudhri
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Mihir Gupta
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Abdullah H Feroze
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Huy M Do
- Department of Radiology, Stanford University School of Medicine, Stanford, California 94305, USA
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Erixon HO, Sorteberg A, Sorteberg W, Eide PK. Predictors of shunt dependency after aneurysmal subarachnoid hemorrhage: results of a single-center clinical trial. Acta Neurochir (Wien) 2014; 156:2059-69. [PMID: 25143185 DOI: 10.1007/s00701-014-2200-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 07/29/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hydrocephalus (HC) after aneurysmal subarachnoid hemorrhage (aSAH) is a common sequel. Proper selection of patients in need of permanent cerebrospinal fluid (CSF) diversion is, however, not straightforward. The aim of this study was to identify predictors of CSF shunt dependency following aSAH. METHODS We re-analyzed data acquired from aSAH patients previously enrolled in a prospective, controlled single-center clinical trial in which shunt dependency was not one of the end points. In the present study patients were allocated into two groups: those receiving a shunt (here denoted as shunt dependent) and those not receiving a shunt, based on a clinical decision process. Predictors of shunt dependency were identified by applying uni- and multivariable analysis. We tested a set of predefined possible risk factors based on the results of the clinical trial, including the impact of CSF drainage volume exceeding 1,500 ml during the 1st week after ictus. RESULTS Ninety patients were included in the study. Significant predictors of shunt dependency were poor clinical grade at admission [odds ratio (OR) 4.7, 95% confidence interval (CI) 1.2-18.4], large amounts of subarachnoid blood (OR 3.8, 95% CI 1.0-14.0), large ventricular size on preoperative cerebral computer tomographic (CT) scans (OR 1.0, 95% CI 1.0-1.1), and CSF volume drainage exceeding 1,500 ml during the 1st week after the ictus (OR 16.3, 95% CI 4.0-67.1). Age ≥70 years, larger amounts of intraventricular blood, vertebrobasilar aneurysm, and endovascular treatment tended to increase the likelihood of receiving a shunt. Outcome was not significantly different between shunted and non-shunted patients. CONCLUSIONS In this cohort of patients with clinical grade aSAH at admission, larger amounts of subarachnoid blood and large ventricular size on preoperative cerebral CT, and CSF drainage in excess of 1,500 ml during the 1st week after the ictus were significant predictors of shunt dependency. Shunt dependency did not hamper outcome.
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Choi JW, Kim SK, Wang KC, Lee JY, Cheon JE, Phi JH. Multifocal intraparenchymal hemorrhages after ventriculoperitoneal shunt surgery in infants. J Neurosurg Pediatr 2014; 14:329-35. [PMID: 25062301 DOI: 10.3171/2014.6.peds13635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Ventriculoperitoneal (VP) shunt surgery is the most common treatment for hydrocephalus. In certain situations, uncommon complications can occur after shunting procedures. The authors undertook this study to analyze the clinical characteristics of pediatric patients who developed multifocal intraparenchymal hemorrhages (MIPHs) as a complication of shunt surgery. The authors also analyzed the risk factors for MIPH in a large cohort of patients with hydrocephalus. METHODS This study included all pediatric patients (age < 18 years) who underwent VP shunt surgery at the authors' institution between January 2001 and December 2012. During this period, 507 VP shunt operations were performed in 330 patients. Four of these patients were subsequently diagnosed as having MIPH. The authors analyzed the clinical characteristics of these patients in comparison with those of the entire group of shunt-treated patients. RESULTS The incidence of MIPH was 1.2% (4 of 330 cases) for all pediatric patients who underwent VP shunt placement but 2.9% (4 of 140 cases) for infants less than 1 year old. When the analysis was limited to patients whose corrected age was less than 3 months, the incidence was 5.3% (4 of 76 cases). Of the 4 patients with MIPH, 2 were male and 2 were female. Their median age at surgery was 54 days (range 25-127 days), and in all 4 cases, the patients' corrected age was less than 1 month. Three patients were preterm infants, whereas one patient was full-term. None of these patients had a prior history of intracranial surgery (including CSF diversion procedures). All showed severe hydrocephalus during the preoperative period. Their clinical courses as patients with MIPH were comparatively favorable, despite the radiological findings. CONCLUSIONS MIPH is a rare but not negligible complication of VP shunt surgery. This complication might be a unique phenomenon in infants, especially young, preterm infants with severe hydrocephalus. Moreover, the absence of previous intracranial procedures might be one of the risk factors for this complication. The rapid alteration of brain conditions in the setting of immaturity might cause MIPH. To prevent this complication, the authors recommend that pressure settings of programmable valves should be gradually adapted to the target pressure.
