Epidemiology of adult-onset hydrocephalus: institutional experience with 2001 patients

Influence of distal insertion technique, valve selection, and patient demographics on shunt survival in ventriculoperitoneal shunt insertion: A retrospective analysis of an Australian case series

BACKGROUND

Ventriculoperitoneal (VP) shunt insertion is a means of diverting cerebrospinal fluid (CSF) for management of hydrocephalus. Revision rates, operating time, and length of stay (LOS) following laparoscopic insertion of the distal catheter have been mixed. There are limited data on the role of adhesiolysis during VP shunt insertion. Valve characteristics have also been shown to influence patient outcomes. There is a paucity of Australian data reporting on the effect of these variables on shunt outcomes. We aimed to study patient demographics, indications, and surgical and instrument variables in the Australian context.

METHODS

We performed a retrospective, multi-surgeon, single-centre analysis of VP shunts inserted in adults via an open or laparoscopic technique. Data on patient demographics and surgery characteristics were collected from the hospital medical records and the Australasian Shunt Registry. The primary outcome was shunt revision rate and secondary outcomes were postoperative complications, operating time and LOS, and shunt survivability.

RESULTS

Fifty-six participants were eligible for analysis. The overall revision rate was 14.3 %, which was lower than the national average. The distal catheter revision rate was 0 %. Laparoscopic insertion of the distal catheter was shown to significantly reduce operating time (70.4 min in the open group and 50.7 min in the laparoscopic group, p < 0.001). This was demonstrated across different aetiologies, and when controlling for age and valve-type (p < 0.05). The revision rate of non-programmable was higher than programmable valves (42.9 % versus 2.9 %, respectively). There were no differences between previous abdominal surgery, LOS, complication, or revision rate between open and laparoscopic insertion. VP shunt survivability was greater in the laparoscopic group (90-day shunt survival of 96.7 % and 92 % in the laparoscopy and open groups, respectively; p > 0.05). We did not find any significant difference in operating time or length of stay for age, sex, or previous abdominal surgery, even when accounting for surgical technique. Indication and shunt survivability varied widely between age groups. The use of laparoscopic insertion increased over time, though surgeons did not crossover techniques.

CONCLUSIONS

The overall distal revision rate of VP shunts is low. Laparoscopic insertion of the distal catheter reduces operating time and may improve shunt survivability. Larger studies are needed to confirm differences in shunt survivability in open versus laparoscopic distal catheter insertion, between age groups, clinical indications, and valve type on patient outcomes.

Structural and functional connectivity in hydrocephalus: a scoping review

Optimizing the treatment of hydrocephalus remains a major challenge in adult and pediatric neurosurgery. Currently, clinical treatment relies heavily on anatomic imaging of ventricular size and clinical presentation. The emergence of functional and structural brain connectivity imaging has provided the basis for a new paradigm in the management of hydrocephalus. Here we review the pertinent advances in this field. Following PRISMA-ScR guidelines for scoping reviews, we searched PubMed for relevant literature from 1994 to April 2023 using hydrocephalus and MRI-related terms. Included articles reported original MRI data on human subjects with hydrocephalus, while excluding non-English or pre-1994 publications that didn't match the study framework. The review identified 44 studies that investigated functional and/or structural connectivity using various MRI techniques across different hydrocephalus populations. While there is significant heterogeneity in imaging technology and connectivity analysis, there is broad consensus in the literature that 1) hydrocephalus is associated with disruption of functional and structural connectivity, 2) this disruption in cerebral connectivity can be further associated with neurologic compromise 3) timely treatment of hydrocephalus restores both cerebral connectivity and neurologic compromise. The robustness and consistency of these findings vary as a function of patient age, hydrocephalus etiology, and the connectivity region of interest studied. Functional and structural brain connectivity imaging shows potential as an imaging biomarker that may facilitate optimization of hydrocephalus treatment. Future research should focus on standardizing regions of interest as well as identifying connectivity analysis most pertinent to clinical outcome.

