Cerebrospinal Fluid Shunt Procedures Research Articles

Comparison of endoscopic third ventriculostomy versus cerebrospinal fluid shunt procedures for the treatment of pediatric hydrocephalus in Taiwan.

Pediatric hydrocephalus is the most common cause of surgically treatable neurological disease in children. Controversies exist whether endoscopic third ventriculostomy (ETV) or cerebrospinal fluid (CSF) shunt placement is the most appropriate treatment for pediatric hydrocephalus. This study aimed to compare the risk of re-operation and death between the two procedures. We performed a retrospective population-based cohort study and included patients younger than 20-years-old who underwent CSF shunt or ETV for hydrocephalus from the Taiwan National Health Insurance Research Database. A total of 3,555 pediatric patients from 2004 to 2017 were selected, including 2,340 (65.8%) patients that received CSF shunt placement and 1215 (34.2%) patients that underwent ETV. The incidence of all-cause death was 3.31 per 100 person-year for CSF shunt group and 2.52 per 100 person-year for ETV group, with an adjusted hazard ratio (HR) of 0.79 (95% confidence interval [CI] = 0.66-0.94, p = 0.009). The cumulative incidence competing risk for reoperation was 31.2% forthe CSF shunt group and 26.4% forthe ETV group, with an adjusted subdistribution HR of 0.82 (95% CI = 0.70-0.96, p = 0.015). Subgroup analysis showed that ETV was beneficial for hydrocephalus coexisting with brain or spinal tumor, central nervous system infection, and intracranial hemorrhage. Our data indicates ETV is a betteroperative procedure for pediatric hydrocephalus when advanced surgical techniques and instruments are available.

Preoperative Risk Factors and Postoperative Complications of COVID-Positive Children Requiring Urgent or Emergent Surgical Care

BackgroundPreoperative COVID-19 testing protocols were widely implemented for children requiring surgery, leading to increased resource consumption and many delayed or canceled operations or procedures. This study using multi-center data investigated the relationship between preoperative risk factors, COVID-positivity, and postoperative outcomes among children undergoing common urgent and emergent procedures. MethodsChildren (<18 years) who underwent common urgent and emergent procedures were identified in the 2021 National Surgical Quality Improvement Program Pediatric database. The outcomes of COVID-positive and non-COVID-positive (negative or untested) children were compared using simple and multivariable regression models. ResultsAmong 40,628 children undergoing gastrointestinal surgery (appendectomy, cholecystectomy), long bone fracture fixation, cerebrospinal fluid shunt procedures, gonadal procedures (testicular detorsion, ovarian procedures), and pyloromyotomy, 576 (1.4%) were COVID-positive. COVID-positive children had higher American Society of Anesthesiologists scores (p ≤ 0.001) and more frequently had preoperative sepsis (p ≤ 0.016) compared to non-COVID-positive children; however, other preoperative risk factors, including comorbidities, were largely similar. COVID-positive children had a longer length of stay than non-COVID-positive children (median 1.0 [IQR 0.0–2.0] vs. 1.0 [IQR 0.0–1.0], p < 0.001). However, there were no associations between COVID-19 positivity and overall complications, pulmonary complications, infectious complications, or readmissions. ConclusionsDespite increased preoperative risk factors, COVID-positive children did not have an increased risk of postoperative complications after common urgent and emergent procedures. However, length of stay was greater for COVID-positive children, likely due to delays in surgery related to COVID-19 protocols. These findings may be applicable to future preoperative testing and surgical timing guidelines related to respiratory viral illnesses in children. Level of EvidenceIII.

The Impact of Social Determinants of Health in Pediatric Shunted Hydrocephalus.

