Case Of Ventriculitis Research Articles

Ventriculitis following neuraxial block.

Dear Editor, Ventriculitis has been mostly reported following neurosurgical procedures such as external ventricular drains, ventricular shunts, trauma, immunocompromised host, intrathecal chemotherapy, or meningitis.[1-3] It is uncommon to have ventriculitis following neuraxial blockade for a non-neurosurgical procedure. The incidence of meningitis after a neuraxial block is extremely low (about 0–2 cases every 10,000 procedures).[4] To best of our knowledge, no case of ventriculitis has been reported following a neuraxial block. We report a case of a patient developing ventriculitis following a neuraxial block. A 53-year-old Indian male presented to the trauma center with circumferential degloving injury of the left lower extremity following a road traffic accident. After a primary survey the patient was taken to the operation theater for debridement and skin grafting. The procedure was done under combined neuraxial-epidural block in L4–5 intervertebral space and the epidural catheter was left in situ for postoperative analgesia. Two days later, a second debridement was done under neuraxial block in L3–4 intervertebral space. The epidural catheter was removed 2 days after this surgery. On the third postoperative day, the patient complained of a severe headache and continued to deteriorate and on the seventh day became irritable with febrile episodes. Emergent intubation was done in the ward to secure the airway and the patient was shifted to ICU. By the end of the second day in the ICU, the GCS/Glasgow coma scale deteriorated even further. Non-contrast computerized tomography of brain did not reveal any abnormalities. The patient continued to worsen clinically with absent pupillary and corneal reflexes and doll’s eye. MRI of the brain was done, which showed signs of debris in the occipital horns of both the lateral ventricle and cisterna magna suggestive of periventriculitis [Figure 1].Figure 1: Isointense-dependent contents in occipital horns of bilateral lateral ventricles and cisterna magna, likely ventriculitisThe CSF samples were collected after external ventricular drain insertion which showed Acinetobacter baumanii infection sensitive only to Colistin. Colistin was initiated, both systemic and intrathecal. By the end of the third day of colistin initiation, improvement in GCS was observed. CSF became sterile by the end of the fourth day. EVD/external ventricular drain as replaced by ommaya reservoir and intrathecal colistin administration was continued through ommaya reservoir for 4 weeks. By the end of 1 week GCS improved significantly. The patient was extubated and discharged after a 4-week course of intrathecal therapy. In the absence of the causes mentioned above we postulate that the possible source for ventriculitis could be related to the procedure of neuraxial block at the time of the second surgery as there was Acinetobacter baumanii suggesting hospital-acquired infection rather than community-acquired. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship - Nil. Conflicts of interest There are no conflicts of interest.

External ventricular drainage for intracranial hypertension after traumatic brain injury: is it really useful?

External ventricular drainage (EVD) is frequently used to control raised intracranial pressure after traumatic brain injury. However, the available evidence about its effectiveness in this context is limited. The aim of this study is to evaluate the effectiveness of EVD to control intracranial pressure and to identify the clinical and radiological factors associated with its success. For this retrospective cohort study conducted in a Level 1 traumacenter in Paris area between May 2011 and March 2019, all patients with intracranial hypertension and treated with EVD were included. EVD success was defined as an efficient and continuous control of intracranial hypertension avoiding the use of third tier therapies (therapeutic hypothermia, decompressive craniectomy, and barbiturate coma) or avoiding a decision to withdraw life sustaining treatment due to both refractory intracranial hypertension and severity of brain injury lesions. 83 patients with EVD were included. EVD was successful in 33 patients (40%). Thirty-two patients (39%) required a decompressive craniectomy, eight patients (9%) received barbiturate coma. In ten cases (12%) refractory intracranial hypertension prompted a protocolized withdrawal of care. Complications occurred in nine patients (11%) (three cases of ventriculitis, six cases of catheter occlusion). Multivariate analysis identified no independent factors associated with EVD success. In a protocol-based management for traumatic brain injury, EVD allowed intracranial pressure control and avoided third tier therapeutic measures in 40% of cases with a favorable risk-benefit ratio.

