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Kim M, Choi JH, Park JC, Ahn JS, Kwun BD, Park W. Ventriculoperitoneal shunt infection and malfunction in adult patients: incidence, risk factors, and long-term follow-up of single institution experience. Neurosurg Rev 2024; 47:269. [PMID: 38864925 DOI: 10.1007/s10143-024-02505-x] [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: 01/08/2024] [Revised: 06/04/2024] [Accepted: 06/05/2024] [Indexed: 06/13/2024]
Abstract
Ventriculoperitoneal shunt surgery was developed to manage excessive cerebrospinal fluid (CSF) in the brain's ventricles and is considered a mainstream treatment. Despite the development of the shunt device system, various complications still occur. In this study, we reported 307 cases and a long-term follow-up of at least five years of adult patients who underwent VP shunt surgery and analyzed various factors that may affect revision surgery. A retrospective study was conducted at Asan Medical Center, Korea, a tertiary medical center. We reviewed 307 cases from January 2012 to December 2018. The patients' neurological status, predisposing medical conditions, laboratory findings, and other operation-related factors were reviewed using electrical medical records. The normal function group comprised 272 cases (88.6%), and the overall incidence of revision group comprised 35 cases (11.4%). Of the 35 revision surgery cases, 30 (85.71%) were due to shunt malfunctions, such as obstruction, overdrainage, and valve-related errors while 5 (14.29%) were due to shunt infection. Patient demographics, mental status, and operation time did not influence revision as risk factors. Serum laboratory findings showed no statistical difference between the two groups. The white blood cell (WBC) count in the CSF profile differed significantly between the two groups. The Hakim Programmable valve (Codman, USA) is mainly used in our center. In addition, various shunt systems were used, including Strata Regulatory valve (Medtronic, USA), proGAV (Aesculap, USA), and Accu-Flo (Codman, USA). This study analyzed the factors affecting long-term outcomes. Based on these findings, efforts are needed to achieve more favorable outcomes in the future.
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Affiliation(s)
- Minwoo Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea
| | - June Ho Choi
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea
| | - Jae Sung Ahn
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea
| | - Byung Duk Kwun
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea
| | - Wonhyoung Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea.
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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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Bonney PA, Briggs RG, Chartrain AG, Giannotta SL, Lee DJ. Preexisting Ventricular Shunts Are Associated with Failed Evacuation of Acute Subdural Hematomas: Single-Institution Case Series of Complications and Management Strategies. World Neurosurg 2021; 158:e1011-e1016. [PMID: 34896347 DOI: 10.1016/j.wneu.2021.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/03/2021] [Accepted: 12/03/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The effect of ventricular shunts on radiographic outcomes after evacuation of acute subdural hematomas (aSDHs) has not yet been established. We studied a series of patients who had undergone craniotomy for aSDH, exploring a possible relationship between the occurrence of a postoperative extra-axial collection (EAC) and the presence of a ventricular shunt. METHODS We reviewed all craniotomies for convexity aSDH performed between July 2015 and June 2020. The medical record review included perioperative coagulation studies, platelet counts, and antiplatelet and anticoagulation agent use. Univariate and multivariate analyses were conducted to identify the factors associated with postoperative EACs and reevacuation. RESULTS A total of 58 patients had undergone craniotomy for aSDHs, including 9 with ventricular shunts. The median age was 67 years (interquartile range, 54-78 years), and 40% of the patients were women. Of the 58 patients, 16 were taking antiplatelet agents, and 6 were taking anticoagulation agents. Ten patients had developed perioperative thrombocytopenia (platelet count, <100,000/μL). Twelve patients had perioperative coagulopathy (international normalized ratio, ≥1.5). A postoperative EAC >10 mm occurred in 17 patients (29.3%). Eight patients (13.8%) had undergone reevacuation. The presence of a shunt and an increasing preoperative aSDH size were independently associated with an EAC >10 mm (P = 0.013 and P = 0.003, respectively). Only the presence of a shunt predicted for the need for reevacuation (P = 0.001). The shunts were explanted (n = 3) or valves were adjusted (n = 3) in all but 3 cases. CONCLUSIONS We found that a lack of brain reexpansion after aSDH evacuation worsens radiographic outcomes and was more common in patients with shunts. Increasing shunt valve resistance might help prevent the formation of large EACs after aSDH evacuation.
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Affiliation(s)
- Phillip A Bonney
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
| | - Robert G Briggs
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Alexander G Chartrain
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Steven L Giannotta
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Darrin J Lee
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Larrew T, Alshareef M, Murphy RF, Eskandari R, Kosnik Infinger L. Interactions between programmable shunt valves and magnetically controlled growing rods for scoliosis. J Neurosurg Pediatr 2020; 26:667-670. [PMID: 33007746 DOI: 10.3171/2020.6.peds20299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/05/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although the advent of magnetic growing rod technology for scoliosis has provided a means to bypass multiple hardware lengthening operations, it is important to be aware that many of these same patients have a codiagnosis of hydrocephalus with magnet-sensitive programmable ventricular shunts. As the magnetic distraction of scoliosis rods has not previously been described to affect the shunt valve setting, the authors conducted an investigation to characterize the interaction between the two devices. METHODS In this ex vivo study, the authors carried out 360 encounters between four different shunt valve types at varying distances from the magnetic external remote control (ERC) used to distract the growing rods. Valve settings were examined before and after every interaction with the remote control to determine if there was a change in the setting. RESULTS The Medtronic Strata and Codman Hakim valves were found to have setting changes at distances of 3 and 6 inches but not at 12 inches. The Aesculap proGAV and Codman Certas valves, typically described as MRI-resistant, did not have any setting changes due to the magnetic ERC regardless of distance. CONCLUSIONS Although it is not necessary to check a shunt valve after every magnetic distraction of scoliosis growing rods, if there is concern that the magnetic ERC may have been within 12 inches (30 cm) of a programmable ventricular shunt valve, the valve should be checked at the bedside with a programmer or with a skull radiograph along with postdistraction scoliosis radiographs.