Social risk factors have been shown to negatively affect health outcomes in children. However, this has not been characterized regarding pediatric shunted hydrocephalus. To explore the impact of social risk factors on outcomes in pediatric shunted hydrocephalus with the goal of identifying specific areas of intervention that might improve the outcomes of children undergoing cerebrospinal fluid (CSF) diversion. In an all-payer administrative database, records between January 2010 and October 2020 were analyzed to identify children undergoing CSF shunting procedures. Children with social risk factors were compared with those without regarding rates of infection, shunt-related interventions, and mortality within 5 years of their shunting procedure. Among the 5420 children who underwent first-time shunting procedures, 263 (4.9%) were identified to have social risk factors. Children with identified social risk factors had increased odds of central nervous system infection (odds ratio [OR] 2.06, 95% CI 1.45-2.91), revision (OR 2.43, 95% I 1.89-3.12), and mortality (OR 2.86, 95% CI 1.23-5.72). The mean numbers of computed tomography studies (14.60 ± 17.78 vs 6.34 ± 6.10), MRI studies (18.76 ± 24.37 vs 7.88 ± 24.37), and shunt series X-rays (17.22 ± 19.04 vs 7.66 ± 8.54) were increased among children with social risk factors. Children with social risk factors had increased rates of central nervous system infection, shunt-related interventions, and mortality within 5 years of CSF shunting. We underscore the importance of characterizing the impact of social risk factors in specific conditions, such as pediatric shunted hydrocephalus, and look to future directions aimed to mitigate these risk factors with coordination and direction of individualized resources, encouragement of advocacy, and community partnership.

Dural Venous Sinus Stenting in Idiopathic Intracranial Hypertension: A National Database Study of 541 Patients.

Dural venous sinus stenting (VSS) is an effective intervention for patients with idiopathic intracranial hypertension (IIH) refractory to medical treatment. Our goal was to evaluate the efficacy by utilizing a large multi-institutional sample. Five hundred forty-one patients >18years old who underwent VSS within 3years of IIH diagnosis were queried using Current Procedural Terminology and International Classification of Diseases, Tenth Revision codes from the TriNetX Analytics Network. Patient demographics, baseline symptoms, procedures, and clinical outcomes were evaluated within 1 year postoperatively. Outcomes examined were headache, tinnitus, blindness/low vision, optic nerve sheath fenestration (ONSF), cerebrospinal fluid (CSF) shunt, and use of medications (acetazolamide, methazolamide, furosemide, topiramate, tricyclic antidepressants, and valproate) for IIH. Prestent and poststent data were compared using Fisher exact test, and the odds ratios were computed using the Baptista-Pike method. The mean age at VSS was 36.7±10.6; 92% were female, 65% of patients were Caucasian, 25% were Black/African American, 1% were Asian, and 9% were of other/unknown race. Within the 1-year follow-up, acetazolamide and topiramate use were significantly reduced post-VSS (P < 0.0001∗; odds ratio, 0.45; confidence interval, 0.35-0.57 and P= 0.03∗; odds ratio, 0.71; confidence interval, 0.52-0.95, respectively). Also, headaches, visual disturbance, dizziness/giddiness, and tinnitus significantly improved post-VSS (P < 0.005∗). Finally, the number of CSF shunt procedures and ONSF procedures demonstrated no significant change post-VSS (P > 0.05). VSS is an effective and safe procedure resulting in significant improvement of headaches, visual impairment, dizziness, and tinnitus, acetazolamide and topiramate usage were lower after VSS in patients with IIH. The paucity of pre-VSS and post-VSS CSF shunt and ONSF procedure data does not provide enough evidence to establish significance.

How do we change practice?

OBJECT: The goal of this video lecture was to show the importance to research group organizing protocols to reduce cerebrospinal fluid (CSF) shunt infection at Hydrocephalus Clinical Research Network (HCRN) centers (from 8.7% to 5.7%). Antibiotic-impregnated catheters (AICs) were not part of the protocol but were used off protocol by some surgeons. The authors therefore began using a new protocol that included AICs in an effort to reduce the infection rate further. The improvement of quality was related to reduce variation and improve outcome. METHODS The previous protocol was implemented at HCRN centers on January 1, 2012, for all shunt procedures (excluding external ventricular drains [EVDs], ventricular reservoirs, and subgaleal shunts). Compliance with the protocol and outcome events up to March 30, 2014, were recorded. The actual protocol is based on 7 points (HCRNq centers): intravenous antibiotics, skin preparation, hand scrub, double gloves, iodophoretic surgical field, catheter and antibiotics, and vancomycin irrigation RESULTS. Before protocol implementation in 30 participating centers, and 1318 subjects (1571 surgical cases) enrolled the overall infection rate was 6.0% (95% CI 5.1%-7.2%). The actual infection rate when using this new protocol has been analyzed. CONCLUSIONS CSF shunt procedures performed in compliance with a new infection prevention protocol at HCRNq centers had a lower infection rate than noncompliant procedures. Based on the current data, HCRNq centers the role of AICs compared with other infection prevention measures is still under analysis.