Pathogenetic variants of ventriculitis in children

The aim of the study: to analyze the pathogenetic structure of ventriculitis, their relationship with age, risk factors, study the etiological characteristics, clinical and diagnostic features, evaluate outcomes of ventriculitis and features of mortality.Materials and methods: a retrospective analysis of inpatient medical charts of 72 children with ventriculitis received treatment in the neurosurgery department of Filatov Children hospital №5, St-Petersburg, from January 2008 to December 2017 was carried out.Results: Most cases of ventriculitis occurred in infants (up to 1 year) and young children (1-3 years old). The largest group among pathogenetic variants of ventriculitis was shunt infection – 50 (69.44%) cases. Other groups were: ventriculostomy-associated ventriculitis – 12 (16,67%) cases; ventriculitis following a neurosurgical procedure without external ventricular drainage – 6 (8,33%) cases; ventriculitis complicated meningitis in patients without prior neurosurgery – 4 (5,56%) cases. The presence of such risk factors for ventriculitis as cerebrospinal fluid leakage (18,06%), intraventricular blood prior to the development of ventriculitis (22,22%), and other systemic infections (59,72%) were noted. The crucial role in the diagnosis of ventriculitis is played by the inflammatory changes in the ventricular cerebrospinal fluid on the background of specific clinical findings and indicative anamnesis. The commonest organism causing ventriculitis in the study was Staphylococcus epidermidis – 24 (33,33%) patients. Ventriculitis mortality rate was 8,33% (6 cases). Analysis of adverse outcomes revealed that aggressive health-care-associated multidrug resistant organisms are more dangerous for life, especially in patients with severe central nervous system pathology prior to ventriculitis.

1150. Evaluating the Impact of Antibiotic Prophylaxis on the Microbiology and Incidence of Ventriculitis in Patients with External Ventricular Drains

BackgroundExternal ventricular drains (EVDs) are frequently used in acute brain injuries for continuous intracranial pressure monitoring and cerebrospinal (CSF) fluid diversion. EVDs are associated with a 0–22% risk of ventriculitis. The evidence for antibiotic prophylaxis (AP) for ventriculitis prevention is not robust. This study aimed to delineate the incidence of EVD-related ventriculitis and causative organisms in patients receiving AP.MethodsA retrospective chart review from 2013 to 2018 at Yale New Haven Hospital was performed. Patients were included if ≥18 years of age, admitted to the neurosciences intensive care unit (ICU), and had AP with cefazolin, vancomycin, sulfamethoxazole/trimethoprim, or clindamycin. Patients were excluded if they had a diagnosis of meningitis or ventriculitis prior to EVD placement, on multiple agents for AP, on antibiotics for indications other than AP, CSF leak, or skull fracture. The primary endpoint was the incidence of ventriculitis per 1,000 EVD-days. Secondary endpoints were causative organisms of ventriculitis, EVD duration, ICU length of stay (LOS), hospital LOS, and 30-day mortality.ResultsFive hundred ninety-nine patients were reviewed and 249 patients were included. Baseline demographics are noted in Table 1. Cefazolin was the most common agent for AP (98%). There were 7 cases of ventriculitis with an incidence rate of 2.8% (4 infections per 1000 EVD-days). All of the causative organisms were resistant to the prophylactic agents administered (Table 2). Patients with ventriculitis had a significantly longer duration of EVD placement (10 ± 3 vs. 7 ± 6 days, P = 0.03), hospital LOS (30 ± 19 days vs. 15 ± 12, P = 0.04), ICU LOS (22 ± 14 vs. 10 ± 7, P = 0.03). Two patients with ventriculitis (28%) died within 30 days of admission compared with 46 patients without ventriculitis (19%, P = 0.53) (Table 3).ConclusionThe rate of ventriculitis in our study was similar to previous studies that did not utilize AP. All of the causative organisms were resistant to the prophylactic agent. Patients who had ventriculitis had a longer duration of EVD placement, hospital LOS, and ICU LOS; however, 30-day mortality was not impacted. Based on our findings, the use of AP to prevent EVD-related ventriculitis should be reconsidered. Disclosures All authors: No reported disclosures.