Do P-glycoprotein Medications Alter the Risk of Ventriculoperitoneal Shunt in Adults with Hydrocephalus?

Hydrocephalus is a disorder caused by excess fluid accumulation in the brain and results in brain damage with consequent cognitive and physical problems. This condition has no cure; the only treatment is brain surgery. Experimental data indicate that P-glycoprotein (P-gp) plays a crucial role in the pathogenesis of hydrocephalus due to its function in clearing macromolecules from the brain. Numerous medications frequently used are classified as P-gp inducers or inhibitors, and comprehending their effects may aid in attaining improved patient outcomes. Therefore, in this single-center retrospective study, we examined the risk of the need for ventriculoperitoneal shunt placement over 10 years among 4588 adult patients with hydrocephalus not exposed to any P-gp inhibitors/inducers or exclusively exposed to either P-gp inhibitors or inducers. Our analysis shows that patients exposed to P-gp inhibitors had a 3.2 times higher risk of requiring ventriculoperitoneal shunt surgery (P < .0001). In contrast, the relative risk was not significantly affected (P = .07) among those exposed to P-gp inducers. Our findings indicate the need for caution when prescribing P-gp inhibitors to patients with hydrocephalus. Additional studies using larger cohorts are required to confirm whether P-gp inducers in patients with hydrocephalus can mitigate the risk of ventriculoperitoneal shunt.

Engineering innovations in medicine and biology: Revolutionizing patient care through mechanical solutions

The overlap between mechanical engineering and medicine is expanding more and more over the years. Engineers are now using their expertise to design and create functional biomaterials and are continually collaborating with physicians to improve patient health. In this review, we explore the state of scientific knowledge in the areas of biomaterials, biomechanics, nanomechanics, and computational fluid dynamics (CFD) in relation to the pharmaceutical and medical industry. Focusing on current research and breakthroughs, we provide an overview of how these fields are being used to create new technologies for medical treatments of human patients. Barriers and constraints in these fields, as well as ways to overcome them, are also described in this review. Finally, the potential for future advances in biomaterials to fundamentally change the current approach to medicine and biology is also discussed.

Ventriculoperitoneal Shunt Surgery for Hydrocephalus: One of the Common Neurosurgical Procedures and Its Related Problems

Objective This study was conducted to assess the outcome in patients with hydrocephalus who underwent ventriculoperitoneal (VP) shunt surgery. Methods This retrospective study was conducted at the neurosurgery department of a tertiary care hospital. The time frame was three years and five months from January 2017 to May 2020 with a follow-up of six months. Results This study included 1030 patients, out of whom 64.2% were male and 35.8% were female. While the majority of the patients were more than 11 years of age (466), age did not have any significant impact on the outcome of the ventriculoperitoneal shunt surgery. The most common cause of hydrocephalus was congenital (47.6%). A good outcome was seen in 63.4%, mortality was 10.6%, and complications were identified for 25.8%. The underlying pathology had a significant impact on the outcome in our study (p-value < 0.05) where the congenital cause of hydrocephalus showed a better outcome than any other cause. Conclusion Ventriculoperitoneal shunt is a good way to manage hydrocephalus, but there is always a high risk of complications.

Imaging of Headaches due to Intracranial Pressure Disorders

Changes in intracranial pressure are a potentially serious etiology of headache. Headache secondary to changes in intracranial pressure frequently present with characteristic clinical features. Imaging plays a key role in the diagnosis and management of this category of headache. In this article, we will review the physiology, clinical presentation, and key imaging findings of major etiologies of changes in intracranial pressure resulting in headache including obstructive and nonobstructive hydrocephalous, idiopathic intracranial hypertension (IIH), and cerebrospinal fluid (CSF) leak.