Bacteriological Profile and Antimicrobial Susceptibility Pattern of Cerebrospinal Fluid Shunt Infections in Infants and Children.

ABSTRACTBackground:Despite the advent of modern neurosurgical techniques, new antibiotics, and modern imaging techniques, infection after ventriculoperitoneal (VP) shunt insertion and/or ventriculostomy is still a serious issue.Aim:The aim of this work was to study bacteriological profile and antimicrobial susceptibility pattern of cerebrospinal fluid shunt infections in infants and children.Materials and Methods:A total of 90 patients under the age of 12 years undergoing cerebrospinal fluid shunt procedures were included. The CSF shunt fluid, external ventricular drain (EVD), shunt tube tip specimens were processed as per standard microbiological techniques. The organisms isolated were subjected to antimicrobial susceptibility using the Kirby–Bauer disk diffusion method.Results:Of 20 infected patients 10 (50%) were culture positive. Most common organisms isolated were Acinetobacter baumannii 03 (30%) followed by Enterococcus faecalis 2 (20%). Two isolates of A. baumannii and one isolate of Klebsiella pneumoniae showed carbapenem resistance, which were sensitive to colistin. All Gram-positive isolates were sensitive to vancomycin and linezolid. Reinfection was found only in one (8.33%) patient. In 12 (60%) infected cases with shunt failure, revision of shunt was done. The shunt related mortality in this study was 1.11%.Conclusion:Most common organisms isolated were A. baumannii followed by E. faecalis. Carbapenem resistance was noted in these isolates which were sensitive to colistin. All Gram-positive isolates were sensitive to vancomycin and linezolid.

Rates of cerebrospinal fluid infection and the causative organisms following shunt procedures in Saudi Arabia

Objectives:To assess the incidence of infection following various cerebrospinal fluid (CSF) shunt procedures among patients with hydrocephalus and related conditions, based on the age of the patient, and to determine the types of pathogens responsible for shunt infections.Methods:This retrospective single center study reviewed the records of patients with culture-confirmed CSF shunt infection diagnosed between January 2012 and December 2017. Cases without central nervous system imaging investigations were excluded.Results:The incidence rate of shunt-related infections was 32.2%. Among the 189 patients whose records were included, Staphylococcus epidermidis (47.5%) and Acinetobacter baumannii (18%) were the most common causative organisms. The incidence of postoperative infection was higher among those who underwent external ventricular drain procedures (65%) than among those who underwent ventriculoperitoneal shunt procedures (24%). There were no intraoperative deaths. However, the postoperative death rate was 12.2% during hospital stay (mean duration = 9 days); 2% of these deaths occurred after shunt removal.Conclusion:The incidence of infections after CSF shunt procedures was high in our tertiary academic hospital during the study period, compared to those reported in similar clinical settings and before developing a detailed standardized protocol for infection control. Although gram-negative organisms were the most prevalent cause of CSF infections, S. epidermidis (a gram-positive organism) was the most commonly encountered causative agent. Shunt protocols should be implemented to address perioperative shortcomings and to reduce overall mortality and morbidity.

Cerebrospinal Fluid Leaks and Pseudomeningocele after Posterior Fossa Surgery: Effect of an Autospray Dural Sealant.