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Affiliation(s)
| | | | - Robert F Murphy
- 2Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, South Carolina
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Feletti A, d'Avella D, Wikkelsø C, Klinge P, Hellström P, Tans J, Kiefer M, Meier U, Lemcke J, Paternò V, Stieglitz L, Sames M, Saur K, Kordás M, Vitanovic D, Gabarrós A, Llarga F, Triffaux M, Tyberghien A, Juhler M, Hasselbalch S, Cesarini K, Laurell K. Ventriculoperitoneal Shunt Complications in the European Idiopathic Normal Pressure Hydrocephalus Multicenter Study. Oper Neurosurg (Hagerstown) 2020; 17:97-102. [PMID: 30169650 DOI: 10.1093/ons/opy232] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 07/28/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ventriculoperitoneal shunt (VP-shunt) is the standard of treatment for idiopathic normal pressure hydrocephalus (iNPH). However, a thorough investigation of VP-shunt complications in this population is lacking. OBJECTIVE To present the analysis and the rates of complications progressively occurring during the first year after shunt surgery in the patients with iNPH included in the European multicenter (EU-iNPH) study. METHODS Patients (n = 142) were prospectively included in the EU-iNPH study by 13 institutions. All patients received a programmable VP-shunt. One hundred fifteen patients completed the 12-mo follow-up. Reexaminations were performed 1, 3, and 12 mo after surgery. Data regarding symptomatic over- or underdrainage, infections, malposition, subdural collections, and shunt surgery were collected and analyzed. RESULTS Thirty patients (26%) experienced symptoms due to shunt underdrainage. Symptomatic overdrainage was reported in 10 (9%). Shunt adjustments were made in 43 (37%). Shunt malposition was recognized as the primary cause of shunt malfunction in 8 (7%), while only 1 infection (0.9%) occurred. Subdural hematoma was diagnosed in 7 (6%) and was treated by increasing the opening pressure of the valve in 5 patients. Hygroma was diagnosed in 10 (9%), requiring surgery in 1 patient. Overall, 17 patients (15%) underwent 19 shunt surgeries. CONCLUSION The advances in valve technology, a careful opening pressure setting, and rigorous follow-up allow a significant reduction of complications, which can be usually managed nonsurgically within the first 3 to 6 mo.
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Affiliation(s)
- Alberto Feletti
- Department of Neurosciences, Unit of Neurosurgery, NOCSAE Modena Hospital, Modena, Italy
| | - Domenico d'Avella
- Department of Neurosciences, Academic Neurosurgery, University of Padova, Padova, Italy
| | - Carsten Wikkelsø
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Petra Klinge
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Per Hellström
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jos Tans
- Department of Neurology, Medical Centre Haaglanden, The Hague, The Netherlands
| | - Michael Kiefer
- Department of Neurosurgery, Saarland University, Homburg-Saar, Germany
| | - Ulrich Meier
- Department of Neurosurgery. Akademisches Lehrkrankenhaus der Freien Universität Berlin. Krankenhaus Berlin-Marzahn, Berlin, Germany
| | - Johannes Lemcke
- Department of Neurosurgery. Akademisches Lehrkrankenhaus der Freien Universität Berlin. Krankenhaus Berlin-Marzahn, Berlin, Germany
| | - Vincenzo Paternò
- Department of Neurosurgery, International Neuroscience Institute Hannover, Hannover, Germany
| | - Lennart Stieglitz
- Department of Neurosurgery, International Neuroscience Institute Hannover, Hannover, Germany
| | - Martin Sames
- Department of Neurosurgery, Masaryk Hospital, Usti nad Labem, The Czech Republic
| | - Karel Saur
- Department of Neurosurgery, Masaryk Hospital, Usti nad Labem, The Czech Republic
| | | | | | | | | | - Michael Triffaux
- Service de Neurochirurgie. Clinique au Jardin Botanique 32, Brussels, Belgium
| | - Alain Tyberghien
- Service de Neurochirurgie. Clinique au Jardin Botanique 32, Brussels, Belgium
| | - Marianne Juhler
- Neurokirurgisk Klinik NK 2092, Memory Disorders Research Unit, The Neuroscience Center, N6702, Rigshospitalet, Copenhagen, Denmark
| | - Stehen Hasselbalch
- Neurokirurgisk Klinik NK 2092, Memory Disorders Research Unit, The Neuroscience Center, N6702, Rigshospitalet, Copenhagen, Denmark
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Garegnani L, Franco JV, Ciapponi A, Garrote V, Vietto V, Portillo Medina SA. Ventriculo-peritoneal shunting devices for hydrocephalus. Cochrane Database Syst Rev 2020; 6:CD012726. [PMID: 32542676 PMCID: PMC7388891 DOI: 10.1002/14651858.cd012726.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Hydrocephalus is a common neurological disorder, caused by a progressive accumulation of cerebrospinal fluid (CSF) within the intracranial space that can lead to increased intracranial pressure, enlargement of the ventricles (ventriculomegaly) and, consequently, to brain damage. Ventriculo-peritoneal shunt systems are the mainstay therapy for this condition, however there are different types of shunt systems. OBJECTIVES To compare the effectiveness and adverse effects of conventional and complex shunt devices for CSF diversion in people with hydrocephalus. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (2020 Issue 2); Ovid MEDLINE (1946 to February 2020); Embase (Elsevier) (1974 to February 2020); Latin American and Caribbean Health Science Information Database (LILACS) (1980 to February 2020); ClinicalTrials.gov; and World Health Organization International Clinical Trials Registry Platform. SELECTION CRITERIA We selected randomised controlled trials or quasi-randomised trials of different types of ventriculo-peritoneal shunting devices for people with hydrocephalus. Primary outcomes included: treatment failure, adverse events and mortality. DATA COLLECTION AND ANALYSIS Two review authors screened studies for selection, assessed risk of bias and extracted data. Due to the scarcity of data, we performed a Synthesis Without Meta-analysis (SWiM) incorporating GRADE for the quality of the evidence. MAIN RESULTS We included six studies with 962 participants assessing the effects of standard valves compared to anti-syphon valves, other types of standard valves, self-adjusting CSF flow-regulating valves and external differential programmable pressure valves. All included studies started in a hospital setting and offered ambulatory follow-up. Most studies were conducted in infants or children with hydrocephalus from diverse causes. The certainty of the evidence for most comparisons was low to very low. 1. Standard valve versus anti-syphon valve Three studies with 296 randomised participants were included under this comparison. We are uncertain about the incidence of treatment failure in participants with standard valve and anti-syphon valves (very low certainty of the evidence). The incidence of adverse events may be similar in those with standard valves (range 0 to 1.9%) and anti-syphon valves (range 0 to 2.9%) (low certainty of the evidence). Mortality may be similar in those with standard valves (0%) and anti-syphon valves (0.9%) (RD 0.01%, 95% CI -0.02% to 0.03%, low certainty of the evidence). Ventricular size and head circumference may be similar in those with standard valves and anti-syphon valves (low certainty of the evidence). None of the included studies reported the quality of life of participants. 