Ventriculoperitoneal shunt infection in Haji Adam Malik Hospital, Medan

Installation of ventriculoperitoneal shunts (VP) represented a substantial progress in the neurosurgical management of hydrocephalus in children. However, infection is the most commonpostoperative complication of aventriculoperitoneal shunt. It is important because it is related to substantial morbidity and mortality, and exerts a negative impact on the quality of life of patients. We retrospectively analyzed all 20 cases of shunt infection from 2013 to 2016. The types of infections found were exposed shunts15 cases (75%), and 5 cases of ventriculitis (25%). Length of infection time which calculated from the beginning of surgery was 350.20 days or 11 months. The most common pathogen types are S. epidermidis followed by P. aeruginosa, E. coli, and A. baumanii. There were many risk factors for shunt infection, but the interesting fact was the level of pre-operative albumin. There was a significant difference between low albumin levels (<3.0) and normal albumin (≥3.0) levels against the risk of exposure shunt, p = 0.015. It means there is asignificant difference between low pre-operative albumin and normal level for the risk of theexposed shunt.

Clinical Experience of Infantile Posthemorrhagic Hydrocephalus Treated with Ventriculo-Peritoneal Shunt

ObjectiveInfantile posthemorrhagic hydrocephalus (IPHH) is the most common cause of infantile acquired hydrocephalus. We present and discuss our experience of treatment of six IPHH patients treated by a ventriculo-peritoneal (VP) shunt.MethodsSix preterm infants treated by a VP shunt due to germinal matrix hemorrhage and hydrocephalus were included in our study. External ventricular drainage (EVD) was performed in patients with symptomatic ventricular dilatation, and a VP shunt was placed in the case of no improvement of the ventricular index despite several rounds of EVD. Radiographic findings and surgical outcomes were analyzed retrospectively.ResultsFour patients were male and two were female. Mean gestational age was 25 weeks and mean weight at birth was 868.3 g. One patient had a Papile grade II (16.7%) hemorrhage, three had a grade III (50%) hemorrhage, and two had a grade IV (33.3%) hemorrhage. EVD complications (one case of ventriculitis and one case of a ventricular abscess) occurred in two patients. VP shunt complications occurred in two patients (33.3%). Three cases had an isolated 4th ventricle; two of these cases had a VP shunt placed whereas the other case had a VP shunt placed in addition to aqueductoplasty using a neuroendoscope. At the last follow-up, three of the six patients had severe neurodevelopmental delay, two had mild neurodevelopmental delay, and one had normal development status.ConclusionIn our study, although it is difficult to present the significant result for management of IPHH, we think that varied efforts are required to treat IPHH patients.

Assessment of the in vivo formation of biofilm on external ventricular drainages

Biofilm formation on external ventricular drainages (EVDs) has been postulated as the main pathogenic mechanism for EVD-associated ventriculitis. However, biofilm on EVDs has never been systematically studied and the in vivo effect of antibiotic-impregnated EVDs on biofilm has not been assessed. The aim of this study was to measure the prevalence of biofilm formation on EVDs and to analyze the influence of antibiotic-impregnated EVD on the risk of biofilm formation and ventriculitis. Consecutive patients with EVDs were included in the study. Surveillance cerebrospinal fluid (CSF) cultures were performed twice a week. Withdrawn EVDs were cultured using standard bacteriologic techniques and examined under a scanning electron microscope. We collected 32 EVDs, 18 of which (56 %) were antibiotic-impregnated EVDs. Biofilm was present on 24 EVDs (75 %), ventriculitis was diagnosed in 6 patients (19 %), and colonization occurred in 12 patients (38 %). All cases of ventriculitis were due to Gram-negative bacteria. Biofilm was more frequent on EVDs originating from patients with ventriculitis or bacterial colonization. Impregnated EVDs did not avoid ventriculitis or colonization, but biofilm development on these devices depended on the time from insertion and varied from 67 % for those used for <7 days to 88 % for those used for ≥ 7 days (p = 0.094). In conclusion, biofilm is a common phenomenon on EVDs. Currently available impregnated EVDs could not avoid ventriculitis due to multidrug-resistant Gram-negative bacteria, but a trend of delayment of biofilm development was observed.