BackgroundPosterior fossa craniotomies can be complicated by cerebrospinal fluid (CSF) leaks, infection, meningitis, neurologic deficits, and intracranial hypotension caused by defective closure of the dura. Secondary dural closures such as pericranial graft, muscle graft, glue, sealants, or fat graft are used. However, there have been few studies examining the use of sealants with a polyethylene glycol and polyethylenimine component.ObjectiveWe studied the effect of one such sealant, Adherus® (HyperBranch Medical Technology, Durham, NC, USA), as an adjunct to secondary closure methods in the reduction of the use of abdominal fat grafting and lumbar puncture/drains.MethodsWe retrospectively reviewed the surgical records of all patients undergoing posterior fossa cranial surgery during a two-year period at a tertiary university affiliated medical center.ResultsOverall, data a total of 122 patients (62 in the no Adherus and 60 in the Adherus group) were collected. There was no statistically significant difference in the 30-day incisional CSF leak rate (4.1% vs. 6.5%; p=0.183), 30-day non-incisional CSF leak rate (11.3% vs. 5.0%; p=0.205), and 30-day pseudomeningocele rate (16.1% vs. 13.3%; p=0.663) in the no Adherus and Adherus groups, respectively. However, there was a significant reduction in the use of abdominal fat grafting (0% vs. 30.7%; p<0.001) and intraoperative CSF diversion techniques (58.1% vs. 23.3%; p<0.001). Every instance of the use of Adherus saved on average, $809.36.ConclusionsA statistically significant reduction in the use of CSF shunting procedures during posterior fossa craniotomy/craniectomy was achieved after the introduction of Adherus with no increase in CSF leak rate.

Cerebrospinal fluid diversion versus bariatric surgery in the management of idiopathic intracranial hypertension

Background: Idiopathic intracranial hypertension (IIH) is a condition affecting predominantly young women with increased body mass index (BMI). Obesity with the related metabolic and biochemical complications are thought to be involved in the pathogenesis of the condition. The aim of this study is to evaluate the safety, outcomes and economic implications of two treatment options for IIH.Methods: We retrospectively analysed cases of morbidly obese IIH patients treated by cerebrospinal fluid (CSF) shunting procedures between 2006 and 2016 in our department and compared their outcome with that of 69 patients undergoing bariatric surgery between 2015 and 2016.Results: A total of 42 female patients with IIH underwent de-novo shunting procedures during the study period. There was a high rate of shunt revisions (67%) and further weight gain in the majority of patients who had the insertion of CSF shunts. Of the 69 female patients undergoing bariatric surgery 4.3% required interventions related to their surgery with a significantly fewer number of hospital inpatient days. Furthermore, in the patients undergoing bariatric surgery, there was a significant improvement in all obesity-related complications.Conclusions: CSF shunting procedures do not address the aetiological factor of IIH and are associated with high rates of morbidity and further weight gain. Bariatric surgery is not only efficacious in the management of patients with IIH but is associated with significant improvements in other obesity-related comorbidities. Bariatric surgery is safe and more cost-effective than CSF shunting.

Anaesthetic management for ventriculoperitoneal shunt insertion in an infant with Dandy–Walker Syndrome

Dandy–Walker Syndrome (DWS) is a rare congenital brain anomaly affecting the cerebellum and the fourth ventricle. The chief components of the syndrome include cystic dilatation of the fourth ventricle and agenesis or hypoplasia of the cerebellar vermis. These abnormalities are typically associated with hydrocephalus. Patients often present in infancy for cerebrospinal fluid shunt procedures. Anaesthetic concerns include those related to other frequently associated congenital abnormalities. Airway management requires particular attention. The limited literature on this subject suggests that these patients require postoperative intensive care admission. This is not always possible in the resource-limited environment. This case report describes the successful anaesthetic management of an infant with Dandy–Walker Syndrome without postoperative intensive care admission.

Neurologische Symptome, Diagnostik, Differenzialdiagnose und medikamentöse Therapie des Pseudotumor cerebri

Persistent headache and loss of visual acuity combined with papilledema are the predominant symptoms of idiopathic intracranial hypertension (IIH). The clinical signs are not different from those seen in other diseases with elevated intracranial pressure. To differentiate primary and secondary forms of increased intracranial pressure neuroimaging procedures and analysis of cerebrospinal fluid (CSF) are absolutely essential according to national and international guidelines. Lumbar puncture reveals an elevated opening pressure in cases of IIH as the only pathological finding. Treatment options are serial lumbar punctures combined with body weight reduction as well as medication with carbonic anhydrase inhibitors, such as acetazolamide and topiramate or diuretic therapy with furosemide. In some patients surgical options, e.g. optic nerve sheath fenestration, CSF shunting procedures including ventriculoperitoneal and lumboperitoneal shunt systems and bariatric surgery also have to be considered. In recent years modern neuroradiological procedures have also been applied (e.g. venous stenting in cases of sinus obstruction) in some centers.

