Cerebrospinal Fluid Diversion In Patients Research Articles

104 Use of the eShunt Implant in Treatment of Aneurysmal Subarachnoid Hemorrhage Communicating Hydrocephalus

INTRODUCTION: Aneurysmal subarachnoid hemorrhage (aSAH) may cause communicating hydrocephalus and elevated intracranial pressure (ICP) not amenable to weaning of cerebrospinal fluid (CSF) external ventricular drainage (EVD), often requiring surgical ventriculoperitoneal shunting (VPS) with risk of hemorrhage and infection. METHODS: Patients having intractable elevated ICP with EVD clamping and favorable inferior petrosal sinus and bony anatomy were included. ICP was monitored before and after eShunt deployment for 36-48 hours. Primary endpoint was reached if ICP remained <20 cmH2O enabling EVD removal. CT imaging of the brain was obtained immediately post-eShunt placement to evaluate eShunt placement and assess for any presence of new procedural hemorrhage. RESULTS: Seven out of eight patients (5 female; age 64 ± 12 years) underwent successful transfemoral transvenous eShunt procedure at 25.3 days (Range 14-38) post aSAH. Primary endpoint was achieved in all with EVD removal by 36-48 hours without procedural or delayed hemorrhage. Mean ICP rapidly decreased from 33.4 to 13 cmH2O at 1 hour (p < 0.0001) and to 9 cmH2O (p < 0.0001) at 36 hours post eShunt placement. CONCLUSIONS: These early encouraging results of the eShunt implant suggest clinical role and utility in the management of subarachnoid hemorrhage associated hydrocephalus possibly eschewing the need for VP shunt surgery and enabling minimally invasive CSF diversion in patients requiring dual anti-platelet or anticoagulant therapy.

Predictors of the Need for Cerebrospinal Fluid Diversion in Patients with Myelomeningocele

Background There is no consensus about the optimal timing and the criteria for cerebrospinal fluid diversion in children with myelomeningocele (MM). The aim of this work is to assess the predictors of the need for cerebrospinal fluid diversion in patients with myelomeningocele to avoid the unnecessary shunting with its complications. Patients and Methods This prospective study included fifty infants with myelomeningocele that were managed in the Neurosurgical department in Ain shams University hospital and October health insurance hospital from August 2016 till December 2018. Results In this study, 22 (44%) patients needed a shunt surgery after repair of the myelomeningocele. The age at presentation was highly significant (HS) for the need for shunt (P-value 0.006), with median age of 4.25 months. There were 22 cases (44%) that crossed the head circumference percentile for age while 28 cases (56%) matched; This was statistically highly significant (P-value 0.000). All patients with lax anterior fontanel (AF) or with mild bulge didn’t need a shunt, while all patients with tense AF needed a shunt (P-value 0.000). It was noticed that persistent vomiting was a sensitive indicator of the increased intracranial pressure since it occurred in all the cases who required shunt, this was statistically highly significant (P-vale 0.000). Four cases (8% of the cases) suffered from cerebrospinal fluid leak from the myelomeningocele wound within the first week post MM repair. Conclusion AF status & HC percentile for age represent the most reliable clinical signs to identify those who will need & benefit from a CSF diversion. The VP shunt should be preserved for cases exhibiting progressive signs of increased ICP (moderate to severe AF bulge- HC crossing percentile for age), while cases showing ventriculomegaly on imaging without signs of increased ICP should be followed up.

The Birmingham Standardized Idiopathic Intracranial Hypertension Shunt Protocol: Technical Note

