CSF Shunt Research Articles

A standardized infection prevention bundle for reduction of CSF shunt infections in adult ventriculoperitoneal shunt surgery performed without antibiotic-impregnated catheters.

Ventriculoperitoneal (VP) shunt insertion and revision surgeries are some of the most common procedures that are performed by neurosurgeons. Shunt infections within the adult population are associated with significant morbidity and mortality and rates remain high. The objective of the current study was to use quality improvement (QI) methodology to create a standardized infection prevention bundle aimed at reducing the rate of shunt infections. A prospective, single-center, single-surgeon QI study was undertaken. Patients were included if they were 18 years of age or older and were undergoing a VP shunt insertion or revision. The primary outcome of the study was the development of a shunt-related surgical site infection, within 1 year of surgery, as defined according to the Canadian Nosocomial Infection Surveillance Program guidelines. There was no standardized protocol prior to July 2013. A bundle coined as the Calgary Adult Shunt Infection Prevention Protocol (CASIPP) was implemented on July 1, 2013, and updated on July 1, 2015, when 2% chlorhexidine gluconate in 70% isopropyl alcohol replaced povidone-iodine for preoperative skin antisepsis. Protocol compliance was regularly monitored using a standardized process. No antibiotic-impregnated catheters were used. A total of 621 consecutive VP shunt insertions and revisions were included in the study. The rate of shunt infection was 5.8% during the period in which there was no standardized shunt protocol. After the implementation of the CASIPP the infection rate decreased to 4.0%, and after introduction of the chlorhexidine/alcohol skin antisepsis, the infection rate was 0% in 379 consecutive procedures (p < 0.0001). Multivariable logistic regression analysis demonstrated that the use of chlorhexidine/alcohol with CASIPP was associated with a significant reduction in the odds of developing a shunt infection (OR 0.032, 95% CI 0-0.19, p = 0.0005). The implementation of a standardized shunt infection prevention bundle within the adult population, without the use of antibiotic-impregnated catheters, significantly reduced the rate of shunt infections which was sustained over many years. The use of 2% chlorhexidine gluconate in 70% isopropyl alcohol for preoperative antisepsis may have played a significant role. Multicenter studies should be completed to verify the effectiveness of the authors' protocol.

Practical Application of Deep Learning in Neurosurgery: Identifying CSF Shunt Systems in Hydrocephalus Patients

Practical Application of Deep Learning in Neurosurgery: Identifying CSF Shunt Systems in Hydrocephalus Patients

The semi-sitting position in patients with indwelling CSF shunts: perioperative management and avoidance of complications

ObjectivePosterior fossa or midline tumors are often associated with hydrocephalus and primary tumor removal with or without perioperative placement of an external ventricular drain (EVD) is commonly accepted as first-line treatment. Shunting prior to posterior fossa surgery (PFS) is mostly reserved for symptomatic cases or special circumstances. There are limited data regarding the anticipated risk for symptomatic pneumocephalus and the perioperative management using the semi-sitting position (SSP) in such a scenario. Here, we therefore assessed the safety of performing PFS in a consecutive series of patients over a period of 15 years to allow the elaboration of recommendations for perioperative management.MethodsAccording to specific inclusion and exclusion criteria a total of 13 patients who underwent 17 operations was identified. Supratentorial pneumocephalus was evaluated with semiautomatic-volumetric segmentation. The volume of pneumocephalus was evaluated according to age and ventricular size.ResultsTen of the 13 patients had a programmable valve (preoperative valve setting range 6–14 cmH20; mean 7.5 cmH20) while 3 patients had non programmable valves. A variable amount of supratentorial air collection was evident in all patients postoperatively (range 3.2–331 ml; mean 122.32 ml). Positive predictors for the volume of postoperative pneumocephalus were higher age and a preoperative Evans ratio > 0.3. In our series, we encountered no cases of tension pneumocephalus necessitating an air replacement procedure as well as no obstruction, disconnection, infection or hardware malfunction of the shunt system.ConclusionsOur findings indicate that a CSF shunt in situ is not a contraindication for performing PFS in the semi-sitting position and it does not increase the pre-existing risk for postoperative tension pneumocephalus. In cases of primary shunting for hydrocephalus associated with posterior fossa tumors a programmable valve set at a medium opening pressure with a gravitational device is a valid option when PFS in the semi-sitting position is opted. In patients with an indwelling shunt diversion system special caution is indicated in order to prevent and detect overdrainage especially in not adjustable valves or shunts without antisiphon devices.