The Current Minor Perception of V-S Complication

ydrocephalus is a common neurosurgical condition and cause of severe neurological damage if left untreated H (14). Shunting of the cerebrospinal fluid (CSF) prevents the associated secondary neurological damage. However, CSF shunting procedures have a significantly high rate of complications. For this reason, in the last few years, the revival of endoscopic third ventriculocisternostomy (TVE) has made this technique the preferred treatment option for noncommunicating hydrocephalus, especially in case of aqueductal stenosis (9, 10). Extrathecal CSF shunts, nearly always ventriculoperitoneal (V-P) shunts, remain the procedure of choice in patients with communicating hydrocephalus, namely postinfective and posttraumatic, as well as in most cases of hydrocephalus secondary to intraventricular hemorrhage, and in spinal dysraphism, in which TVE benefits only in a minority of the affected subjects (1, 13).

Evolution of surgical interventions for hydrocephalus: patient preferences and the need for proper information

The treatment of hydrocephalus has undergone remarkable transformation since it was first documented over two thousand years ago. Currently, the focus of hydrocephalus research is on minimally invasive techniques of treatment. This article reviews the evolution of hydrocephalus therapy, and examines current attitudes towards modern methods. We relied on journal publications, as well as literature on hydrocephalus obtained from the Internet (Google, Yahoo and PUBMED search) making use of the following search terms: “hydrocephalus: history; treatment; complications”, “cerebrospinal fluid shunt”, “endoscopic third ventriculostomy: indications of; complications of; advantages; disadvantages; successes; failure”. Numerous medical and surgical approaches have been adopted in the treatment of hydrocephalus in the past. However, the breakthrough that ushered in the modern era of hydrocephalus treatment was the introduction of valve-regulated systems in the middle of the last century. Endoscopic third ventriculostomy has evolved to become an alternative to traditional shunts. Cerebrospinal fluid shunt procedures are very effective in the treatment of hydrocephalus and have radically transformed the outcome of the disorder. However, they have a number of limitations. The alternative to shunts, endoscopic third ventriculostomy, is relatively safe, effective and durable. It does not, however, succeed in every patient; and also has some potentially devastating complications. Preoperative counseling is imperative to ensure that patients are properly guided. KEYWORDS: Cerebrospinal fluid shunt; Complications; Endoscopic third ventriculostomy; Hydrocephalus; Indications; Patient selection

Healthcare Savings Associated with Reduced Infection Rates Using Antimicrobial Suture Wound Closure for Cerebrospinal Fluid Shunt Procedures

Background/Aims/Methods: This is a follow-up study from a recent randomized controlled trial conducted at the Women and Children’s Hospital of Buffalo that investigated the use of antimicrobial sutures (AMS) for wound closure during cerebrospinal fluid shunting procedures. Our purpose was to determine the average cost of shunt infections at our institution and estimate the healthcare savings associated with reduced infection rates secondary to AMS use. Result: We found that the treatment and management of a shunt infection resulted in a 5.3-fold increase in hospital charges. Conclusion: The potential healthcare savings associated with reduced infection rates are significant. These calculations demonstrate the profound economic effect a reduction in shunt infection rates may have on a healthcare system.

Haemophilus influenzae and Streptococcus pneumoniae Infections in Children with Cerebrospinal Fluid Shunts

Objective: This paper reviews the frequency of central nervous system infections due to Haemophilus influenzae and Streptococcus pneumoniae associated with cerebrospinal fluid (CSF) shunts in pediatric patients. The need for immunizations in this patient population is also evaluated. Patients: All patients with cerebrospinal fluid shunts except those with brain tumors seen in our clinics. Methods: We reviewed data in three computer databases, kept prospectively recording details of CSF shunt procedures and CSF shunt-related infections. Results: 1,226 patients underwent 3,889 shunt placements between 1957 and 2007. Twelve patients had 14 episodes of Haemophilus or pneumococcal infections. Conclusions: Children with CSF shunts are at high risk for infection with H. influenzae and S. pneumoniae. Routine immunizations during infancy in addition to the 23-valent polysaccharide pneumococcal vaccine should be highly and actively encouraged by health care providers caring for children with CSF shunts. Additional expanded-coverage vaccines should be utilized if and when they become available.