2. Comparison between different types of standard valves Two studies with 174 randomised participants were included under this comparison. We are uncertain about the incidence of treatment failure in participants with different types of standard valves (early postoperative period: RR 0.41, 95% CI 0.13 to 1.27; at 12 months follow-up: RR 1.17, 95% CI 0.72 to 1.92, very low certainty of the evidence). None of the included studies reported adverse events beyond those included under "treatment failure". We are uncertain about the effects of different types of standard valves on mortality (range 2% to 17%, very low certainty of the evidence). The included studies did not report the effects of these interventions on quality of life, ventricular size reduction or head circumference. 3. Standard valve versus self-adjusting CSF flow-regulating valve One study with 229 randomised participants addressed this comparison. The incidence of treatment failure may be similar in those with standard valves (42.98%) and self-adjusting CSF flow-regulating valves (39.13%) (low certainty of the evidence). The incidence of adverse events may be similar in those with standard valves (range 0 to 1.9%) and those with self-adjusting CSF flow-regulating valves (range 0 to 7.2%) (low certainty of the evidence). The included study reported no deaths in either group in the postoperative period. Beyond the early postoperative period, the authors stated that nine patients died (no disaggregated data by each type of intervention was available, low certainty of the evidence). The included studies did not report the effects of these interventions on quality of life, ventricular size reduction or head circumference. 4. External differential programmable pressure valve versus non-programmable valve One study with 377 randomised participants addressed this comparison. The incidence of treatment failure may be similar in those with programmable valves (52%) and non-programmable valves (52%) (RR 1.02, 95% CI 0.84 to 1.24, low certainty of the evidence). The incidence of adverse events may be similar in those with programmable valves (6.19%) and non-programmable valves (6.01%) (RR 0.97, 95% CI 0.44 to 2.15, low certainty of the evidence). The included study did not report the effect of these interventions on mortality, quality of life or head circumference. Ventricular size reduction may be similar in those with programmable valves and non-programmable valves (low certainty of the evidence). AUTHORS' CONCLUSIONS Standard shunt valves for hydrocephalus compared to anti-syphon or self-adjusting CSF flow-regulating valves may cause little to no difference on the main outcomes of this review, however we are very uncertain due to the low to very low certainty of evidence. Similarly, different types of standard valves and external differential programmable pressure valves versus non-programmable valves may be associated with similar outcomes. Nevertheless, this review did not include valves with the latest technology, for which we need high-quality randomised controlled trials focusing on patient-important outcomes including costs.
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Affiliation(s)
- Luis Garegnani
- Research Department, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Juan Va Franco
- Argentine Cochrane Centre, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Agustín Ciapponi
- Argentine Cochrane Centre, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Buenos Aires, Argentina
| | - Virginia Garrote
- Biblioteca Central, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Valeria Vietto
- Family and Community Medicine Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Wetzel C, Goertz L, Noé P, von Spreckelsen N, Penner M, Kabbasch C, Goldbrunner R, Krischek B. Flow-regulated versus differential pressure valves for idiopathic normal pressure hydrocephalus: comparison of overdrainage rates and neurological outcome. Acta Neurochir (Wien) 2020; 162:15-21. [PMID: 31713158 DOI: 10.1007/s00701-019-04088-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/24/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND To compare flow-regulated (FR) and differential pressure (DP) valves for treatment of patients with idiopathic normal hydrocephalus (iNPH) focusing on overdrainage and neurological outcome. METHODS This is a retrospective study of patients with iNPH treated with FR and DP valves at a single institution between 2008 and 2018. The neurological status was evaluated retrospectively with the Kiefer scale at baseline, after shunt placement and at the 6-month follow-up. Groups were compared using inverse probability of treatment weighting based on propensity scores. RESULTS The study cohort consisted of 38 patients treated with FR valves and 49 with DP valves. The mean patient age was 72.0 ± 7.6 years. Based on the Kiefer scale score, neurological improvement at the 6-month follow-up was recorded in 79.6% in the DP group and 89.5% in the FR group (p = 0.252). The overdrainage rates were higher among DP valves (10.2%) than among FR valves (2.6%, adjusted p = 0.002). Valve malfunction occurred in 2.0% in the DP group and 5.3% in the FR group (adjusted p = 0.667). CONCLUSIONS The current study demonstrates a comparable neurological improvement between DP and FR valves, with potentially lower overdrainage rates among FR valves. Long-term studies will be necessary to draw a definite conclusion on FR valves for treatment of iNPH patients.
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Affiliation(s)
- Christian Wetzel
- Faculty of Medicine and University Hospital, Center for Neurosurgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Lukas Goertz
- Faculty of Medicine and University Hospital, Center for Neurosurgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany.