Shewanella algae Bacteremia in a Preterm Newborn

To the Editors: Human infections with Shewanella are rare and most commonly involve ears, skin, and soft tissue, with or without bacteremia.1 We report the first case of bacteremia in a child caused by Shewanella algae and the first report in the western hemisphere. A preterm baby boy was born to a 14-year-old mother at 32 weeks of gestation via vaginal delivery at the Carolina University Hospital in Puerto Rico. The mother had been admitted at 24 weeks of gestation and treated for acute pyelonephritis, without bacteremia caused by Escherichia coli. She returned 8 weeks later with advanced preterm labor, intact membranes, and no evidence of chorioamnionitis or infection. The mother reported swimming in seawater early in the pregnancy. The baby had a birth weight of 1640 g and was admitted to the Neonatal Intensive Care Unit. He required mechanical ventilation because of hyaline membrane disease, and he was treated with exogenous surfactant. The baby required inotropic support because of hypotension and poor peripheral perfusion. He was treated with ampicillin and gentamicin. The complete blood count showed neutropenia (neutrophils, 832 per μL). The C-reactive protein was elevated. The blood culture at birth was negative. On the third day of life, a blood culture taken on day 2 showed Gram-negative bacilli. Gentamicin was discontinued, and amikacin and imipenem were added. Disseminated intravascular coagulation was diagnosed requiring blood products transfusions. On the fourth day of life, the organism was identified as Shewanella algae susceptible to amikacin, ciprofloxacin, gentamicin, imipenem, and tobramycin. Blood cultures from the third and fifth day of life showed S. algae. On the seventh day of life, he was successfully weaned from mechanical ventilation. The neutropenia and thrombocytopenia resolved. Blood culture taken on this day was negative. He recovered well after antibiotic treatment for 10 days and was sent home at 18 days old. Shewanella spp. are Gram-negative bacilli, which produce hydrogen sulfide. The S. spp. found in clinical specimens are Shewanella putrefaciens and Shewanella algae, and most isolates from humans are S. algae. The usual source for infection is exposure to seawater.1 The first cases of S. algae bacteremia were reported in Denmark (1999) in 2 patients with chronic leg ulcers. They had been exposed to the same marine environment.2 Bacteremia with S. algae was reported in a Japanese woman undergoing hemodialysis.3 Cases of S. algae bacteremia have been reported in Spain, Japan, Taiwan, and Korea.4–9 Cases of S. algae bacteremia reported in the literature, risks factors, and treatment are summarized in Table 1, Supplemental Digital Content 1, https://links.lww.com/INF/A982. S. algae infections have been reported in children, but there have been no previous reports of bacteremia. Ear infections are common, and a series of 65 cases described children who had otitis media that occurred during the summer.1 Recently, a case of ventriculitis and peritonitis caused by S. algae was reported in Croatia in a child with ventriculoperitoneal shunt. The infection developed after contact with seawater and began as otitis.10 Lourdes García-Fragoso, MD Inés García-García, MD Amarilis Rivera, MD Neonatology section Department of Pediatrics University of Puerto Rico School of Medicine San Juan, Puerto Rico

Recurrent shunt associated ventriculitis caused by methicillin-resistant Staphylococcus aureus: Case with fatal outcome despite linezolid therapy

Ventriculoperitoneal shunt-associated ventriculitis is a serious though under-reported nosocomial complication of neurocritical settings. The treatment of CNS Methicillin-resistant Staphylococcus aureus (MRSA) infections is usually successful with vancomycin or linezolid. Here, we report a case of ventriculitis due to MRSA following a shunt infection, which did not show clinical response to linezolid therapy. With the increasing use of invasive procedures, nosocomial infections have increased exponentially. Exercising extreme care in such CNS procedures becomes very important.