Skull Fracture Healing in Children Up to 36 Months - A Cohort Analysis

During medicolegal proceedings in cases of suspected child abuse it is sometimes argued that skull fractures could be sequelae from complications at birth or resulted from a prior witnessed accidental trauma that may have preceded the suspected abusive event. There is paucity of scientific evidence indicating timing for skull fracture healing in children up to 36 months old. Objective of this study was to assess the average time to imaging documentation of skull fracture healing in children up to 36 months old. We performed retrospective chart review and image analysis in children with documented skull fractures after trauma between May 2009 and December2014, excluding any patients who underwent cranial procedures related to the head injury, patients with pre-existing CSF shunts, patients who were referred for child abuse evaluation, and patients who were admitted to the General Surgery service for multi-organ trauma.We analyzed 185 skull fractures: 82 fractures were not healed, 49 fractures were partially healed, and 54 fractures were healed on follow-up imaging. The mean time to imaging evidence of healing among patients with healed fractures was 108 days (3.6 months), the median was 112 days (3.7 months), the minimum was 22 days, and the maximum was 225 days (7.5 months). Chi-square analysis showed a significant relationship between the skull fracture healed status and presence of bleed (P = 0.001) and with fracture characteristics of displaced, depressed, or dehiscent (P= 0.009). There was no significant association with the age group (P= 0.32) nor with involvement of multiple cranial plates (P= 0.73). This information may be useful during medicolegal proceedings in patients with suspected abusive head trauma mechanism.

A Case Report VP shunt in Non Communicating Hydrocephalus due to Intracerebral Hemorrhage

Stroke is one of the top three cause of death and disability globally. Approximately, only 10% to 15% of first-ever stroke are intracerebral hemorrhages (ICHs), but the rates of disability and death are significantly higher. Hydrocephalus may occur in more than 50% of patients with intraventricular hemorrhage (IVH), which is secondary to ICH. Intraventricular hemorrhage (IVH), an accumulation of blood to ventricles that may be cause by extension of ICH, occurs in up to 50% of patients with primary ICH. Hydrocephalus itself may serves as a predictor of poor outcome after ICH.1,2,3&#x0D; A 71 years old male came to the hospital with the complaint of loss of consciousness, difficulty in communicating, and weakness of extremities on the left side of the body since 12 hours ago. The complaint was preceded by headache that did not alleviate with medication since 1 day before admission and there was history of slurred speech. A head CT scan without contrast was done and the result showed an intracerebral hemorrhage and a suggestive obstructive hydrocephalus. The patient was diagnosed noncommunicating hydrocephalus due to spontaneous intracerebral haemorrhage (ICH) at the right thalamus with intraventricular haemorrhage due to suspect hypertension with differential diagnosis of cerebral amyloid angiopathy with emergency hypertension. The patient was advised to underwent an emergency VP shunt placement.&#x0D; Implantation of a ventriculoperitoneal (VP) shunt is the most widely used treatment of hydrocephalus. Considered to be a major privonce of neurosurgery, it accounts for 70.000 hospital admission in the US. Even though, VP shunting of CSF reduces the morbidity and mortality of post-hemorrhagic. hydrocephalus, it is associated with potential complications requiring multiple surgical procedures, as well as shunt revision due to its failure during the patient’s lifetime.4

Safety and effectiveness of the assessment and treatment of idiopathic normal pressure hydrocephalus in the Adult Hydrocephalus Clinical Research Network.