A comparison of Adult and Pediatric Hydrocephalus

Hydrocephalus is a common clinical problem encountered in neurosurgical practice. With greater subspecialisation, pediatric neurosurgery has emerged as a special discipline in several countries. However, in the developing world, which inhabits a large pediatric population, a limited number of neurosurgeons manage all types of hydrocephalus across all ages. There are some essential differences in pediatric and adult hydrocephalus. The spectrum of hydrocephalus of dysgenetic origin in a neonate and that of normal pressure hydrocephalus of the old age has a completely different strategy of management. Endoscopic third ventriculostomy outcomes are known to be closely associated with age at presentation and surgery. Efficacy of alternative pathways of CSF absorption also differs according to age. Managing this disease in various age groups is challenging because of these differences in etiopathology, tempo of the disease, modalities of investigations and various treatment protocols as well as prognosis.

Mechanical Properties in the Glioma Microenvironment: Emerging Insights and Theranostic Opportunities

Gliomas represent the most common malignant primary brain tumors, and a high-grade subset of these tumors including glioblastoma are particularly refractory to current standard-of-care therapies including maximal surgical resection and chemoradiation. The prognosis of patients with these tumors continues to be poor with existing treatments and understanding treatment failure is required. The dynamic interplay between the tumor and its microenvironment has been increasingly recognized as a key mechanism by which cellular adaptation, tumor heterogeneity, and treatment resistance develops. Beyond ongoing lines of investigation into the peritumoral cellular milieu and microenvironmental architecture, recent studies have identified the growing role of mechanical properties of the microenvironment. Elucidating the impact of these biophysical factors on disease heterogeneity is crucial for designing durable therapies and may offer novel approaches for intervention and disease monitoring. Specifically, pharmacologic targeting of mechanical signal transduction substrates such as specific ion channels that have been implicated in glioma progression or the development of agents that alter the mechanical properties of the microenvironment to halt disease progression have the potential to be promising treatment strategies based on early studies. Similarly, the development of technology to measure mechanical properties of the microenvironment in vitro and in vivo and simulate these properties in bioengineered models may facilitate the use of mechanical properties as diagnostic or prognostic biomarkers that can guide treatment. Here, we review current perspectives on the influence of mechanical properties in glioma with a focus on biophysical features of tumor-adjacent tissue, the role of fluid mechanics, and mechanisms of mechanical signal transduction. We highlight the implications of recent discoveries for novel diagnostics, therapeutic targets, and accurate preclinical modeling of glioma.

Inflammatory hydrocephalus

Reparative inflammation is an important protective response that eliminates foreign organisms, damaged cells, and physical irritants. However, inappropriately triggered or sustained inflammation can respectively initiate, propagate, or prolong disease. Post-hemorrhagic (PHH) and post-infectious hydrocephalus (PIH) are the most common forms of hydrocephalus worldwide. They are treated using neurosurgical cerebrospinal fluid (CSF) diversion techniques with high complication and failure rates. Despite their distinct etiologies, clinical studies in human patients have shown PHH and PIH share similar CSF cytokine and immune cell profiles. Here, in light of recent work in model systems, we discuss the concept of "inflammatory hydrocephalus" to emphasize potential shared mechanisms and potential therapeutic vulnerabilities of these disorders. We propose that this change of emphasis could shift our thinking of PHH and PIH from a framework of life-long neurosurgical disorders to that of preventable conditions amenable to immunomodulation.

A Prospective Study and Analysis of Ventriculoperitoneal Shunt Surgery: Their Indication and Complication in a Single Tertiary Care Center

Background Ventriculoperitoneal (VP) shunt insertion is routinely performed for the treatment of hydrocephalus due to different indications like congenital, infective, tumor, posttraumatic, and normal pressure hydrocephalus (NPH). A lot of common and rare complications following this procedure have been reported.

Objectives To analyze the clinical profile, indications, anesthetic, and postoperative complications for VP shunt surgery in our center.

Materials and Methods This prospective clinical review study was conducted in the Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, between October 2018 to January 2020 and included 454 cases of hydrocephalus who underwent VP shunt surgery. The data was compiled and analyzed.