Insertion of cerebrospinal fluid (CSF) shunts in patients with idiopathic intracranial hypertension (IIH) is challenging mainly due to the small ventricles and phenotypical body habitus. In this report the authors present their surgical protocol for insertion of a ventriculoperitoneal shunt (VPS) in patients with IIH and the associated revision rates. The protocol comprises the following: shuntsurgery by neurosurgeons with expertise in CSF disorders; a frontal VPS usually right sided but left sided if the left ventricle is bigger; use of the proGAV 2.0 valve with gravitational unit, set at 10 and the M.scio telemetric sensor; cannulation of the ventricle with StealthStation EM navigation system; and laparoscopic insertion of the peritonealcatheter. The authors describe the protocol and rationale and evidence behind each component and presentthe results of a prospective analysis on revision rates. The protocol has been implemented since 1 July, 2019, and by 28 February, 2022, sixty-two patients with IIH had undergone primary VPS insertion. The 30-day revision rate was 6.5%, and overall 11.3% of patients underwent revision during the study period, which compares favorably with the literature. The etiology for early failures was related to the surgical technique. The components of the Birmingham standardized IIH shunt protocol are evidence based and address the technical challenges of CSF diversion in patients with IIH. This protocol is associated with a low revision rate, and the authors recommend standardization for CSF shunting in IIH.

Stereotactic-Guided Transcerebellar Cisternoperitoneal Shunt Placement for Idiopathic Intracranial Hypertension.

Idiopathic intracranial hypertension (IIH) can cause debilitating symptoms and optic nerve ischemia if untreated. Cerebrospinal fluid diversion is often necessary to reduce intracranial pressure; however, current ventriculoperitoneal and lumboperitoneal shunting techniques have high failure rates in patients with IIH. To describe our experience treating IIH with a novel stereotactic-guided transcerebellar cisternoperitoneal shunt (SGTC-CPS) technique that places the proximal shunt catheter in the posterior cisterna magnum. Retrospective perioperative and postoperative data from all patients who underwent SGTC-CPS placement for IIH from March 1, 2015, to December 31, 2020, were analyzed. Patients were positioned as for ventriculoperitoneal shunt placement but with the head turned farther laterally to adequately expose the retrosigmoid space. Using neuronavigation, an opening was made near the transverse-sigmoid junction, and the proximal catheter was inserted transcerebellarly into the posterior foramen magnum. Thirty-two patients underwent SGTC-CPS placement (29 female; mean body mass index, 36.0 ± 7.5; 14 with prior shunt failures). The mean procedure time for shunt placement was 145 minutes. No intraoperative complications occurred, and all patients were discharged uneventfully. At the 6-month follow-up, 81% of patients (21 of 26) had relief of their presenting symptoms. Shunt survival without revision was 86% (25 of 29) at 1 year and 67% (10 of 15) at 3 years, with no infections. The SGTC-CPS offers an alternative solution for cerebrospinal fluid diversion in patients with IIH and demonstrates a lower failure rate and more durable symptom relief compared with ventriculoperitoneal or lumboperitoneal shunt placement. Using proper techniques and equipment promotes safe and facile placement of the proximal catheter.

430 Trans-cerebellar Stereotactic-guided Cisternoperitoneal Shunt Placement for Idiopathic Intracranial Hypertension

INTRODUCTION: Idiopathic intracranial hypertension (IIH, pseudotumor cerebri) mainly affects young, obese females and can cause debilitating symptoms as well as optic nerve ischemia if not treated. Cerebrospinal fluid (CSF) diversion is often necessary to reduce intracranial pressure (ICP). Ventriculoperitoneal shunts (VPS) and lumboperitoneal shunts (LPS) are the main methods of CSF diversion but both are fraught with high rates of shunt failures in IIH patients. We propose the novel trans-cerebellar stereotactic-guided cisternoperitoneal shunt (TCSG-CPS) technique, which places the proximal shunt catheter in the posterior cisterna magnum, which is a non-collapsible CSF space. METHODS: Retrospective data regarding perioperative and postoperative data from all patients who underwent TCSG-CPS placement from 2015-2020 for IIH were collected. Intraoperatively, patients are positioned as for VPS but with the head turned further laterally to adequately expose the retrosigmoid space. Using neuronavigation, the transverse and sigmoid sinuses are located and an opening is made at the transverse-sigmoid junction. The proximal catheter is then inserted transcerebellarly into the posterior foramen magnum using electromagnetic neuronavigation to accurately track the catheter tip. RESULTS: Thirty-two patients underwent TCSG-CPS placement. 91% were female, with a mean BMI of 36.0 ± 7.5. Fourteen patients had undergone prior VPS or LPS placement with shunt failures. Shunt placement, including removal of prior shunts when applicable, took an average of 150 minutes. There were no intraoperative complications and patients were discharged uneventfully after mean 1.7 days. On follow-up visits at 6 months, 81% had relief of their presenting symptoms. Shunt survival without revision at 1 and 3 year were 86% and 67%, respectively. Overall infection rate was 0% in the study period. CONCLUSION: The TCSG-CPS offers an alternative solution to VPS and LPS for CSF diversion in patients with IIH and demonstrates a lower failure rate and more durable symptom relief compared to historical data on VPS and LPS. Using the proper techniques and equipment promotes safe and facile placement of the proximal catheter.