| | - Philipp Noé
- Faculty of Medicine and University Hospital, Center for Neurosurgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
- Department of Neurosurgery, Bundeswehrkrankenhaus Koblenz, Rübenacher Strasse 170, 56072, Koblenz, Germany
| | - Niklas von Spreckelsen
- Faculty of Medicine and University Hospital, Center for Neurosurgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
- Harvey Cushing Neuro-Oncology Laboratories, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Marina Penner
- Faculty of Medicine and University Hospital, Center for Neurosurgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Christoph Kabbasch
- Department of Neuroradiology, University Hospital of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Roland Goldbrunner
- Faculty of Medicine and University Hospital, Center for Neurosurgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Boris Krischek
- Faculty of Medicine and University Hospital, Center for Neurosurgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
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Orrego-González E, Enriquez-Marulanda A, Ascanio LC, Jordan N, Hanafy KA, Moore JM, Ogilvy CS, Thomas AJ. A Cohort Comparison Analysis of Fixed Pressure Ventriculoperitoneal Shunt Valves With Programmable Valves for Hydrocephalus Following Nontraumatic Subarachnoid Hemorrhage. Oper Neurosurg (Hagerstown) 2019; 18:374-383. [DOI: 10.1093/ons/opz195] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 04/16/2019] [Indexed: 12/24/2022] Open
Abstract
AbstractBACKGROUNDHydrocephalus after nontraumatic subarachnoid hemorrhage (SAH) is a common sequela that may require the placement of ventriculoperitoneal shunts (VPS). Adjustable-pressure valves (APVs) are being widely used in this situation though more expensive than differential-pressure valves (DPVs).OBJECTIVETo compare outcomes between APV and DPV in SAH-induced hydrocephalus.METHODSWe performed a retrospective chart review of patients with nontraumatic SAH who underwent VPS placement for the treatment of hydrocephalus after SAH, between July 2007 and December 2016. Patients were classified according to the type of valve (APV vs DPV). We evaluated factors that could predict the type of valve used, outcomes in VPS revision/replacement rate, and complications.RESULTSA total of 66 patients underwent VPS placement who were equally distributed into the 2 groups of valves. VPS failure with the need for revision/replacement occurred in 13 (19.7%) cases. Ten (30.3%) patients with DPV had a VPS failure, while 3 (9.1%) patients with an APV had a similar failure with the need for revision/replacement (P = .03). VPS placement before discharge during the initial hospitalization (P = .02) was statistically significant associated with the use of a DPV, while the reason of external ventricular drain (EVD) failure (P = .03) was associated with the use of an APV.CONCLUSIONAPVs had a lower rate of surgical revisions compared to DPVs. Early placement of VPS was associated with the use of a DPV. The need for EVD replacement due to EVD infection or malfunction was associated with higher rates of APV use.
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Affiliation(s)
- Eduardo Orrego-González
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Universidad Icesi. Facultad de Ciencias de la Salud. Cali, Colombia
| | | | - Luis C Ascanio
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Noah Jordan
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Khalid A Hanafy
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Justin M Moore
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Ogilvy
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajith J Thomas
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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9
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Paff M, Alexandru-Abrams D, Muhonen M, Loudon W. Ventriculoperitoneal shunt complications: A review. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2018. [DOI: 10.1016/j.inat.2018.04.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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10
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Sundström N, Lagebrant M, Eklund A, Koskinen LOD, Malm J. Subdural hematomas in 1846 patients with shunted idiopathic normal pressure hydrocephalus: treatment and long-term survival. J Neurosurg 2017; 129:797-804. [PMID: 29076787 DOI: 10.3171/2017.5.jns17481] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Subdural hematoma (SDH) is the most common serious adverse event in patients with shunts. Adjustable shunts are used with increasing frequency and make it possible to noninvasively treat postoperative SDH. The objective of this study was to describe the prevalence and treatment preferences of SDHs, based on fixed or adjustable shunt valves, in a national cohort of patients with shunted idiopathic normal pressure hydrocephalus (iNPH), as well as to evaluate the effect of SDH and treatment on long-term survival. METHODS Patients with iNPH who received a CSF shunt in Sweden from 2004 to 2015 were included in a prospective quality registry (n = 1846) and followed regarding SDH, its treatment, and mortality. The treatment of SDH was categorized into surgery, opening pressure adjustments, or no treatment. RESULTS During the study period, the proportion of adjustable shunts increased from 75% to 95%. Ten percent (n = 184) of the patients developed an SDH. In 103 patients, treatment was solely opening pressure adjustment. Surgical treatment was used in 66 cases (36%), and 15 (8%) received no treatment. In patients with fixed shunt valves, 90% (n = 17) of SDHs were treated surgically compared with 30% (n = 49) in patients with adjustable shunts (p < 0.001). There was no difference in long-term patient survival between the SDH and non-SDH groups or between different treatments. CONCLUSIONS SDH remains a common complication after shunt surgery, but adjustable shunts reduced the need for surgical interventions. SDH and treatment did not significantly affect survival in this patient group, thus the noninvasive treatment offered by adjustable shunts considerably reduces the level of severity for this common adverse event.
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Affiliation(s)
- Nina Sundström
- Departments of1Radiation Sciences, Biomedical Engineering, and
| | - Marcus Lagebrant
- 2Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Anders Eklund
- Departments of1Radiation Sciences, Biomedical Engineering, and
| | | | - Jan Malm
- 2Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
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Serarslan Y, Yilmaz A, Çakır M, Güzel E, Akakin A, Güzel A, Urfalı B, Aras M, Kaya ME, Yılmaz N. Use of programmable versus nonprogrammable shunts in the management of normal pressure hydrocephalus: A multicenter retrospective study with cost-benefit analysis in Turkey. Medicine (Baltimore) 2017; 96:e8185. [PMID: 28953678 PMCID: PMC5626321 DOI: 10.1097/md.0000000000008185] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Ventriculoperitoneal shunt systems that are used in the treatment of normal pressure hydrocephalus are often associated with drainage problems. Adjustable shunt systems can prevent or treat these problems, but they may be expensive. The aim of our study is to compare the complications and total cost of several shunt systems.Patients with normal pressure hydrocephalus who underwent ventriculoperitoneal shunting between 2011 and 2016 were included in the study. The study involves patient consent and the informed consent was given. Complications and the average cost per person were compared between patients with adjustable and nonadjustable shunts. Shunt prices, surgical complications, and revision costs were taken into account to calculate the average cost.Of the 110 patients who were evaluated, 80 had a nonadjustable shunt and 30 had an adjustable shunt. In the group with adjustable shunts, the rates of subdural effusion and hematoma were 19.73% and 3.29%, respectively. In the group with nonadjustable shunts, these rates were 22.75% and 13.75%, respectively. One patient in the adjustable group underwent surgery for subdural hematoma, while 8 patients in the nonadjustable group underwent the same surgery. Ten patients required surgical intervention for subdural effusion and existing shunt systems in these patients were replaced by an adjustable shunt system. When these additional costs were factored into the analysis, the difference in cost between the shunt systems was reduced from 600 United States dollars (USD) to 111 USD.When the complications and additional costs that arise during surgical treatment of normal pressure hydrocephalus were considered, the price difference between adjustable and nonadjustable shunt systems was estimated to be much lower.