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Ko JK, Cha SH, Choi BK, Lee JI, Yun EY, Choi CH. Hemorrhage rates associated with two methods of ventriculostomy: external ventricular drainage vs. ventriculoperitoneal shunt procedure. Neurol Med Chir (Tokyo) 2014; 54:545-51. [PMID: 24522005 PMCID: PMC4533471 DOI: 10.2176/nmc.oa.2013-0178] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cerebrospinal fluid (CSF) diversion is an essential component of neurosurgical care, but the rates and significance of hemorrhage associated with external ventricular drainage (EVD) and ventriculoperitoneal (VP) shunt procedures have not been well quantified. In this retrospective study, the authors examined the frequencies of hemorrhagic complications associated with EVD and VP shunt procedures, and attempted to identify associated risk factors. The treatment records of 370 EVDs in 276 patients and 102 VP shunts in 96 patients performed between 2008 and 2010 were retrospectively reviewed. Post-insertion computed tomographic (CT) scans were analyzed for any new hemorrhage related to the ventricular catheter. The effects of diagnosis at admission, endovascular treatment, anti-platelet medication, and a concurrent craniotomy operation were included in the analysis conducted to identify risk factors of ventricular catheter-related hemorrhage. Hemorrhage following EVD was detected on CT scans in 76 (20.5%) of the 370 cases. However, symptomatic hemorrhage occurred in only 5 cases (1.4% of all EVDs). VP shunt was associated with a higher incidence of ventricular catheter-related hemorrhage than EVD (hemorrhage rate: 43.1%) and the rate of detectable neurological change was 2.9%. Multivariate logistic-regression analysis of risk factors of EVD-related hemorrhage identified preoperative anti-platelet medication as the only significant factor (odds ratio, 3.583 [95% confidence interval, 1.353 to 9.486]; p = 0.010). Ventriculostomy-related hemorrhagic complications were more common than anticipated, especially for the VP shunt procedure. However, such hemorrhages are rarely large, rarely the cause of neurological deterioration, and rarely require surgical removal. Preoperative anti-platelet medication appears to affect EVD-related hemorrhage development.
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Affiliation(s)
- Jun Kyeung Ko
- Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital
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26
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Abstract
Intracerebral hemorrhage (ICH) remains a life-threatening disease that carries significant morbidity and mortality despite recent diagnostic and management advances. Various conditions are associated with increased risk of intracerebral hemorrhage. Understanding the etiology of these conditions and their pathophysiological contribution to ICH will likely lead to better therapeutic and preventative measures and improve the morbidity and mortality associated with intracerebral hemorrhage. We will review the current literature regarding important etiologies/risk factors of intracerebral hemorrhage.
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27
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Kosty J, Pukenas B, Smith M, Storm PB, Zager E, Stiefel M, LeRoux P, Hurst R. Iatrogenic Vascular Complications Associated With External Ventricular Drain Placement: A Report of 8 Cases and Review of the Literature. Oper Neurosurg (Hagerstown) 2012; 72:ons208-13; discussion ons213. [DOI: 10.1227/neu.0b013e318279e783] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
BACKGROUND:
Placement of an external ventricular drain (EVD) is a commonly performed and often lifesaving procedure. Although hemorrhage is one of the commonest complications associated with the procedure, ventricular catheter–induced vascular injury is rarely reported.