Results A total of 454 patients with male predominance were studied. Pediatric and adolescent patients were 48.9% (222/454). Obstructive hydrocephalus due to tumors was the etiology of 48.7% (221/454) cases. The incidence of overall shunt complications was 9.7% (44/454), of which obstruction and infection was 5.9% (27/454) and 3.1% (14/454), respectively. Factors associated with increased shunt complications include redo and infective etiology and cases having higher protein in perioperative cerebrospinal fluid (CSF) analysis. Neuronavigation, antibiotic-impregnated shunt and biventricular shunt are associated with lower complications.

Conclusion Obstructive hydrocephalus due to tumors happened to be the most common cause of VP shunt, and shunt obstruction is most common complication, especially in infective and redo cases.

Impact of Hospital Volume on Outcome After Surgical Treatment for Hydrocephalus: A U.S. Population Study From the National Inpatient Sample

Introduction

Hydrocephalus remains a common condition with significant patient morbidity; however, accurate accounting of the incidence of this disease as well as of the impact of hospital volume on outcome remains limited.

Methods

The National Inpatient Sample was used to evaluate patients who underwent surgical treatment of hydrocephalus from 2009-2013. Patient demographics (e.g., length of stay, disposition, charges), and the impact of hospital volume on outcomes were evaluated.

Results

A total of 156,205 patients were identified. Ventriculoperitoneal (VP) shunting the most common type of device (35.8%) followed by shunt replacement (23.9%). Treatment charges for hydrocephalus were $332 million in 2009 and $418 million in 2013 nationally. High-volume hospitals had more routine discharges compared with lower-volume hospitals (65.7% vs. 50.9%, p<0.0001), which was a trend that improved over time. Multivariate analysis confirmed that hospital volume was independently associated with routine disposition after adjusting for other factors such as patient age, length of stay, and shunt type. However, hospital volume showed a small association with length of stay (β = -0.05, p = 0.0001) and did not impact hospital charges on multivariate analysis.

Conclusion

This analysis provides a recent update of hydrocephalus epidemiology, trends, and outcomes nationally. Estimates from this study suggest that hydrocephalus is a common and costly problem. Hospital volume was for the first time to be associated with important differences in patient outcomes.

Differential DNA Methylation of the Genes for Amyloid Precursor Protein, Tau, and Neurofilaments in Human Traumatic Brain Injury

Traumatic brain injury (TBI) is an established risk factor for neurodegenerative disorders and dementias. Epigenetic modifications, such as DNA methylation, may alter the expression of genes without altering the DNA sequence in response to environmental factors. We hypothesized that DNA methylation changes may occur in the injured human brain and be implicated in the neurodegenerative aftermath of TBI. The DNA methylation status of genes related to neurodegeneration; for example, amyloid beta precursor protein (APP), microtubule associated protein tau (MAPT), neurofilament heavy (NEFH), neurofilament medium (NEFM), and neurofilament light (NEFL), was analyzed in fresh, surgically resected human brain tissue from 17 severe TBI patients and compared with brain biopsy samples from 19 patients with idiopathic normal pressure hydrocephalus (iNPH). We also performed an epigenome-wide association study (EWAS) comparing TBI patients with iNPH controls. Thirty-eight CpG sites in the APP, MAPT, NEFH, and NEFL genes were differentially methylated by TBI. Among the top 20 differentially methylated CpG sites, 11 were in the APP gene. In addition, the EWAS evaluating 828,888 CpG sites revealed 308 differentially methylated CpG sites in genes related to cellular/anatomical structure development, cell differentiation, and anatomical morphogenesis. These preliminary findings provide the first evidence of an altered DNA methylome in the injured human brain, and may have implications for the neurodegenerative disorders associated with TBI.

Comparison of ventriculoperitoneal shunt to lumboperitoneal shunt in the treatment of posthemorrhagic hydrocephalus: A prospective, monocentric, non-randomized controlled trial

BACKGROUND

Ventriculoperitoneal shunt (VPS) surgery remains the most widely accepted and used option method to treat post-hemorrhagic hydrocephalus (PHH) worldwide while lumboperitoneal shunt (LPS) serves as an effectively alternative treatment. However, the outcomes of VPS and LPS in the treatment of PHH have not been compared in a prospective trial.