Dose Effect of Intraventricular Fibrinolysis in Ventricular Hemorrhage

The aim of the current study was to investigate the dose-dependent efficacy of intraventricular fibrinolysis (IVF) in patients with severe intraventricular hemorrhage (IVH). Patients with intracerebral hemorrhage, severe IVH, and obstructive hydrocephalus with the need for external ventricular drainage were treated with IVF through external ventricular drainage. The time course of IVH resolution and the safety profile were compared between patients treated with high-dose IVF (4 mg alteplase every 12 hours, maximum 20 mg; n=32) and low-dose IVF (1 mg alteplase every 8 hours, maximum 12 mg; n=22). CT scans on Days 1 to 4, 7 ± 1 and 10 ± 1 after admission, were analyzed volumetrically. Outcome was assessed after 3 months. The overall effect of IVF dosage was not significantly different between the 2 groups (F=1.3, P=0.25). The course of IVH volume in the third and fourth ventricles was similar with high- and low-dose IVF. High-dose IVF resulted in lower total IVH volumes on Days 7 (4.4 ± 4.2 mL versus 8.8 ± 8.1 mL; P=0.01) and 10 (1.4 ± 2.8 mL versus 4.9 ± 65.8 mL; P=0.005). Total clot half-life was 78 ± 43 hours in the low-dose and 56 ± 25 hours in the high-dose group (P=0.02). One asymptomatic ventricular bleeding, 2 cases of ventriculitis, and 1 death due to pulmonary embolism occurred in the high-dose group. There was no difference in outcome at 3 months. Low-dose IVF (3 mg alteplase/day) has a similar effect on IVH clearance from the third and fourth ventricles and a similar safety profile when compared with high-dose IVF (8 mg alteplase/day).

Do bactisealventriculostomy catheters have a low rate of ventriculitis and catheter colonization in clinical practice?

BackgroundWhile Bactiseal catheters have been shown to decreaseventriculo-peritoneal shunt infection rates, similar evi-dence for external ventricular drains (EVD) is lacking[1]. This retrospective study was undertaken to evaluatewhether the introduction of Bactiseal EVD in 2004 hasdecreased infection rates.Materials and methodsOne hundred and ten patients had undergone EVDinsertions from January 2000 to March 2008. Afterexcluding patients who had died within 5 days of theprocedure and also those with pre-existing CSF sepsis, atotal of 90 patients (with 119 EVD insertions- 66 Stan-dard, 53 Bactiseal) were included in the study. The prac-tice of sending catheter tips for culture was started withthe introduction of Bactiseal drains. The parameters stu-died were age, sex, ASA score, grade of surgeon, signifi-cant medical history, trauma, concurrent surgeries,revisional surgery, peri-operative antibiotic, Bactiseal,tunnelling and duration of drainage. The incidence ofexternal ventricular drain related ventriculitis, cathetertip colonisation and the responsible pathogens werenoted.ResultsEleven cases of ventriculitis were recorded and themajority were caused by Gram positive bacteria. BothBactiseal and standard catheters were associated withsimilar infection rates (Fishers Exact test, p= 0.53). A sig-nificantly longer average length of in-situ stay of ventri-cular catheters was observed in the cases developingventriculitis (Kolmogorov-Smirnov test, p<0.01). TheBactiseal catheters took longer time to develop infectionas compared to Standard catheters. But, this differencewas not statistically significant (Kaplan-Meier survivalanalysis, p = 0.12). Analysis comparing infectionincidence for the rest of the risk factors shows that onlyrevisional surgery was associated with higher infectionrates (Fishers Exact test, p= 0.03). Twenty sixBactisealcatheter tips were sent for culture, including catheter tipsfor 6 cases with ventriculitis. Only 2 catheters were foundto be colonised and Pseudomonas was cultured fromboth (1 with and 1 without associated ventriculitis).ConclusionsVentriculostomy related infections are strongly associatedwith longer in-situ stay of ventricular catheters. Bactisealcatheters may be the preferred option in those patientsneeding prolonged ventricular drainage. As comparedwith historical controls [2],Bactisealventriculostomycatheters have a low rate of colonisation and Pseudomonasseems to be the major culprit. 1. Prevention of infection inneurosurgery: role of “antimicrobial” catheters.

Investigation and management of an outbreak of multidrug-carbapenem-resistant Acinetobacter baumannii in Cambridge, UK

Multidrug-resistant Acinetobacter baumannii resistant to carbapenems (MRAB-C) has become endemic in many hospitals in the UK. We describe an outbreak of MRAB-C that occurred on two intensive care units using ORION criteria (Outbreak Reports and Intervention studies Of Nosocomial infection). All patients colonised or infected with MRAB-C were included. Enhanced infection control precautions were introduced in Phase 1 of the outbreak. The adult neurosciences critical care unit (NCCU) was partially closed in Phase 2 and strict patient segregation, barrier nursing and screening thrice weekly was introduced. When control was achieved, NCCU was reopened (Phase 3) with post-discharge steam cleaning and monthly cleaning of extract and supply vents. There were 19 cases, 16 on NCCU and three on the general intensive care unit (ICU). Mean age was 52 years, with six cases being female. All patients were mechanically ventilated and ten had either an extraventricular drain or intracranial pressure monitoring device in place. Four patients developed a bacteraemia, with one further case of ventriculitis. Nine patients had no clinical evidence of infection and four were identified initially on screening. Ten patients were treated; there were eight deaths. Environmental samples showed heavy contamination throughout NCCU. MRAB-C affects critically ill patients and is associated with high mortality. This outbreak was controlled by early involvement of management, patient segregation, screening of patients and the environment, and increased hand hygiene environmental cleaning and clinical vigilance. A multidisciplinary approach to outbreak control is mandatory.

