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Farke D, Siwicka AK, Olszewska A, Czerwik A, Büttner K, Schmidt MJ. Risk factors, treatment, and outcome in dogs and cats with subdural hematoma and hemispheric collapse after ventriculoperitoneal shunting of congenital internal hydrocephalus. J Vet Intern Med 2023; 37:2269-2277. [PMID: 37675951 PMCID: PMC10658535 DOI: 10.1111/jvim.16861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 08/24/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Overshunting and hemispheric collapse are well-known complications after ventriculoperitoneal shunt (VPS) implantation. Risk factors that predispose to overshunting, treatment options, and prognosis after therapeutic intervention have not been described. HYPOTHESIS/OBJECTIVES To identify preoperative risk factors for overshunting, the effect of surgical decompression, and their outcomes. ANIMALS Seventy-five dogs and 7 cats. METHODS Retrospective case cohort study. Age, breed, sex, body weight, number of dilated ventricles, ventricle brain ratio, intraventricular pressure, and implanted pressure valve systems were evaluated as possible risk factors. RESULTS Overshunting had a prevalence of 18% (Cl 95% 9.9-26.66). An increase of 0.05 in VBR increased the risk of overshunting by OR 2.23 (Cl 95% 1.4-3.5; P = .001). Biventricular hydrocephalus had the highest risk for overshunting compared to a tri- (OR 2.48 with Cl 95% 0.5-11.1) or tetraventricular hydrocephalus (OR 11.6 with Cl 95% 1.7-81.1; P = .05). There was no influence regarding the use of gravitational vs differential pressure valves (P > .78). Overshunting resulted in hemispheric collapse, subdural hemorrhage, and peracute deterioration of neurological status in 15 animals. Subdural hematoma was removed in 8 dogs and 2 cats with prompt postoperative improvement of clinical signs. CONCLUSIONS AND CLINICAL IMPORTANCE Biventricular hydrocephalus and increased VBR indicate a higher risk for overshunting. The use of differential valves with gravitational units has no influence on occurrence of overshunting related complications and outcomes. Decompressive surgery provides a favorable treatment option for hemispheric collapse and has a good outcome.
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Affiliation(s)
- Daniela Farke
- Department of Veterinary Clinical Sciences, Small Animal ClinicJustus‐Liebig‐University, Frankfurter Strasse 11435392 GiessenGermany
| | - Anna K. Siwicka
- Department of Veterinary Clinical Sciences, Small Animal ClinicJustus‐Liebig‐University, Frankfurter Strasse 11435392 GiessenGermany
| | - Agnieszka Olszewska
- Department of Veterinary Clinical Sciences, Small Animal ClinicJustus‐Liebig‐University, Frankfurter Strasse 11435392 GiessenGermany
| | - Adriana Czerwik
- Department of Veterinary Clinical Sciences, Small Animal ClinicJustus‐Liebig‐University, Frankfurter Strasse 11435392 GiessenGermany
| | - Kathrin Büttner
- Unit for Biomathematics and Data Processing, Faculty of Veterinary MedicineJustus Liebig‐University‐GiessenGiessenGermany
| | - Martin J. Schmidt
- Department of Veterinary Clinical Sciences, Small Animal ClinicJustus‐Liebig‐University, Frankfurter Strasse 11435392 GiessenGermany
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Davis M, Wheelock V, Talman L, Latimer C, Vicars B, Lin A, Jayadev S, Bird T. Subdural Hematoma as a Serious Complication of Huntington's Disease: An Observational Study. J Huntingtons Dis 2021; 10:385-390. [PMID: 34366363 DOI: 10.3233/jhd-210478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Persons with Huntington's disease (HD) are at increased risk for subdural hematomas (SDH) because of underlying brain atrophy and increased frequency of falls and head trauma. SDH can cause serious disability, but there is little information about the association of SDH with HD in the medical literature. OBJECTIVE To review the occurrence and characteristics of SDH seen in clinics specializing in HD. METHODS A retrospective review identifying the occurrence and manifestations of SDH in HD patients attending three HDSA Centers of Excellence. RESULTS Twenty-five HD patients (16F/9M) were identified with SDH. Twelve (44%) SDH were bilateral, 16 (60%) required surgical intervention, and 2 resulted in death. Mean age at the time of SDH was 60 years, mean duration of HD symptoms prior to event was 8 years, mean CAG repeat expansion size was 43 and mean UHDRS motor score obtained closest to time of SDH was 51 (16 patients). Most SDH occurred in the context of ground level falls or using stairs although 5 patients had no history of head trauma. Additional brain injury may occur along with the SDH. The most common symptoms were altered mental status, hemiparesis and loss of consciousness. The over-representation of females in this study requires replication and further investigation. CONCLUSION Patients with HD are at increased risk for SDH. An increased suspicion for SDH in HD patients should be considered, as this phenomenon may be initially unrecognized, may require extensive utilization of medical resources and is a potential cause of death.