METHODS AND DESIGN

In this monocentric, assessor-blinded, non-randomized controlled trial, 75 eligible patients with PHH for each group will be recruited to compare the outcomes of VPS cohort with that of LPS cohort. Each participant is evaluated before surgery, at the time of discharge, 3, and 6 months after surgery by experienced and practiced assessors. The primary outcome is the rate of shunt failure 6 months after shunt surgery. The secondary measure of efficacy is National Institute of Health stroke scale, together along with Glasgow coma scale, modified Rankin Scale, and Evans index at the evaluation point. A favorable outcome is defined as shunt success with an improvement of more than 1 point in the National Institute of Health stroke scale. Complication events occurring within 6 months after surgery are investigated. A serious adverse events throughout the study are recorded regarding the safety of shunts.

DISCUSSION

The results of this trial will provide evidence for the treatment options for patients with PHH.

A Noninvasive Retrograde Flushing System for Shunted Hydrocephalus: Initial Case Series of 25 Patients

Hydrocephalus is a common neurosurgical pathology associated with high patient morbidity and systemwide healthcare costs. A significant portion of these costs are related to the failure of ventricular shunting systems. Despite decades of research and technological development, the rate of shunt failure and revision has not significantly improved. The Reflow™ Ventricular System (Anuncia, Inc., Lowell, MA) is a recent technological development with the potential to prolong the shunt lifespan. This system introduces a noninvasive means of flushing a shunt proximally with a controlled, repeatable pulse of cerebral spinal fluid (CSF) and of creating a new ventricular opening for occluded shunts. In this multicenter case series, we present the early clinical experiences with this device and discuss its potential.

Role of psychiatric, cardiovascular, socioeconomic, and demographic risk factors on idiopathic normal pressure hydrocephalus: A retrospective case-control study

OBJECTIVES

Currently, predicting and preventing idiopathic normal pressure hydrocephalus (iNPH) remains challenging, especially for patients without a history of cerebrovascular disease. By exploring the role of cardiovascular and psychiatric history, demographics, and socioeconomic status in iNPH, will provide better direction for elucidating the etiology or addressing healthcare inequalities.

PATIENTS AND METHODS

To investigate iNPH with respect to the selected risk factors, we conducted a retrospective case-control study from a neuroscience institute in Hawaii with a patient pool of 25,843. After excluding patients with a history of cerebrovascular disease, we identified 29 cases which meet the American-European guidelines for iNPH diagnosis. Meanwhile, 116 controls matched to age, sex, and race were also randomly selected.

RESULTS

Median age at diagnosis was 83 (IQR: 74-88), with cases estimated 22 years older than controls (95 % CI: 14.00-29.00; p = 0.0000001). Patients with iNPH were more likely to be White (OR 4.01, 95 % CI: 1.59-10.11; p = 0.0042) and less likely Native Hawaiian and other Pacific Islander (OR 0.010, 95 % CI: 0.00-0.78; p = 0.014). Median household income was $2874 (95 % CI: 0.000089-6905; p = 0.088) greater amongst iNPH cases. Effect size amongst cardiovascular risk factors was not found statistically significant (i.e., body mass index, hyperlipidemia, type 2 diabetes mellitus, hypertension, coronary artery disease or prior myocardial infarction history, peripheral vascular disease, smoking status, congestive heart failure, atrial fibrillation/flutter, and history of prosthetic valve replacement). However, iNPH patients were more likely to have a history of alcohol use disorder (OR 8.29, 95 % CI: 0.99-453.87; p = 0.050) and history of a psychiatric disorder (OR 2.48; 95 % CI: 1.08-5.68; p = 0.029). Odds ratio for autoimmune disorder, thyroid disorder, glaucoma, and seizures did not reach statistical significance.