A rare presentation of ventriculitis and brain abscess caused by Fusobacterium nucleatum

Anaerobic ventriculitis is rare, and usually seen in patients with predisposing factors such as otitis media, mastoiditis, sinusitis or recent neurosurgery. We report what we believe to be the first case of ventriculitis and brain abscess due to Fusobacterium nucleatum infection in a man with no significant predisposing factors. He was successfully treated with antibiotic therapy.

Nosocomial ventriculitis due to Roseomonas gilardii complicating subarachnoid haemorrhage

Roseomonas gilardii is a pink-pigmented, non-fermentative, Gram-negative coccobacillus that has been recognized as a rare cause of human infections. We report the first case of ventriculitis caused by R. gilardii in a 54-year-old man with a subarachnoid haemorrhage secondary to a vertebral artery aneurysm; discuss previous reports of this organism as a nosocomial and community-acquired pathogen, laboratory diagnosis, and patient management.

Endoscopic management of cysticercal cysts within the lateral and third ventricles.

In this report the authors review their 3-year experience with the endoscopic management of patients with hydrocephalus who harbored cysticercal cysts within the third and lateral ventricles. The management plan was to utilize an endoscopic approach to remove the cysts and to incorporate techniques useful in treating obstructive hydrocephalus. The ultimate goals were to avoid having to place a complication-prone cerebrospinal fluid shunt and to eliminate the risk of complications related to cyst degeneration. A retrospective analysis of 10 patients with hydrocephalus and cysticercal cysts within the third or lateral ventricles who were endoscopically managed was performed. A general description of the instrumentation and technique used for removal of the intraventricular cysts is given. At presentation, neuroimaging revealed findings suggestive of obstructive hydrocephalus in eight patients. Seven of the 10 patients treated endoscopically were spared the necessity of shunt placement. Three successful third ventriculostomies and one therapeutic septum pellucidotomy were performed. Despite frequent rupture of the cyst walls during removal of the cysts, there were no cases of ventriculitis. The endoscopic approach allowed successful removal of a cyst situated in the roof of the anterior third ventricle. One patient suffered from recurrent shunt obstructions secondary to a shunt-induced migration of cysts from the posterior fossa to the lateral ventricles. The endoscopic removal of third and lateral ventricle cysticercal cysts, combined with a third ventriculostomy or septum pellucidotomy in selected cases, is an effective treatment in patients with hydrocephalus and should be considered the primary treatment for this condition.

Endoscopic management of cysticercal cysts within the lateral and third ventricles

In this report the authors review their 3-year experience with the endoscopic management of patients with hydrocephalus who harbored cysticercal cysts within the third and lateral ventricles. The management plan was to utilize an endoscopic approach to remove the cysts and to incorporate techniques useful in treating obstructive hydrocephalus. The ultimate goals were to avoid having to place a complication-prone cerebrospinal fluid shunt and to eliminate the risk of complications related to cyst degeneration. A retrospective analysis of 10 endoscopically managed patients with hydrocephalus and cysticercal cysts within the third or lateral ventricles was performed. A general description of the instrumentation and the technique used for removal of the intraventricular cysts is given. At presention, neuroimaging revealed findings suggestive of obstructive hydrocephalus in eight patients. Seven of the 10 patients treated endoscopically were spared the necessity of shunt placement. Three successful third ventriculostomies and one therapeutic septum pellucidotomy were performed. Despite frequent rupture of the cyst walls during removal of the cyst, there were no cases of ventriculitis. The endoscopic approach successfully allowed removal of a cyst situated in the roof of the anterior third ventricle. One patient suffered from recurrent shunt obstructions secondary to a shunt-induced migration of cysts from the posterior fossa to the lateral ventricles. The endoscopic removal of third and lateral ventricle cysticercal cysts, combined with a third ventriculostomy or septum pellucidotomy in selected cases, is an effective treatment in patients with hydrocephalus and should be considered the primary treatment for this condition.

