Positional shunt assist for slit ventricle syndrome

PURPOSE

Hydrocephalus is one of the most common pathologies in pediatric neurosurgery. One of the causes of recurring events of headaches among shunted children is "slit ventricle syndrome" (SVS). Several potential treatments have been proposed, yet SVS often represents a treatment challenge. The goal of the current series is to present our experience with adding a positional shunt-assist (SA) (Miethke, Aesculap) for the treatment of SVS.

METHODS

Clinical data was retrospectively collected from all consecutive children with SVS that were treated with SA (Miethke, Aesculap) at our center. Surgical and clinical outcomes as expressed by hospital visits, or need for additional surgery, were evaluated.

RESULTS

Nine cases were included. Hydrocephalus etiology included IVH (6), postinfectious (1), and congenital syndromes (2). Average age at first shunt was 4 months. Primary shunt type was differential-pressure-valve in all. Average age at SVS onset was 4 years. Average age at SA placement was 5.5 years. There were no perioperative complications besides a single stich abscess. A 6-month follow-up period after SA was compared to a 6-month period prior to the SA: average hospital visits decreased from 2.4 to 0.6 per patient (p < 0.0002). 4/9 patients needed an LP or shunt revision before the SA surgery, while no procedure was indicated during the immediate 6-month follow-up. At the last follow-up, there was a significant reduction in the rate of ER visits compared to prior to surgery; however, the number of neurosurgical procedures did not significantly differ.

CONCLUSION

Using a SA for SVS was associated with a short-term improvement of symptoms in the majority of cases, reduction in hospital visits, and reduced need for SVS-related procedures.

Subtemporal Decompression in Resistant Slit Ventricle Syndrome in Children: An Observational Study and Survival Analysis

INTRODUCTION

Slit ventricle syndrome (SVS) remains a challenging problem in the early-shunted paediatric population. Various surgical and non-surgical treatments have been devised for this condition. However, there is currently no gold standard for its optimal management. Among various treatment modalities, subtemporal decompression (STD) is often performed as a last resort. We present our experience of STD in paediatric patients with SVS in whom initial treatment with programmable valves and anti-syphon device were not successful.

METHODS

This is a single-centre retrospective observational study and survival analysis. Patients who underwent STD for SVS were included. Pre- and post-operative imaging data and clinical outcomes were collected.

RESULTS

There were 20 patients (12 M, 8 F) with a mean age of 9 years (SD: 4) at first STD. 90% (n = 18) of patients had multiple shunt revisions pre-STD. At first STD, 70% (n = 14) and 30% (n = 6) of patients had unilateral or bilateral STD, respectively. STD led to a reduction in the frequency of shunt revisions in 60% (n = 12) of patients. The median time required before further STD, shunt surgery, or cranial vault surgery was 14 months. The median time before a further STD was required (either revision or contralateral side) was 89 months. At a median follow-up of 66.5 months (range: 1-159), 65% (n = 13) of patients had improvement in symptoms.

CONCLUSIONS

A large proportion of patients with persistent SVS symptoms, refractory to multiple shunt revisions, benefitted from STD in combination with shunt optimization. It was also safe and well-tolerated. Therefore, in patients who have multiple failed shunts, STD may reduce the morbidity associated with further shunt revisions and can significantly improve symptomatology.

Noninvasive intracranial pressure monitoring throughout brain compliance guiding a ventriculoperitoneal shunt replacement in hydrocephalus-case report

INTRODUCTION

Ventriculoperitoneal (VP) shunt is the primary therapy for hydrocephalus in children; however, this technique is amenable to malfunctions, which could be detected through an assessment of clinical signs and imaging results. Furthermore, early detection can prevent patient deterioration and guide clinical and surgical treatment.

CASE PRESENTATION

A 5-year-old female with a premedical history of neonatal IVH, secondary hydrocephalus, multiple VP shunts revisions, and slit ventricle syndrome was evaluated using a noninvasive intracranial pressure monitor device at the early stages of the clinical symptoms, evidencing increased intracranial pressure and poor brain compliance. Serial MRI images demonstrated a slight ventricular enlargement, leading to the use of a gravitational VP shunt, promoting progressive improvement. On the follow-up visits, we used the noninvasive ICP monitoring device to guide the shunt adjustments until symptom resolution. Furthermore, the patient has been asymptomatic for the past 3 years without requiring new shunt revisions.