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Affiliation(s)
| | - Atilla Yilmaz
- Neurosurgery Department, Mustafa Kemal University, Hatay
| | - Mürteza Çakır
- Neurosurgery Department, Ataturk University, Erzurum
| | - Ebru Güzel
- Radiology Department, Gaziantep Medical Park Hospital, Gaziantep
| | - Akin Akakin
- Neurosurgery Department, Bahcesehir University, Istanbul
| | - Aslan Güzel
- Neurosurgery Department, Gaziantep Medical Park Hospital, Bahcesehir University, Gaziantep
| | - Boran Urfalı
- Neurosurgery Department, Mustafa Kemal University, Hatay
| | - Mustafa Aras
- Neurosurgery Department, Mustafa Kemal University, Hatay
| | | | - Nebi Yılmaz
- Neurosurgery Department, Eryaman Hospital, Ankara, Turkey
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12
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Daou B, Klinge P, Tjoumakaris S, Rosenwasser RH, Jabbour P. Revisiting secondary normal pressure hydrocephalus: does it exist? A review. Neurosurg Focus 2017; 41:E6. [PMID: 27581318 DOI: 10.3171/2016.6.focus16189] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There are several etiologies that can lead to the development of secondary normal pressure hydrocephalus (sNPH). The aim of this study was to evaluate the etiology, diagnosis, treatment, and outcome in patients with sNPH and to highlight important differences between the separate etiologies. METHODS A comprehensive review of the literature was performed to identify studies conducted between 1965 and 2015 that included data regarding the etiology, treatment, diagnosis, and outcome in patients with sNPH. Sixty-four studies with a total of 1309 patients were included. The inclusion criteria of this study were articles that were written in English, included more than 2 patients with the diagnosis of sNPH, and contained data regarding the etiology, diagnosis, treatment, or outcome of NPH. The most common assessment of clinical improvement was based on the Stein and Langfitt grading scale or equivalent improvement on other alternative ordinal grading scales. RESULTS The main etiologies of sNPH were subarachnoid hemorrhage (SAH) in 46.5%, head trauma in 29%, intracranial malignancies in 6.2%, meningoencephalitis in 5%, and cerebrovascular disease in 4.5% of patients. In 71.9% of patients the sNPH was treated with ventriculoperitoneal shunt placement, and 24.4% had placement of a ventriculoatrial shunt. Clinical improvement after shunt placement was reported in 74.4% and excellent clinical improvement in 58% of patients with sNPH. The mean follow-up period after shunt placement was 13 months. Improvement was seen in 84.2% of patients with SAH, 83% of patients with head trauma, 86.4% of patients with brain tumors, 75% of patients with meningoencephalitis, and 64.7% of patients with NPH secondary to stroke. CONCLUSIONS Secondary NPH encompasses a diverse group of clinical manifestations associated with a subset of patients with acquired hydrocephalus. The most common etiologies of sNPH include SAH and traumatic brain injury. Secondary NPH does indeed exist, and should be differentiated from idiopathic NPH based on outcome and on clinical, pathophysiological, and epidemiological characteristics, but should not be considered as a separate entity.
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Affiliation(s)
- Badih Daou
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Petra Klinge
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania; and
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13
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Pereira RM, Suguimoto MT, Oliveira MF, Tornai JB, Amaral RA, Teixeira MJ, Pinto FCG. Performance of the fixed pressure valve with antisiphon device SPHERA® in the treatment of normal pressure hydrocephalus and prevention of overdrainage. ARQUIVOS DE NEURO-PSIQUIATRIA 2015; 74:55-61. [PMID: 26602193 DOI: 10.1590/0004-282x20150190] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/05/2015] [Indexed: 05/28/2023]
Abstract
Normal pressure hydrocephalus (NPH) is characterized by the triad of gait apraxia, dementia and urinary incontinence associated with ventriculomegaly and normal pressure of cerebrospinal fluid. Treatment is accomplished through the implantation of a ventricular shunt (VPS), however some complications are still frequent, like overdrainage due to siphon effect. This study analyses the performance of a valve with anti-siphon device (SPHERA®) in the treatment of patients with NPH and compares it with another group of patients with NPH who underwent the same procedure without anti-siphon mechanism (PS Medical® valve). 30 patients were consecutively enrolled in two groups with 15 patients each and followed clinically and radiologically for 1 year. Patients submitted to VPS with SPHERA® valve had the same clinical improvement as patients submitted to VPS with PS Medical®. However, complications and symptomatology due to overdrainage were significantly lower in SPHERA® group, suggesting it as a safe tool to treat NPH.
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Affiliation(s)
| | | | - Matheus F Oliveira
- Departamento de Neurocirurgia, Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil
| | - Juliana B Tornai
- Instituto de Psiquiatria, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ricardo A Amaral
- Instituto de Psiquiatria, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Manoel Jacobsen Teixeira
- Instituto de Psiquiatria, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brazil
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14
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Oliveira MFD, Reis RC, Trindade EM, Pinto FCG. Evidences in the treatment of idiopathic normal pressure hydrocephalus. Rev Assoc Med Bras (1992) 2015; 61:258-62. [PMID: 26248249 DOI: 10.1590/1806-9282.61.03.258] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 08/26/2014] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION idiopathic normal pressure hydrocephalus (INPH) is characterized by gait apraxia, cognitive dysfunction and urinary incontinence. There are two main treatment options: ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV). However, there are doubts about which modality is superior and what type of valve should be applied. We are summarizing the current evidence in INPH treatment. METHODS an electronic search of the literature was conducted on the Medline, Embase, Scielo and Lilacs databases from 1966 to the present to obtain data published about INPH treatment. RESULTS the treatment is based on three pillars: conservative, ETV and VPS. The conservative option has fallen into disuse after various studies showing good results after surgical intervention. ETV is an acceptable mode of treatment, but the superiority of VPS has made the latter the gold standard. CONCLUSION well-designed studies with a high level of appropriate evidence are still scarce, but the current gold standard for treatment of INPH is conducted using VPS.