CONCLUSION

Patient race (i.e., White; Native Hawaiian or other Pacific Islander) was found associated with iNPH development. Meanwhile, after excluding those with cerebrovascular disease, cardiovascular risk factors were not found associated with iNPH. Lastly, iNPH cases were more inclined to have a history of alcohol use disorder and prior psychiatric disorder. Overall, this data reveals that a racial disparity exists amongst iNPH, as well as highlights the role of various cardiovascular and psychiatric risk factors, which can potentially provide direction in etiology elucidation.

Inflammation in acquired hydrocephalus: pathogenic mechanisms and therapeutic targets

Hydrocephalus is the most common neurosurgical disorder worldwide and is characterized by enlargement of the cerebrospinal fluid (CSF)-filled brain ventricles resulting from failed CSF homeostasis. Since the 1840s, physicians have observed inflammation in the brain and the CSF spaces in both posthaemorrhagic hydrocephalus (PHH) and postinfectious hydrocephalus (PIH). Reparative inflammation is an important protective response that eliminates foreign organisms, damaged cells and physical irritants; however, inappropriately triggered or sustained inflammation can respectively initiate or propagate disease. Recent data have begun to uncover the molecular mechanisms by which inflammation - driven by Toll-like receptor 4-regulated cytokines, immune cells and signalling pathways - contributes to the pathogenesis of hydrocephalus. We propose that therapeutic approaches that target inflammatory mediators in both PHH and PIH could address the multiple drivers of disease, including choroid plexus CSF hypersecretion, ependymal denudation, and damage and scarring of intraventricular and parenchymal (glia-lymphatic) CSF pathways. Here, we review the evidence for a prominent role of inflammation in the pathogenic mechanism of PHH and PIH and highlight promising targets for therapeutic intervention. Focusing research efforts on inflammation could shift our view of hydrocephalus from that of a lifelong neurosurgical disorder to that of a preventable neuroinflammatory condition.

A systematic review on the epidemiology of normal pressure hydrocephalus

BACKGROUND

The aim of this systematic review is to gather all available studies reporting prevalence and incidence rates of iNPH and to assess their methodological quality and consistency.

METHODS

All available studies published up to June 2019 were retrieved searching the databases PubMed, ISI Web of Science, and the Cochrane Database of Systematic Reviews. All included studies were qualitatively assessed by two independent reviewers using the MORE Checklist for Observational Studies of Incidence and Prevalence.

KEY RESULTS

Bibliographic searches and other sources yielded 659 records. A total of 28 studies were selected and applied the predefined inclusion and exclusion criteria. Fourteen studies were further excluded, and 14 studies (10 on prevalence and 6 on incidence) were included in the qualitative analysis. Results from the prevalence studies reported crude overall rates ranging from 10/100 000 to 22/100 000 for probable iNPH and 29/100 000 for possible iNPH, and age-specific rates ranging from 3.3/100 000 in people aged 50-59 to 5.9% in people aged ≥ 80 years. Results from incidence studies reported overall crude rates ranging from 1.8/100 000 to 7.3/100 000 per year, and age-specific rates ranging from 0.07/100 000/year in people aged < 60 years to 1.2/1000/year in people aged ≥ 70 years.

CONCLUSIONS & INFERENCES

The high methodological and clinical heterogeneity of included studies does not allow drawing adequate conclusions on the epidemiology of iNPH. Further, high-quality, population-based studies should be carried out to allow for a better understanding of the epidemiology of this condition. Moreover, the implementation in current clinical practice of guidelines on the diagnosis and management of iNPH should also be endorsed.

Establishment and Benefits of a Normal Pressure Hydrocephalus Support Group on Patient Education and Experience

Introduction: Normal pressure hydrocephalus (NPH) is a debilitating, neurological condition that can lead to mental deterioration. With the diagnosis and treatment of NPH constantly evolving and its symptoms worsening with age, education for patients and their families is crucial. In this study, we aim to explore the potential educational benefits of a physician-led NPH support group.