Antimicrobial suture wound closure for cerebrospinal fluid shunt surgery: a prospective, double-blinded, randomized controlled trial

Implantation of cerebrospinal fluid (CSF) shunting devices is associated with a 5-15% risk of infection as cited in contemporary pediatric neurosurgical literature. Shunt infections typically require complete removal of the device and prolonged antibiotic treatment followed by shunt replacement. Moreover, shunt infections are commonly associated with prolonged hospital stays, potential comorbidity, and the increased risk of neurological compromise due to ventriculitis or surgical complications. The authors prospectively evaluated the incidence of CSF shunt infection following shunt procedures performed using either antimicrobial suture (AMS) or conventional suture. In a single-center, prospective, double-blinded, randomized controlled trial, the authors enrolled 61 patients, among whom 84 CSF shunt procedures were performed over 21 months. Randomization to the study (AMS) or control (placebo) group was stratified to minimize the effect of known shunt infection risk factors on the findings. Antibacterial shunt components were not used. The primary outcome measure was the incidence of shunt infection within 6 months of surgery. The shunt infection rate in the study group was 2 (4.3%) of 46 procedures and 8 (21%) of 38 procedures in the control group (p = 0.038). There were no statistically significant differences in shunt infection risk factors between the groups (procedure type and time, age < 6 months, weight < 4 kg, recent history of shunt infection). No suture-related adverse events were reported in either group. These results support the suggestion that the use of AMS for CSF shunt surgery wound closure is safe, effective, and may be associated with a reduced risk of postoperative shunt infection. A larger randomized controlled trial is needed to confirm this association.

Efecto de los catéteres impregnados con antibiótico en la incidencia de infección tras procedimientos de derivación de líquido cefalorraquídeo

Infection is a major complication after cerebrospinal fluid (CSF) shunt systems insertion. Antibiotic-impregnated (AI) catheters seem to reduce infection rate in clinical practice. The objective of this study was to determine if the use of AI catheters reduces Staphylococcus spp. infection rate, as it is the most commonly isolated organism. Authors retrospectively reviewed all patients who underwent rifampin-impregnated and clindamycin-impregnated catheters at our hospital. These included external ventricular catheters (inserted from January 2006 to January 2007) and internalized shunts (inserted from January 2004 to January 2007). They also reviewed patients who underwent insertion of non-impregnated external catheters and internalized shunts during the same periods. Overall infection rate, Staphylococcus spp. infection rate and gram negative bacilli infection rate were compared in both groups by means of chi2 test. Sixty-five procedures with AI catheters and 66 procedures with non-AI catheters were performed. Overall infection rate as well as Staphylococcus spp. infection rate were significantly lower in the AI catheters cohort (p = 0.046 and p = 0.029, respectively), without increasing gram negative bacilli infections. The use of rifampin and clindamycin-impregnated catheters is a useful tool to reduce Staphylococcus spp. infections after CSF shunting procedures. However, future clinical trials are required to confirm these results.

Reduction in shunt infection using antibiotic impregnated CSF shunt catheters: An Australian prospective study

Antibiotic impregnated shunt catheters have emerged as a promising tool against the continuing challenge of shunt infection. We present our prospective evaluation of the efficacy of antibiotic (rifampicin and clindamycin) impregnated cerebrospinal fluid (CSF) shunt catheters (AIC) in a mixed paediatric and adult Australian population. We have prospectively evaluated all the cerebrospinal fluid shunt procedures carried out in our institution over a 3-year period since July 2002, after the introduction of AIC in our practice. Patient demographics, indication for shunt procedure, risk factors for infection, shunt infections and other relevant factors were documented. The data has been compared with similar data collected over the previous 7 years of our experience with non-antibiotic impregnated catheters for CSF shunt procedures. Pearson’s chi-square and Fisher’s exact tests are used for statistical evaluation. From July 2002 to June 2005, 243 shunt procedures were carried out using AICs in 178 patients. There were three shunt infections (1.2%). Rigorous retrospective evaluation of shunt procedures over the preceding 7 years revealed 36 infections in 551 shunt procedures (6.5%). This reduction in the infection rate was statistically significant ( p = 0.0015 on Pearson’s chi-square test and p = 0.000529 on Fisher’s exact test). We also report that the introduction of ceftriaxone prophylaxis during this period was associated with a reduction in Gram-negative shunt infection, but no effect on overall infection rate. We report rifampicin and clindamycin impregnated CSF shunt catheters significantly reduce the rate of shunt infection in Australian clinical practice. This data and the literature support the routine usage of AIC for all CSF shunt procedures.