Endoscopic Third Ventriculostomy: An Outcome Analysis

Endoscopic third ventriculostomy (ETV) has gained widespread acceptance as an effective way to manage hydrocephalus in selected patients. To determine which patient groups have the highest chance of successful ETV, a retrospective case review was performed. From June 1992 to December 1996, 97 patients underwent a total of 98 ETVs at our institution. There were 59 males and 38 females with a mean age of 8.1 years (range 1 day to 29.5 years). Twenty-six of 98 procedures (26%) were abandoned due to either unfavorable anatomy, inability to perform a cisternostomy, or hemorrhage. Follow-up data was available in 92 patients for a mean of 24.2 months. The rate of successful ETV in 71 patients, with either complete shunt avoidance or removal, varied widely by diagnosis and patient age. The highest success rates were achieved in patients with aqueductal stenosis, tectal plate tumor, myelomeningocele and posterior fossa tumor. Complications included one transient herniation syndrome, one basilar artery perforation, 2 cases of ventriculitis, one transient decrease in level of consciousness, and one transient hemiparesis. We feel these results support the continued use of ETV in only carefully selected patients with hydrocephalus.

Risk factor of complications requiring neurosurgical intervention in infants with bacterial meningitis

Among 50 consecutive cases of bacterial meningitis in infants aged 6 months or less, 9 (Group I) were confirmed to have complications requiring neurosurgery during the first 2 weeks of antibiotic treatment. Neurosurgery was performed in 40, 33, and 30% of cases caused by Streptococcus pneumoniae, Pseudomonas aeruginosa, and Escherichia coli, respectively. There were 5 cases of subdural empyema, 1 case of brain abscess, 1 case of subdural empyema and brain abscess, and 2 cases of ventriculitis with severe hydrocephalus. All complications requiring neurosurgery were initially detected by cranial ultrasonography. The other 41 patients who did not undergo neurosurgery were classified as Group II. Comparison of clinical presentations and laboratory findings between the two groups showed that Group 1 contained more patients with a history of inadequate treatment, and longer duration of illness before diagnosis. Except for prolonged disturbance of consciousness, there was no difference between the two groups in clinical and laboratory data on admission or in clinical course during therapy. Due to the high incidence of complications requiring neurosurgical treatment, cost-effective cranial ultrasound is recommended for screening every young infant with bacterial meningitis, especially in cases caused by S. pneumoniae.

Neurological outcome following neonatal post-haemorrhagic hydrocephalus: the effects of maximum raised intracranial pressure and ventriculo-peritoneal shunting.

The neuromotor outcome of 33 survivors of grade 3 or 4 neonatal post-haemorrhagic hydrocephalus born between 1975 and 1988 was assessed at a mean age of 4.7 years (9 months to 13 years). Two outcomes were determined: 12 patients were either normal (10 or had neurological signs without functional impairments (2), while 21/33 were moderately (16), severely (2), or profoundly impaired (3). Intracranial pressure (ICP) was measured in 26/33 patients (4-40 mm Hg): 2 had normal pressures (< 5.6 mm Hg) and were normal. Raised ICP was not significantly different between outcome groups. Twenty-seven children were shunted; 10/27 had five or more operations (up to 14) and all of these had abnormal neurological outcomes, whereas the number of children with 1-4 shunt procedures was equal in both outcome groups. The rise in morbidity after the fourth shunt procedure may be associated with the ventriculitis suffered by 9 of the 10 patients with more than four shunts (P < 0.01): this compares with 4/14 cases of ventriculitis in the children with 2-4 shunts and no cases of infection in the 3/27 who were shunted once. Outcome was independent of antenatal and perinatal factors including the age at or mode of presentation, and was unrelated to grade of intraventricular haemorrhage or parenchymal changes on ultrasound or CT scanning. for these small numbers, adverse outcome is statistically related to more than four shunt procedures and ventriculitis but independent of maximum ICP or other perinatal factors.