Methods: Between December 2015 and November 2018, six semiannual NPH support group meetings were held for patients and their families. Attendees, ages 20-90, completed a Likert scale-based survey designed to assess the support group’s educational benefits using the following primary outcome variables: (1) subjective knowledge, (2) perceived utility/efficacy, and (3) patient satisfaction.

Results: Our survey data suggests that patients and their family members agree on the efficacy of the support group in learning about NPH. They felt that the support group served its purpose and improved their comfort/knowledge regarding NPH. There was consensus about sustaining and maintaining the support group for the future. Of 65 survey responses, the composite average score of questions pertaining to subjective knowledge, perceived utility/efficacy, and patient satisfaction was 4.5 out of 5.0.

Conclusion: We demonstrated that support groups are effective in educating the adult NPH population and their family/friends about NPH onset and treatment. Enhanced educational awareness for patients and families can help patients cope with their neurological condition and improve patient adherence to follow-up and physician recommendations.

Ventricular Volume Dynamics During the Development of Adult Chronic Communicating Hydrocephalus in a Rodent Model

INTRODUCTION

The pathophysiology of normal-pressure hydrocephalus and the correlation with its symptomatology is not well understood.

OBJECTIVE

To monitor and evaluate the enlargement patterns of the ventricular system for each ventricle and its correlation with the presenting symptoms.

METHODS

Bilateral kaolin injection into the subarachnoid space overlying the cranial convexities was done in 18 adult rats. Magnetic resonance imaging was performed on an 11.7-T scanner 15, 60, 90, and 120 days after injection. Volumes of the ventricular system were measured for each ventricle and correlated with biweekly behavioral findings.

RESULTS

There was a progressive increase in the ventricular volume for the lateral ventricles since day 15 in the kaolin-injected animals. There was a nonsignificant trend in volume growth for the third ventricle, but its enlargement was synchronous with the lateral ventricles. No significant change for the fourth ventricle. No symptoms were detected in the first 60 days. Association was found between the ventricular volume and locomotor changes. In addition, the odds of locomotor symptoms increased by 3% for every additional cubic millimeter of volume in the left (P < 0.001) and right (P = 0.023) ventricles, and for the total magnetic resonance imaging volume by 1% (P = 0.013).

CONCLUSIONS

Expansion of the lateral ventricles maintained similar proportions over time, accompanied by a synchronous third ventricular expansion with less proportion and a nonsignificant fourth enlargement. Lateral ventricles enlarged most in those animals that were to develop late locomotor deterioration. Further research using this animal model combined with different radiologic imaging techniques, such as diffusion tensor imaging and perfusion studies, is recommended.

An experience with ventriculoperitoneal shunting at keen's point for hydrocephalus

Objective:

This study was conducted to assess outcomes in patients with hydrocephalus who underwent ventriculoperitoneal shunting at Keen’s point.

Methods:

This retrospective study was conducted in Combined Military Hospital (CMH) Peshawar. Time frame was four years from January 2011 to January 2015. The presenting complaints, clinical findings, investigations, treatment plans and surgical outcomes were noted. Ventriculo-Peritoneal (VP) shunting was done at Keen’s point. The presence of shunt complications in the first week post-surgery was noted and at a three-month follow up in the outpatient department. General condition of the patient, shunt complications, presence of seizure and worsening of vision were noted.

Results:

Study included 143 patients, out of whom 46 were females and 95 were male patients. Most common causes of hydrocephalus were congenital (79). Majority of adults had hydrocephalus due to central nervous system tumors while congenital hydrocephalus in children was most frequently due to aqueductal stenosis. Good clinical improvement was seen in 114 patients after shunt placement, satisfactory in 20 patients, 7 patients died while we observed no change in two patients.

Conclusion:

Our experience with VP shunting at Keen’s point resulted in excellent outcomes. It can be used for the management of hydrocephalus both in pediatric as well as adult population.