Long tunnel external ventricular drain: an adjunct in the management of patients with infection associated hydrocephalus

Objective: To evaluate the safety and efficacy of long tunnelled external ventricular drains (LTEVD) as a temporizing measure in patients with ventriculitis/meningitis requiring cerebrospinal fluid (CSF) diversion in whom immediate shunt surgery is not feasible.Methods: A retrospective review of the records of 15 patients with ventriculitis/meningitis, in whom an LTEVD was inserted, was performed to evaluate its safety, new onset CSF infection and need for permanent CSF diversion.Results: 15 patients with ventriculitis/meningitis had 16 LTEVDs placed between May 2006 and December 2016. There were 10 males and 5 females, their mean age being 16.5 years (range, 8 months–50 years). The mean duration of CSF drainage was 15.6 days (range, 4 to 44 days). Of the 16 LTEVDs that were inserted, two (13.3% - one CSF infection and one wound infection) developed new infection after 44 and 17 days of continuous CSF drainage respectively. The LTEVDs were removed and permanent CSF diversion procedures were performed in 10 patients during the same admission and in one patient later. At a mean follow up of 11.6 months (range 2–40 months), 8 of the 11 patients who underwent a permanent CSF diversion procedure had no clinical features of meningitis/ventriculitis.Conclusion: LTEVDs are an effective method of temporary CSF diversion in patients requiring the same for more than 5 days. These drains have a low infection rate when placed up to four weeks making them a safe and efficacious adjunct in management of ventriculitis/meningitis associated hydrocephalus.

Duration of Preoperative External Ventricular Drain in Pediatric Posterior Fossa Tumors—Does It Matter?

Objective: Aim of the study was to assess the duration of preoperative external ventricular drain (EVD) as a predictor for permanent cerebrospinal fluid (CSF) diversion in pediatric posterior fossa tumors. Methods: The study was conducted in the Department of Pediatric Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia from January 2010 to December 2013. The data were collected retrospectively. The patients who had emergency insertion of external ventricular drain (EVD) due to hydrocephalus before the definitive posterior fossa tumor surgery were included in the study. Results: The preoperative emergency insertion of EVD was done in 38 patients with pediatric posterior fossa tumors. The patients were divided into two groups. Group A consists of those patients who had duration of preoperative EVD equal or less than 7 days. Group B includes those patients who had duration of preoperative EVD more than 7 days. Group A has 16 patients while Group B has 22 patients. The predominant clinical feature was symptoms and signs of raised intracranial pressure (ICP) only. Infection related to EVD was seen in seven patients. Ventriculoperitoneal (VP) shunt was required in 31.25% of Group A patients and 18.18% of Group B patients (p value = 0.35). Overall shunt rate was 23.68%. Conclusion: There are well known number of factors that can determine the need of permanent CSF diversion in patients with posterior fossa tumors. However, there is no effect of preoperative duration of EVD in determining the requirement of postoperative VP shunt.

Predictors of the need for cerebrospinal fluid diversion in patients with myelomeningocele.