OBJECTIVE:
To describe 9 cases of EVD-related vascular trauma: 7 arteriovenous fistulas and 2 traumatic aneurysms.
METHODS:
During a 3-year period, 299 patients had EVDs placed. Eight patients (2.75%), 3 male and 5 female (mean age, 48 ± 20 years), developed vascular lesions associated with EVDs. Six patients developed arteriovenous fistulas and 2 patients developed a traumatic aneurysm. The arterial feeders of 5 superficial draining fistulas arose from the middle meningeal artery, and the arterial feeder of a deep-draining fistula originated from a lenticulostriate artery. One traumatic aneurysm arose from a distal branch of the anterior cerebral artery, and the second from a branch of the superficial temporal artery. Four of the superficial fistulas were treated with transarterial embolization.
RESULTS:
Two superficial fistulas and the deep-draining fistula resolved spontaneously after EVD removal. The intracranial aneurysm was embolized with Onyx18, and the superficial temporal artery aneurysm was managed conservatively. There were no hemorrhages associated with any of these vascular lesions and no complications after treatment.
CONCLUSION:
Our data suggest that iatrogenic vascular trauma associated with EVD insertions (2.75%) may be more common than is currently appreciated. Endovascular treatment is effective and may be necessary when these lesions do not resolve spontaneously.
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Affiliation(s)
- Jennifer Kosty
- Departments of Radiology, West Chester Medical Center, Valhalla, New York
- Departments of Neurosurgery, West Chester Medical Center, Valhalla, New York
| | - Bryan Pukenas
- Departments of Radiology, West Chester Medical Center, Valhalla, New York
- Departments of Neurosurgery, West Chester Medical Center, Valhalla, New York
| | - Michelle Smith
- Departments of Radiology, West Chester Medical Center, Valhalla, New York
- Departments of Neurosurgery, West Chester Medical Center, Valhalla, New York
| | - Phillip B. Storm
- Departments of Radiology, West Chester Medical Center, Valhalla, New York
- Departments of Neurosurgery, West Chester Medical Center, Valhalla, New York
| | - Eric Zager
- Departments of Radiology, West Chester Medical Center, Valhalla, New York
- Departments of Neurosurgery, West Chester Medical Center, Valhalla, New York
| | - Michael Stiefel
- Department of Neurosurgery, West Chester Medical Center, Valhalla, New York
| | - Peter LeRoux
- Departments of Radiology, West Chester Medical Center, Valhalla, New York
- Departments of Neurosurgery, West Chester Medical Center, Valhalla, New York
| | - Robert Hurst
- Departments of Neurosurgery, West Chester Medical Center, Valhalla, New York
- Departments of Radiology, West Chester Medical Center, Valhalla, New York
- Departments of Neurosurgery, West Chester Medical Center, Valhalla, New York
- Departments of Neurology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
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28
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Zhou F, Liu Q, Ying G, Zhu X. Delayed intracerebral hemorrhage secondary to ventriculoperitoneal shunt: two case reports and a literature review. Int J Med Sci 2012; 9:65-7. [PMID: 22219712 PMCID: PMC3245413 DOI: 10.7150/ijms.9.65] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Accepted: 11/20/2011] [Indexed: 11/07/2022] Open
Abstract
Ventriculoperitoneal (VP) shunt has become a popular operation to achieve cerebrospinal fluid (CSF) diversion, but is associated with many complications. Postoperative delayed intracerebral hemorrhage is a kind of rare but severe event, which has not thus far been reported in retrospective case analyses. Here we present two cases of delayed intracerebral hemorrhage, along the path of the ventricular catheter, which occurred on postoperative days 3 and 5. We also provide a literature review regarding this rare complication.
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Affiliation(s)
- Feng Zhou
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, China
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29
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Self-reported functional outcome after surgical intervention in patients with idiopathic normal pressure hydrocephalus. J Clin Neurosci 2011; 18:649-54. [DOI: 10.1016/j.jocn.2010.08.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Revised: 08/19/2010] [Accepted: 08/21/2010] [Indexed: 11/19/2022]
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