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Affiliation(s)
- Marie Davis
- Departments of Neurology, University of WashingtonSchool of Medicine, Seattle, WA, USA.,Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Vicki Wheelock
- Department of Neurology, University of California-Davis, Sacramento, CA, USA
| | - Lauren Talman
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Caitlin Latimer
- Departments of Pathology, University ofWashington School of Medicine, Seattle, WA, USA
| | - Brenda Vicars
- Departments of Neurology, University of WashingtonSchool of Medicine, Seattle, WA, USA
| | - Anny Lin
- Departments of Neurology, University of WashingtonSchool of Medicine, Seattle, WA, USA
| | - Suman Jayadev
- Departments of Neurology, University of WashingtonSchool of Medicine, Seattle, WA, USA
| | - Thomas Bird
- Departments of Neurology, University of WashingtonSchool of Medicine, Seattle, WA, USA.,Departments of Medicine, University of Washington School of Medicine, Seattle, WA, USA.,Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
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Lalou AD, Czosnyka M, Placek MM, Smielewski P, Nabbanja E, Czosnyka Z. CSF Dynamics for Shunt Prognostication and Revision in Normal Pressure Hydrocephalus. J Clin Med 2021; 10:jcm10081711. [PMID: 33921142 PMCID: PMC8071572 DOI: 10.3390/jcm10081711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Despite the quantitative information derived from testing of the CSF circulation, there is still no consensus on what the best approach could be in defining criteria for shunting and predicting response to CSF diversion in normal pressure hydrocephalus (NPH). OBJECTIVE We aimed to review the lessons learned from assessment of CSF dynamics in our center and summarize our findings to date. We have focused on reporting the objective perspective of CSF dynamics testing, without further inferences to individual patient management. DISCUSSION No single parameter from the CSF infusion study has so far been able to serve as an unquestionable outcome predictor. Resistance to CSF outflow (Rout) is an important biological marker of CSF circulation. It should not, however, be used as a single predictor for improvement after shunting. Testing of CSF dynamics provides information on hydrodynamic properties of the cerebrospinal compartment: the system which is being modified by a shunt. Our experience of nearly 30 years of studying CSF dynamics in patients requiring shunting and/or shunt revision, combined with all the recent progress made in producing evidence on the clinical utility of CSF dynamics, has led to reconsidering the relationship between CSF circulation testing and clinical improvement. CONCLUSIONS Despite many open questions and limitations, testing of CSF dynamics provides unique perspectives for the clinician. We have found value in understanding shunt function and potentially shunt response through shunt testing in vivo. In the absence of infusion tests, further methods that provide a clear description of the pre and post-shunting CSF circulation, and potentially cerebral blood flow, should be developed and adapted to the bed-space.