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15
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Symss NP, Oi S. Is there an ideal shunt? A panoramic view of 110 years in CSF diversions and shunt systems used for the treatment of hydrocephalus: from historical events to current trends. Childs Nerv Syst 2015; 31:191-202. [PMID: 25547875 DOI: 10.1007/s00381-014-2608-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Accepted: 12/09/2014] [Indexed: 11/24/2022]
Abstract
OBJECT The goal of this study is to evaluate whether an "ideal shunt" exists. METHODS This is a retrospective analysis based on original papers in the field of Hydrocephalus and Shunts. Patients of all age groups, who had hydrocephalus, and underwent some form of CSF diversion were included. The study has been divided into four stages: from 1900 to 1949, 1950 to 1974, 1975 to 1999, and from 2000 to 2010. RESULTS In stage 1 (historical era): Saphenous vein grafts, rubber conduits, and other materials were used in CSF diversions. In 1949, the first implantable shunt tube was developed by Nulsen. In stage 2 (experimental stage): the Holter valve was developed. Newer innovations were developed in relation to the ventriculo-atrial shunt, which was the preferred CSF diversion. In stage 3 (developmental stage), a large number of different design shunt systems were developed, with the aim of reducing complications. The ventriculo-peritoneal shunt had become the preferred CSF diversion. Also, the programmable valve was born. In stage 4 (era of programmable valve, there is a preference for the use of programmable shunt systems. However, shunt failure rate at 1 year being around 25 to 40%, and shunt survival at 1 and 2 years are 50-70 and 47-53% in most series. CONCLUSION Every shunt is an ideal shunt provided the choice of the shunt used should be made by the matching performance of the shunt system to the altered profile of CSF dynamics of a given patient. The most important factor being the opening pressure.
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Affiliation(s)
- Nigel Peter Symss
- Division of Pediatric Neurosurgery, Global Neurosciences, Global Health City, Cheran Nagar, Perumbakkam, Sholinganallur Road, Chennai, 600 100, Tamil Nadu, India,
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16
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Patients benefit from low-pressure settings enabled by gravitational valves in normal pressure hydrocephalus. Clin Neurol Neurosurg 2013; 115:1982-6. [DOI: 10.1016/j.clineuro.2013.06.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 05/24/2013] [Accepted: 06/09/2013] [Indexed: 11/22/2022]
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17
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El Ahmadieh TY, Adel JG, El Tecle NE, Daou MR, Aoun SG, Nanney AD, Bendok BR. Surgical treatment of elevated intracranial pressure: decompressive craniectomy and intracranial pressure monitoring. Neurosurg Clin N Am 2013; 24:375-91. [PMID: 23809032 DOI: 10.1016/j.nec.2013.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Surgical techniques that address elevated intracranial pressure include (1) intraventricular catheter insertion and cerebrospinal fluid drainage, (2) removal of an intracranial space-occupying lesion, and (3) decompressive craniectomy. This review discusses the role of surgery in the management of elevated intracranial pressure, with special focus on intraventricular catheter placement and decompressive craniectomy. The techniques and potential complications of each procedure are described, and the existing evidence regarding the impact of these procedures on patient outcome is reviewed. Surgical management of mass lesions and ischemic or hemorrhagic stroke occurring in the posterior fossa is not discussed herein.
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Affiliation(s)
- Tarek Y El Ahmadieh
- Department of Neurological Surgery, McGaw Medical Center, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 2210, Chicago, IL 60611, USA
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18
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Oliveira MFD, Saad F, Reis RC, Rotta JM, Pinto FCG. Programmable valve represents an efficient and safe tool in the treatment of idiopathic normal-pressure hydrocephalus patients. ARQUIVOS DE NEURO-PSIQUIATRIA 2013; 71:229-36. [DOI: 10.1590/0004-282x20130007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 10/31/2012] [Indexed: 11/22/2022]
Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is characterized by gait disturbance, dementia and /or urinary incontinence, dilation of the ventricular system and normal opening cerebrospinal fluid pressure. Shunt surgery is the standard treatment of iNHP. Diversions with programmable valves are recommended, once drainage pressure can be changed. However, well-defined protocols still lack guiding the steps to attain proper pressure for each patient. Methods: In our study, we reported the experience of shunting 24 patients with iNPH using Strata® (Medtronic) valve, following a protocol based on a positive Tap Test. Results: We observed clinical improvement in 20 patients and stability/worsening in 4 patients. Complications occurred in five patients, including one death. The results display improvement, and complications occurred at a lower rate than reported in other studies. Conclusions: The Strata® valve used in the proposed protocol represents an efficient and safe tool in the treatment of iNPH.
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19
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Lang SS, Kofke WA, Stiefel MF. Monitoring and intraoperative management of elevated intracranial pressure and decompressive craniectomy. Anesthesiol Clin 2012; 30:289-310. [PMID: 22901611 DOI: 10.1016/j.anclin.2012.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Elevated intracranial pressure can be caused by a variety of underlying conditions. Several physiologic and pharmacologic factors have a significant impact on intracranial hypertension, mostly caused by changes on cerebral blood volume, flow, and oxygenation. There are many therapies that can be used to decrease intracranial pressure ranging from pharmacologic to the surgical decompressive removal of the calvarium. Special consideration is made for the anesthetic management of these patients perioperatively.
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Affiliation(s)
- Shih-Shan Lang
- Department of Neurosurgery, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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20
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Hoya K, Tanaka Y, Uchida T, Takano I, Nagaishi M, Kowata K, Hyodo A. Treatment of traumatic acute subdural hematoma in adult hydrocephalus patients with cerebrospinal fluid shunt. Clin Neurol Neurosurg 2012; 114:211-6. [PMID: 22030155 DOI: 10.1016/j.clineuro.2011.10.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2010] [Revised: 08/15/2011] [Accepted: 10/08/2011] [Indexed: 11/29/2022]
Affiliation(s)
- Katsumi Hoya
- Department of Neurosurgery, Dokkyo Medical University Koshigaya Hospital, 2-1-5 Minami-Koshigaya, Koshigaya 343-8555, Japan.