Surgical shunt infection: significant reduction when using intraventricular and systemic antibiotic agents

Infection represents the most common serious complication of shunt surgery, and typically its incidence ranges between 5 and 15%, despite the use of systemic antibiotic agents. Because systemic antibiotic medications generally penetrate the cerebrospinal fluid (CSF) poorly, the authors investigated, in a controlled study, whether the addition of intraventricular antibiotic treatment decreases the incidence of perioperative infection in adult patients. Data pertaining to all CSF shunt procedures conducted at the authors' institution during an 11-year period were reviewed. Perioperative infection was defined as culture-positive CSF and the clinical presence of infection-related symptoms occurring within 90 days of surgery. All patients underwent intraoperative systemic antistaphylococcal antibiotic therapy. Before May 16, 1999, the senior author (R.H.S.) also administered 4 mg of gentamicin intraventricularly at surgery (Group I); thereafter, 10 mg of vancomycin was additionally administered (Group II). Other neurosurgeons at this institution did not use intraventricular antibiotic therapy, and their patients served as additional controls in identical time periods (Groups III and IV). A total of 802 shunt procedures were performed in 534 patients. Control infection rates were 5.4% (eight of 147) in Group I; 6.2% (nine of 145) in Group III; and 6.7% (18 of 267) in Group IV. With the combination of systemic antibiotic and intraventricular gentamicin and vancomycin (Group II), the infection rate fell significantly to 0.4% (one of 243). No complications were noted in association with intraventricular antibiotic administration. The combination of intraventricular gentamicin and vancomycin with systemic antibiotic therapy significantly decreased the incidence of perioperative shunt infection. It is presumed that intraventricular antibiotic therapy extends prophylactic antibiotic coverage into the CSF and prevents bacterial seeding.

Rapidly Rising Incidence of Cerebrospinal Fluid Shunting Procedures for Idiopathic Intracranial Hypertension in the United States, 1988–2002

Obesity, a major risk factor for idiopathic intracranial hypertension (IIH), is rapidly increasing in all ages of the United States population. We studied trends in the incidence of cerebrospinal fluid (CSF) shunts for IIH in the United States between 1988 and 2002, using a national hospital discharge database. This was a retrospective study using the Nationwide Inpatient Sample and robust weighted least-squares regression, adjusted for stratified survey methodology. There were 2779 admissions for CSF shunting procedures (new or revision) in IIH patients in the database. In-hospital mortality for new shunts was 0.5% (0.9% for ventricular shunts and 0.2% for lumbar shunts). The estimated total United States caseload of CSF shunting procedures for IIH increased 350% between 1988 and 2002 (P < 0.001). (The 2002 United States caseload was 1370 admissions). New shunt placements increased 320% during this interval (P < 0.001). In some subpopulations in which obesity is less important as a risk factor for IIH, caseload increases were less marked: pediatric IIH shunting (age < 13 yr) increased 52% and shunting in male IIH patients increased 38%, but shunting in older patients (age > 44 yr) increased 240% during the study period. Bariatric procedures (e.g., gastric bypass) increased very rapidly in incidence since 1998, with nearly 200 such procedures performed on IIH patients in 2002. The incidence of CSF shunting for IIH is increasing in the population of the United States at about the same relative rate as morbid obesity. Studies to establish the best shunting method in IIH and to explore alternative treatment strategies, such as optic nerve sheath fenestration and bariatric surgery, are urgently needed.