Many patients with myelomeningocele (MMC) develop hydrocephalus, and most will undergo CSF diversion. The goal of this retrospective study was to determine whether there was a change in the shunt rate over the 7 consecutive years of the study. The authors will also identify the criteria used to determine the need for shunt placement. During a 7-year period, 73 patients underwent MMC closure at Arkansas Children's Hospital. The shunt rate for each year was calculated. Clinical characteristics were evaluated, including apneic and bradycardic spells, CSF leak, level of the MMC, head circumference, and rate of head growth. In addition, radiological images were reviewed, and the frontooccipital horn ratio (FOHR), ventricular index (VI), and thalamooccipital distance (TOD) were calculated. Comparisons were made between those patients who underwent shunt placement and those who did not. One patient was excluded due to death in the perinatal period. Of the 72 remaining patients, 54 (75%) underwent placement of a ventriculoperitoneal shunt. This rate did not change significantly over time. Between the cohorts with and without a shunt there was no significant difference in age, sex, or race. There was no significant difference in apneic episodes or bradycardic episodes. There was a statistically significant difference in fontanelle characteristics, head circumference at birth, and rate of head growth. Patients who required CSF diversion had a mean head growth of 0.32 cm/day compared with those who did not receive a shunt (0.13 cm/day; p < 0.05). All radiological parameters were found to be statistically significant. In this study, several classic indicators of hydrocephalus in the neonate were not found to be significantly associated with the need for CSF diversion. Fontanelle characteristics, head circumference at birth, and head growth velocity were associated with the need for shunt placement. Imaging information including the VI, TOD, and FOHR are statistically significant measures to evaluate prior to placement of a ventriculoperitoneal shunt. The optimal patient with MMC for CSF diversion will have full to tense fontanelle, increasing head circumference of more than 3 mm/day, and radiological evidence of an elevated VI, TOD, and/or FOHR.

Securing Cranial Horizontal-Vertical Valve in Proper Orientation For Use in Ventriculoperitoneal Shunting: Technical note

Introduction: There are several options for cerebrospinal fluid diversion in patients with normal pressure hydrocephalus. Fixed and programmable valves, with or without anti-siphon devices, have been used for ventriculoperitoneal shunts and horizontal-vertical valves for lumboperitoneal shunts. Recently, a horizontal-vertical valve was developed for ventriculoperitoneal shunts and has been demonstrated to be efficacious. This series describes the surgical method we employ for securing the valve in a true vertical position. Materials and Methods: The bone of the retroauricular region above the superior nuchal line is exposed. A trough is made in the bone in the vertical orientation to seat the valve which is then secured with a titanium plate and screw. Results: The technique has been used without complications in nine patients to date. No patient has exhibited signs of shunt malfunction. Conclusion: The authors propose this method for the safe, secure maintenance of an horizontal-vertical valve used for ventriculoperitoneal shunting in the upright vertical position.

Risk Factors for Conversion to Permanent Ventricular Shunt in Patients Receiving Therapeutic Ventriculostomy for Traumatic Brain Injury

Intracranial pressure is routinely monitored in patients with severe traumatic brain injury (TBI). Patients with TBI sometimes develop hydrocephalus, requiring permanent cerebrospinal fluid (CSF) diversion. To quantify the need for permanent CSF diversion in patients with TBI. Patients who received a ventriculostomy after TBI between June 2007 and July 2008 were identified, and their medical records were abstracted to a database. Sixteen of 71 patients (22.5%) receiving a ventriculostomy required a ventriculoperitoneal or ventriculoatrial shunt before discharge from the hospital. The average number of days between ventriculostomy and shunt was 18.3. Characteristics that predispose these patients to require permanent CSF diversion include the need for craniotomy within 48 hours of admission (odds ratio, 5.20; 95% confidence interval, 1.48-18.35) and history of culture-positive CSF (odds ratio, 5.52; 95% confidence interval, 1.19-25.52). Length of stay was increased in patients receiving permanent CSF diversion (average length of stay, 61 vs 31 days; P = .04). Patient discharge disposition was similar between shunted and nonshunted patients. In this retrospective study, 22% of TBI patients who required a ventriculostomy eventually needed permanent CSF diversion. Patients with TBI should be assessed for the need for permanent CSF diversion before discharge from the hospital. Care must be taken to prevent ventriculitis. Future studies are needed to evaluate more thoroughly the risk factors for the need for permanent CSF diversion in this patient population.