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21
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Nakajima M, Bando K, Miyajima M, Arai H. Lumboperitoneal shunt placement using computed tomography and fluoroscopy in conscious patients. J Neurosurg 2009; 111:618-22. [PMID: 19249929 DOI: 10.3171/2009.1.jns08204] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors have developed a minimally invasive lumboperitoneal shunt placement procedure conducted after administration of a local anesthetic. The procedure involves placing a guide wire and a peel-away sheath under fluoroscopic and CT guidance. Between June 2004 and August 2006, 40 patients (21 men and 19 women; mean age 72.5 years [range 33-86 years]) underwent surgery. A Codman Hakim programmable valve system (82-3844, Codman & Shurtleff, Inc.) was used for the procedure. The mean operating time was 53 minutes, and 7 patients (17.5%) developed shunt dysfunction complications. These complications comprised an infected shunt valve in 2 patients, postoperative lower-limb pain in 1 patient, and shunt obstruction (caused by debris and hemorrhage) at the ventral and lumbar ends in 2 patients each. This procedure is less invasive than conventional lumboperitoneal shunt insertion and could be performed as an outpatient surgery for treatment of idiopathic normal-pressure hydrocephalus.
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Affiliation(s)
- Madoka Nakajima
- Department of Neurosurgery, Juntendo University, Tokyo, Japan
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22
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Mukerji N, Cahill J, Rodrigues D, Prakash S, Strachan R. Flow dynamics in lumboperitoneal shunts and their implications in vivo. J Neurosurg 2009; 111:632-7. [DOI: 10.3171/2009.2.jns08912] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Lumboperitoneal shunting is the standard treatment for pseudotumour cerebri or idiopathic intracranial hypertension. Complications are common, particularly the problem of overdrainage leading to low pressure symptoms. The authors designed a simple experiment using catheters of different lengths that drained at different pressure heads and with different vertical drops to study the flow characteristics in these shunts and determine the optimal catheter placement and length that would reduce the occurrence of low pressure headaches.
Methods
The flow rates through catheters of 3 different lengths (60, 83, and 100 cm) with the same internal radius, at 3 different pressure heads (15, 25, and 35 cm H2O to simulate 3 different placements in the lumbar theca), and 3 different vertical drops (10, 20, and 30 cm to simulate the possible effect of siphoning) were measured and the results analyzed.
Results
Application of Poiseuille's law and Bernoulli's principle to the experimental design shows that the volume of flow is directly proportional to the sum of the pressure head and the vertical drop and inversely proportional to the length of the catheter. The flow rate through the standard catheter lengths over the course of 24 hours can be abnormally high. An attempt to predict the optimal catheter length was made.
Conclusions
Although the catheter position in the theca and abdomen cannot be altered significantly and the internal radius of the tube cannot be reduced further without increasing the risk of blockage, the length of the tube can be increased to combat overdrainage. The authors suggest that currently available catheters are too short.
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Management of neonatal hydrocephalus: feasibility of use and safety of two programmable (Sophy and Polaris) valves. Childs Nerv Syst 2008; 24:549-56. [PMID: 17924120 DOI: 10.1007/s00381-007-0512-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Neonates represent a unique group of pediatric patients with special peculiarities. Hydrocephalus valves have not always been designed to meet the requirements of these small children. Few series have addressed the problem of cerebrospinal fluid shunting in newborn babies. OBJECTIVES We aimed (1) to evaluate the feasibility of the use of two programmable valves (Sophy and Polaris) in hydrocephalic neonates and (2) to ascertain complications and safety issues arising from their use. MATERIALS AND METHODS We performed a prospective study of 100 consecutive preterm and term babies (<2 months of age) given a programmable valve. Valves' settings were readjusted at different pressure levels as required. Outcomes were obtained from the records of our Outpatient Clinic. RESULTS The study group was formed by 60 term and 40 preterm infants (average weight 2,440 g, mean age of 25 days). Mean follow-up was 55 months. Only one fifth deaths was shunt-related. In 70 babies, no complications occurred, and hydrocephalus was successfully controlled. Proximal catheter obstruction presented in 20% and infection in 5% of cases. Several external adjustments of the valves apparently avoided several surgical shunt revisions. CONCLUSIONS (1) Both programmable valves (Sophy and Polaris) can be safely used for treatment of neonatal hydrocephalus, introducing some technical modifications. (2) Both valves are comparable to other shunts with regard to indications, performance, and safety. (3) The possibility of modifying their working pressure seems to constitute their main advantage. Prevention of late overdrainage syndromes with these valves needs a longer follow-up.
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24
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Stein SC, Burnett MG, Sonnad SS. Shunts in normal-pressure hydrocephalus: do we place too many or too few? J Neurosurg 2007; 105:815-22. [PMID: 17405250 DOI: 10.3171/jns.2006.105.6.815] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The average 65-year-old patient with moderate dementia can look forward to only 1.4 quality-adjusted life years (QALYs), that is, longevity times quality of life. Some of these patients suffer from normal-pressure hydrocephalus (NPH) and respond dramatically to shunt insertion. Currently, however, NPH cannot be diagnosed with certainty. The authors constructed a Markov decision analysis model to predict the outcome in patients with NPH treated with and without shunts. METHODS Transition probabilities and health utilities were obtained from a review of the literature. A sensitivity analysis and Monte Carlo simulation were applied to test outcomes over a wide range of parameters. Using shunt response and complication rates from the literature, the average patient receiving a shunt would gain an additional 1.7 QALYs as a result of automatic shunt insertion. Even if 50% of patients receiving a shunt have complications, the shunt response rate would need to be less than 5% for empirical shunt insertion to do more harm than good. Authors of most studies have reported far better statistics. CONCLUSIONS In summary, many more patients with suspected NPH should be considered for shunt insertion.