Comparative durability and costs analysis of ventricular shunts

OBJECTIVEVentricular shunt (VS) durability has been well studied in the pediatric population and in patients with normal pressure hydrocephalus; however, further evaluation in a more heterogeneous adult population is needed. This study aims to evaluate the effect of diagnosis and valve type-fixed versus programmable-on shunt durability and cost for placement of shunts in adult patients.METHODSThe authors retrospectively reviewed the medical records of all patients who underwent implantation of a VS for hydrocephalus at their institution over a 3-year period between August 2013 and October 2016 with a minimum postoperative follow-up of 6 months. The primary outcome was shunt revision, which was defined as reoperation for any indication after the initial procedure. Supply costs, shunt durability, and hydrocephalus etiologies were compared between fixed and programmable valves.RESULTSA total of 417 patients underwent shunt placement during the index time frame, consisting of 62 fixed shunts (15%) and 355 programmable shunts (85%). The mean follow-up was 30 ± 12 (SD) months. The shunt revision rate was 22% for programmable pressure valves and 21% for fixed pressure valves (HR 1.1 [95% CI 0.6-1.8]). Shunt complications, such as valve failure, infection, and overdrainage, occurred with similar frequency across valve types. Kaplan-Meier survival curve analysis showed no difference in durability between fixed (mean 39 months) and programmable (mean 40 months) shunts (p = 0.980, log-rank test). The median shunt supply cost per index case and accounting for subsequent revisions was $3438 (interquartile range $2938-$3876) and $1504 (interquartile range $753-$1584) for programmable and fixed shunts, respectively (p < 0.001, Wilcoxon rank-sum test). Of all hydrocephalus etiologies, pseudotumor cerebri (HR 1.9 [95% CI 1.2-3.1]) and previous shunt malfunction (HR 1.8 [95% CI 1.2-2.7]) were found to significantly increase the risk of shunt revision. Within each diagnosis, there were no significant differences in revision rates between shunts with a fixed valve and shunts with a programmable valve.CONCLUSIONSLong-term shunt revision rates are similar for fixed and programmable shunt pressure valves in adult patients. Hydrocephalus etiology may play a significant role in predicting shunt revision, although programmable valves incur higher supply costs regardless of initial diagnosis. Utilization of fixed pressure valves versus programmable pressure valves may reduce supply costs while maintaining similar revision rates. Given the importance of developing cost-effective management protocols, this study highlights the critical need for large-scale prospective observational studies and randomized clinical trials of ventricular shunt valve revisions and additional patient-centered outcomes.

Ventriculoperitoneal shunt insertion for hydrocephalus in human immunodeficiency virus-infected adults: a systematic review and meta-analysis protocol

BACKGROUND

Hydrocephalus is a recognised complication of human immunodeficiency virus (HIV)-related opportunistic infections. Symptomatic raised cerebrospinal fluid pressure can be treated with ventriculoperitoneal shunt insertion (VPS). In HIV-infected patients however, there is a concern that VPS might be associated with unacceptably high rates of mortality. We aim to systematically review and appraise published literature to determine reported outcomes and identify predictors of outcome following VPS in relevant subgroups of HIV-infected adults.

METHODS

The following electronic databases will be searched: The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), EMBASE, CINAHL (EBSCOhost), LILACS (BIREME), Research Registry ( www.researchregistry.com ), the metaRegister of Controlled Trials (mRCT) ( www.controlled-trials.com ), ClinicalTrials.gov ( www.clinicaltrials.gov ) and OpenSIGLE database. Any randomised studies, cohort studies, case-control studies, interrupted time series or sequential case series reporting survival following VPS in HIV-infected individuals will be included. If high-quality homogenous studies exist, meta-analysis will be conducted to determine 1-, 6- and 12-month mortality with comparison made between underlying aetiologies of hydrocephalus.

DISCUSSION AND CONCLUSION

This study will generate a comprehensive review of VPS in HIV-infected patients for publication. The primary outcome of meta-analysis is 12-month survival. If only low-quality, heterogeneous studies are available, this study will demonstrate this deficiency and will be of value in justifying and aiding the design of future studies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016052239.