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Affiliation(s)
- Afroditi Despina Lalou
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
- Correspondence: ; Tel.: +44-774-3567-585
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
- Institute of Electronic Systems, Faculty of Electronics and Information Sciences, Warsaw University of Technology, 00-661 Warsaw, Poland
| | - Michal M. Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
| | - Eva Nabbanja
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
| | - Zofia Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
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Funnell JP, D’Antona L, Craven CL, Thorne L, Watkins LD, Toma AK. Ultra-low-pressure hydrocephalic state in NPH: benefits of therapeutic siphoning with adjustable antigravity valves. Acta Neurochir (Wien) 2020; 162:2967-2974. [PMID: 32989519 DOI: 10.1007/s00701-020-04596-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/24/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Idiopathic normal-pressure hydrocephalus (NPH) is a condition of the elderly treated by ventriculoperitoneal shunt (VP) insertion. A subset of NPH patients respond only temporarily to shunt insertion despite low valve opening pressure. This study aims to describe our experience of patients who benefit from further CSF drainage by adding adjustable antigravity valves and draining CSF at ultra-low pressure. METHODS Single-centre retrospective case series of patients undergoing shunt valve revision from an adjustable differential pressure valve with fixed antigravity unit to a system incorporating an adjustable gravitational valve (Miethke proSA). Patients were screened from a database of NPH patients undergoing CSF diversion over 10 consecutive years (April 2008-April 2018). Clinical records were retrospectively reviewed for interventions and clinical outcomes. RESULTS Nineteen (10F:9M) patients underwent elective VP shunt revision to a system incorporating an adjustable gravitational valve. Mean age 77.1 ± 7.1 years (mean ± SD). Eleven patients (58%) showed significant improvement in walking speed following shunt revision. Fourteen patients/carers (74%) reported subjective improvements in symptoms following shunt revision. CONCLUSIONS Patients presenting symptoms relapse following VP shunting may represent a group of patients with ultra-low-pressure hydrocephalus, for whom further CSF drainage may lead to an improvement in symptoms. These cases may benefit from shunt revision with an adjustable gravitational valve, adjustment of which can lead to controlled siphoning of CSF and drain CSF despite ultra-low CSF pressure.
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Hadjiathanasiou A, Kilinc F, Behmanesh B, Bernstock J, Güresir E, Heimann M, Konczalla J, Scharnböck E, Schneider M, Weinhold L, Seifert V, Vatter H, Gessler F, Schuss P. Impact of Comorbidities and Frailty on Early Shunt Failure in Geriatric Patients With Normal Pressure Hydrocephalus. Front Med (Lausanne) 2020; 7:596270. [PMID: 33330560 PMCID: PMC7734184 DOI: 10.3389/fmed.2020.596270] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/11/2020] [Indexed: 12/12/2022] Open
Abstract
Background/Aim: Older patients are considered to bear a higher perioperative risk. Since idiopathic normal pressure hydrocephalus (NPH) predominantly concerns older patients, identifying risk factors for early shunt failure for preoperative risk/benefit assessment is indispensable for indication and/or consultation of patients for ventriculoperitoneal shunting (VPS). Methods: We performed a retrospective study design, including data acquired from two university hospital neurosurgical institutions between 2012 and 2019. Overall, 211 consecutive patients with clinical/radiological signs for NPH who additionally showed alleviation of symptoms after lumbar cerebrospinal fluid (CSF) drainage, received VPS and were included for further analysis. Frailty was measured using the Clinical Frailty Scale (CFS). Main outcome was early shunt failure or post-operative complications within 30 days after initial VPS surgery. Results: The overall complication rate was 14%. Patient-related complications were observed in 13 patients (6%) and procedure-related complications in 16 patients (8%). Early post-operative complications resulted in a significantly prolonged length of hospital stay 6.9 ± 6.8 vs. 10.8 ± 11.8 days (p = 0.03). Diabetes mellitus with end-organ damage (OR 35.4, 95% CI 6.6 – 189.4, p < 0.0001) as well as preexisting Parkinson's disease were associated with early patient-related post-surgical complications after VPS for NPH. Conclusions: Patients comorbidities but not frailty were associated with early post-operative patient-related complications in patients suffering NPH. While frailty may deter patients from other (neurosurgical) procedures, VPS surgery might contribute to treating NPH in these patients at a tolerable risk.
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Affiliation(s)
| | - Fatma Kilinc
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Bedjan Behmanesh
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Joshua Bernstock
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, United States
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Muriel Heimann
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Jürgen Konczalla
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Elisa Scharnböck
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | | | - Leonie Weinhold
- Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University Hospital Bonn, Bonn, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Florian Gessler
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Patrick Schuss
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
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