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Affiliation(s)
- Sherman C Stein
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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25
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Bergsneider M, Yang I, Hu X, McArthur DL, Cook SW, Boscardin WJ. Relationship between valve opening pressure, body position, and intracranial pressure in normal pressure hydrocephalus: paradigm for selection of programmable valve pressure setting. Neurosurgery 2005; 55:851-8; discussion 858-9. [PMID: 15458593 DOI: 10.1227/01.neu.0000137631.42164.b8] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2003] [Accepted: 05/06/2004] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE There is little scientific basis for guidance in selecting the optimal valve for the treatment of normal pressure hydrocephalus. The aim of this study was to determine the programmable valve opening pressure setting that would result in a slight reduction in intracranial pressure (ICP) after a ventriculoperitoneal shunt is implanted. We also assessed whether shunt-induced ICP could be predicted on the basis of a simple hydrodynamic equation. METHODS In this prospective study of 11 patients with normal pressure hydrocephalus, ICP was measured before and after implantation of a shunt incorporating a programmable valve without an antisiphon device. Pressure measurements, including intraperitoneal pressure, were recorded at body angles ranging from 0 to 55 degrees and at valve settings ranging from 30 to 200 mm H(2)O. Measured ICP values were compared with values computed using a simple hydrodynamic equation. RESULTS Even at a valve setting greater than the mean baseline ICP (200 mm H(2)O), the supine ICP was significantly lower than the baseline value (baseline ICP, 164 +/- 64 mm H(2)O; postoperative ICP, 125 +/- 69 mm H(2)O, P = 0.04). Valve pressure did not equate 1:1 with the measured postoperative ICP. Comprehensive ICP measurements at upright body positions demonstrated a stepwise reduction in ICP rather than a precipitous decline as a result of so-called siphoning. CONCLUSION This study indicates that very high valve opening pressure settings may be optimal for the initial treatment of normal pressure hydrocephalus. The relationship between ICP and opening pressure valves is linear but not predicted by simple hydrodynamics.
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Affiliation(s)
- Marvin Bergsneider
- Division of Neurosurgery, David Geffen School of Medicine at University of California at Los Angeles, 90095-6901, USA.
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26
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Ringel F, Schramm J, Meyer B. Comparison of programmable shunt valves vs standard valves for communicating hydrocephalus of adults: a retrospective analysis of 407 patients. ACTA ACUST UNITED AC 2005; 63:36-41; discussion 41. [PMID: 15639519 DOI: 10.1016/j.surneu.2004.03.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2003] [Accepted: 03/31/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND The aim of the present study was to clarify whether programmable shunt valves are advantageous in the treatment of adults with communicating hydrocephalus with respect to valve-related shunt complications and surgical shunt revisions, in comparison with standard valves. METHODS Adult patients with communicating hydrocephalus treated with Codman Hakim programmable (CHP) valves or Hakim (H) standard valves during 12 years were retrospectively studied. Patients were analyzed for demographic data, implantation diagnosis, valve type, opening pressure at implantation, opening pressure adjustments, and incidence of shunt complications, especially valve-related complications. The end point of the study was a surgical shunt revision. RESULTS In 407 patients, 247 CHP valves and 160 H valves were implanted. Median opening pressure of CHP at implantation was 110 mm H(2)O, while 3 low-pressure, 153 medium-pressure, and 4 high-pressure H valves were implanted. Opening pressure adjustments were performed in 39% of CHP patients--1.44 adjustments per adjusted valve. Overall complication rate as well as the rate of surgical revisions for infections and catheter- and valve-related problems did not show any significant difference between CHP and H valves. The incidence of nontraumatic subdural hematomas and hygromas was significantly higher in the CHP group; however, the rate of surgical decompressions did not differ. CONCLUSIONS The advantage of reprogramming of CHP did not translate into a reduction in surgical shunt revisions. Therefore, in conjunction with the present data, we believe it is still justified to implant H standard valves in adult patients with communicating hydrocephalus.
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Affiliation(s)
- Florian Ringel
- Department of Neurosurgery, Friedrich-Wilhelms-University Bonn, Bonn 53105, Germany
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McConnell KA, Zou KH, Chabrerie AV, Bailey NO, Black PM. Decreases in ventricular volume correlate with decreases in ventricular pressure in idiopathic normal pressure hydrocephalus patients who experienced clinical improvement after implantation with adjustable valve shunts. Neurosurgery 2004; 55:582-92; discussion 592-3. [PMID: 15335425 PMCID: PMC1350579 DOI: 10.1227/01.neu.0000134385.23401.01] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2003] [Accepted: 04/07/2004] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE This retrospective study examined whether changes in ventricular volume correspond with changes in adjustable valve pressure settings in a cohort of patients who received shunts to treat idiopathic normal pressure hydrocephalus. We also examined whether these pressure-volume curves and other patient variables would co-occur with a positive clinical response to shunting. METHODS We selected 51 patients diagnosed with idiopathic normal pressure hydrocephalus who had undergone implantation of a Codman Hakim programmable valve (Medos S.A., Le Locle, Switzerland). Clinical data were gathered from the patients' records and clinical notes by an investigator blinded to patients' ventricular volumes. Ventricular volume was measured using 3D Slicer, an image analysis and interactive visualization software package developed and maintained at the Surgical Planning Laboratory at Brigham and Women's Hospital. RESULTS Eighty-six percent of patients with gait disturbance at presentation showed improvement of this symptom, 70% experienced improvement in incontinence, and 69% experienced improvement in dementia. For the group showing 100% clinical improvement, the correlation coefficient of average changes in valve pressure over time (delta P/delta T) and average changes in ventricular volume over time (delta V/delta T) were high at 0.843 (P < 0.05). For the group experiencing no or only partial improvement, the correlation coefficient was 0.257 (P = 0.32), indicating no correlation between average delta V/delta T and average delta P/delta T for each patient. CONCLUSION This was a carefully analyzed modeling study of idiopathic normal pressure hydrocephalus treatment made possible only by adjustable valve technology. With careful volumetric analysis, we found that changes in ventricular volume correlated with adjustments in valve pressure settings for those patients who improved clinically after shunting. This suggests that positive clinical responders retained parenchymal elasticity, emphasizing the importance of dynamic changes in this cohort.
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Affiliation(s)
- Kathleen A McConnell
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Zemack G, Romner B. Adjustable Valves in Normal-pressure Hydrocephalus: A Retrospective Study of 218 Patients. Neurosurgery 2002. [DOI: 10.1227/01.neu.0000309115.09463.7d] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Göran Zemack
- Division of Neurosurgery, Department of Clinical Neuroscience, Lund University Hospital, Lund, Sweden
| | - Bertil Romner
- Division of Neurosurgery, Department of Clinical Neuroscience, Lund University Hospital, Lund, Sweden
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