DISCUSSION

Slit ventricle syndrome and VP shunt dysfunctions are challenging diagnoses for the neurosurgeon. The noninvasive intracranial monitoring has allowed a closer follow-up assisting early assessment of brain compliance changes related to a patient's symptomatology. Furthermore, this technique has high sensitivity and specificity in detecting alterations in the intracranial pressure, serving as a guide for the adjustments of programmable VP shunts, which may improve the patient's quality of life.

CONCLUSION

Noninvasive ICP monitoring may lead to a less invasive assessment of patients with slit ventricle syndrome and could be used as a guide for adjustments of programmable shunts.

Slit Ventricle as a Neurosurgical Emergency: Case Report and Review of Literature

BACKGROUND

Symptomatic slit ventricle is one of the most challenging complications of shunt surgery in children. Clinical signs and symptoms may appear with a wide range of intracranial pressure (ICP) values. We report the case of a 10-year-old girl, who did not present the classic clinical features of extremely elevated ICP, which was proven by multiple invasive ICP recordings, performed during shunt revisions.

CASE DESCRIPTION

At the age of 6 months, the patient presented squeal for many hours, accompanied with sunset eyes, bulging anterior fontanel, and dilated ventricles of all 4 ventricles on computed tomography scan. Acute ventriculoperitoneal shunt insertion was performed with adjustable valve. During the following 9 years, she was regularly seen and medically treated for intermittent headache, with nausea and vomiting. From 9 years of age, she was hospitalized for severe (10/10 on the visual analog scale), unbearable headache, agitation, and screaming on multiple occasions. Altogether, we had to revise the shunt system 5 times throughout 1 year. Radiologic imaging always showed narrow ventricles. Ophthalmologic examination of the fundus never revealed signs of raised ICP. Perioperative monitoring of the ICP with intraparenchymal sensor showed unexpected high values of 40-45 mm Hg. However, repetitive shunt revisions were successful only temporarily because the symptoms always returned. Only bilateral shunting of the ventricular system was able to eliminate the symptoms permanently.

CONCLUSIONS

Images of slit ventricle can be associated either with low or extremely high ICP needing urgent surgical consideration, including ICP monitoring. Bilateral shunt insertion can be effective treatment for slit ventricle syndrome.

ETV as a last resort

INTRODUCTION

The field of neuroendoscopy is rapidly expanding with increasing indications for endoscopic third ventriculostomy (ETV).

DISCUSSION

As a treatment for hydrocephalus, ETV has the advantage of providing a more physiological cerebrospinal fluid diversion without shunt hardware which reduces the risk of recurrent infection and malfunction. The success rate of ETV has been increasing with decreasing morbidity and mortality.

CONCLUSION

Originally, ETV was indicated for cases of obstructive hydrocephalus, however the indications are expanding. To highlight this, we present a small series of cases were ETV is not traditionally indicated and was a treatment of last choice.

Shunt dependency syndrome after cystoperitoneal shunting of arachnoid cysts

PURPOSE

The goal of this study was to investigate the mechanisms, diagnosis, and treatment of shunt dependency syndrome in patients with temporal lobe arachnoid cysts who were initially treated with cystoperitoneal (CP) shunting.

METHODS

Thirteen patients with temporal lobe arachnoid cysts who had initially been treated with CP shunt placement and had developed shunt dependency syndrome were treated by the senior author at Tiantan Hospital between April 2010 and January 2012. The clinical manifestations, neuroimaging findings, intracranial pressure (ICP) data, treatment methods, and therapeutic results were reviewed retrospectively.

RESULTS

The study included ten males and three females. The mean age at the time of development of shunt dependency syndrome was 12.3 years (range 5.5-24 years). In most patients, neuroimaging findings showed a collapsed cyst (the cyst appeared almost unchanged in only one patient) and normal or small ventricles (only one patient had enlarged ventricles). Three patients underwent simple replacement of the shunt, four underwent ventriculoperitoneal shunt placement, and the other six underwent lumboperitoneal shunt placement. All patients experienced resolution of their symptoms postoperatively. The mean duration of follow-up was 20 months.

CONCLUSIONS

Shunt dependency syndrome is a rare but serious complication of shunting an arachnoid cyst. This condition is similar to the slit ventricle syndrome, but also has some differences. ICP monitoring may confirm the diagnosis when there are no significant radiological findings. Achievement of a shunt-free state might be the ultimate goal for all shunted patients.