POSTOPERATIVE HYDROCEPHALUS IN PATIENTS UNDERGOING DECOMPRESSIVE HEMICRANIECTOMY FOR ISCHEMIC OR HEMORRHAGIC STROKE

We have frequently observed the development of postoperative communicating hydrocephalus in patients undergoing decompressive hemicraniectomy. This condition may persist in some patients after cranioplasty and require permanent cerebrospinal fluid (CSF) diversion. To confirm an independent correlation between hemicraniectomy and the development of communicating hydrocephalus, and to detail the frequency and potential clinical factors contributing to this complication, we evaluated our series of patients undergoing hemicraniectomy for life-threatening increases in intracranial pressure secondary to ischemic or hemorrhagic stroke. A retrospective analysis was performed with a cohort of consecutive patients who underwent emergent hemicraniectomy for medically refractory elevations in intracranial pressure. Patients with known independent risk factors for the development of communicating hydrocephalus were excluded. Clinical and imaging data were reviewed to determine the incidence and type of hydrocephalus after hemicraniectomy, the persistence of hydrocephalus after cranioplasty, and the need for permanent CSF diversion. Eighty-eight percent of the eligible patients undergoing hemicraniectomy in our cohort developed postoperative communicating hydrocephalus. Half of these patients harbored persistent hydrocephalus after cranioplasty and required placement of a ventriculoperitoneal shunt. We noted a strong correlation between prolonged time to replacement of the bone flap and persistence of hydrocephalus. Communicating hydrocephalus is an almost universal finding in patients after hemicraniectomy. Delayed time to cranioplasty is linked with the development of persistent hydrocephalus, necessitating permanent CSF diversion in some patients. We propose that early cranioplasty, when possible, may restore normal intracranial pressure dynamics and prevent the need for permanent CSF diversion in patients after hemicraniectomy.

Choroid Plexectomy Reduces Neurosurgical Intervention in Patients with Hydranencephaly

Introduction: The removal of the choroid plexus from the lateral ventricles was attempted by Dandy in the early 20th century but later discarded as complications arose and other methods of cerebrospinal fluid (CSF) diversion were introduced. We compare our experience with a variation of this operation to CSF diversion in patients with hydranencephaly or near hydranencephaly. Methods: The hospital and office charts of patients with a diagnosis of hydranencephaly were reviewed from the two institutions spanning the career of the senior author. Thirteen patients were identified, of whom 9 underwent CSF diversionary procedures (group A) and 4 underwent choroid plexectomy (group B). Results: The mean number of reoperations (2 in group A, 0 in group B), neurosurgical readmissions (1.5 in group A, 0 in group B) and days of hospitalization related to neurosurgical readmissions (43.5 in group A, 0 in group B) were all less in patients who underwent choroid plexectomy. The total incidence of complications related to surgery was also lower in this group (7 in group A, 0 in group B). Conclusion: In our experience, choroid plexectomy in patients with hydranencephaly reduces the incidence of reoperation and readmission, the number of days of hospitalization related to the surgical procedure and the total number of complications in comparison to patients undergoing CSF diversion. Further neurosurgical intervention is minimized as is the financial burden from multiple emergency department visits and radiological procedures for shunt evaluation. Choroid plexectomy is a viable alternative to CSF diversion in patients with hydranencephaly and a rapidly enlarging head. It avoids the chronic issues and complications surrounding CSF diversion in this difficult group of patients.

Ascites Complicating Ventriculoperitoneal Shunts

SummaryVentriculoperitoneal shunts are currently a standard therapy for obstructive hydrocephalus. These shunts are associated with a variety of abdominal complications, one of which is the development of ascites. We report an 11‐year‐old girl with a ventriculoperioneal shunt in whom a low‐grade peritoneal infection presented with ascites. This case demonstrates the importance of diagnostic paracenteses, appropriate antibiotic therapy and the potential need to establish an alternative rout for cerebrospinal fluid diversion in patients with ventriculoperitoneal shunts and ascites.