The aim of this study was to describe the processes and outcomes associated with patients at five sites in the Adult Hydrocephalus Clinical Research Network (AHCRN) who had undergone evaluation and treatment for suspected idiopathic normal pressure hydrocephalus (iNPH) and had 1-year postoperative follow-up. Subjects with possible iNPH who had been prospectively enrolled in the AHCRN registry between November 19, 2014, and December 31, 2018, were evaluated by CSF drainage via either lumbar puncture or external lumbar drainage, consistent with recommendations of the international iNPH guidelines. Standardized clinical evaluations of gait, cognition, urinary symptoms, depression, and functional outcomes were conducted at baseline, before and after CSF drainage, and at 4-month intervals after shunt surgery. Complications of CSF drainage and shunt surgery were recorded. Seventy-four percent (424/570) of patients with possible iNPH had CSF drainage, and 46% of them (193/424) underwent shunt surgery. The mean change in gait velocity with CSF drainage was 0.18 m/sec in patients who underwent shunt surgery versus 0.08 m/sec in patients who did not. For shunt surgery patients, gait velocity increased by 54% from 0.67 m/sec before CSF drainage to 0.96 m/sec 8-12 months after surgery, and 80% of patients had an increase of at least 0.1 m/sec by the first postoperative visit. Evaluation of cognition, urinary symptoms, depression, and functional outcomes also revealed improvement after shunt surgery. Of 193 patients who had undergone shunt surgery, 176 (91%) had no complications and 17 (9%) had 28 complications. Eleven patients (6%) had 14 serious complications that resulted in the need for surgery or an extended hospital stay. The 30-day reoperation rate was 3%. Using criteria recommended by the international iNPH guidelines, the authors found that evaluation and treatment of iNPH are safe and effective. Testing with CSF drainage and treatment with shunt surgery are associated with a high rate of sustained improvement and a low rate of complications for iNPH in the 1st year after shunt surgery. Patients who had undergone shunt surgery for iNPH experienced improvement in gait, cognitive function, bladder symptoms, depression, and functional outcome measures. Gait velocity, which is an easily measured, objective, continuous variable, should be used as a standard outcome measure to test a patient's response to CSF drainage and shunt surgery in iNPH.

Ventriculo-Peritoneal Shunt Infection: Three Years Experience in Combined Military Hospital, Dhaka

Introduction: Treatment of Hydrocephalus by placement of Ventriculo-peritoneal (V-P) Shunt is a common neurosurgical practice. But presence of shunt predisposes to increased infection. Objective: To focus on aetiological factors for developing shunt infection. Methods: This prospective observational study was carried out at Neurosurgery Center, Combined Military Hospital, Dhaka during the period of June 2015 to May 2018. A total of 33 patients were included in the study, all of them underwent CSF shunt surgery at this centre. They were followed up for one month after surgery. Age, sex and socioeconomic condition of the patients, types (obstructive or communicating) of hydrocephalus (HCP), aetiology of HCP, duration of surgery, shunt type used and routine or emergency surgery were the factors that were analysed for possible association with infection. Results: Eight (24.2%) patients developed shunt infection, among whom infants and male were predominate. Low socio-economic group, prolonged operation time and emergency surgery were found to have association with increased rate of infection. Conclusion: V-P shunt insertions had unacceptably high infection rate despite the presence of a protocol for the procedure. A protocol should be developed for strict compliance and where possible, alternative procedure Endoscopic Third Ventricullostomy (ETV) or External Ventricular Drain (EVD) should be employed to minimize shunt infection. JAFMC Bangladesh. Vol 18, No 1 (June) 2022: 16-18

Endoscopic third ventriculostomy in previously shunt-treated patients.

Endoscopic third ventriculostomy (ETV) is an option for treatment of hydrocephalus, including for patients who have a history of previous treatment with CSF shunt insertion. The purpose of this study was to report the success of postshunt ETV by using data from a multicenter prospective registry. Prospectively collected data in the Hydrocephalus Clinical Research Network (HCRN) Core Data Project (i.e., HCRN Registry) were reviewed. Children who underwent ETV between 2008 and 2019 and had a history of previous treatment with a CSF shunt were included. A Kaplan-Meier survival curve was created for the primary outcome: time from postshunt ETV to subsequent CSF shunt placement or revision. Univariable Cox proportional hazards models were created to evaluate for an association between clinical and demographic variables and subsequent shunt surgery. Postshunt ETV complications were also identified and categorized. A total of 203 children were included: 57% male and 43% female; 74% White, 23% Black, and 4% other race. The most common hydrocephalus etiologies were postintraventricular hemorrhage secondary to prematurity (56, 28%) and aqueductal stenosis (42, 21%). The ETV Success Score ranged from 10 to 80. The median patient age was 4.1 years. The overall success of postshunt ETV at 6 months was 41%. Only the surgeon's report of a clear view of the basilar artery was associated with a lower likelihood of postshunt ETV failure (HR 0.43, 95% CI 0.23-0.82, p = 0.009). None of the following variables were associated with postshunt ETV success: age at the time of postshunt ETV, etiology of hydrocephalus, sex, race, ventricle size, number of previous shunt operations, ETV performed at time of shunt infection, and use of external ventricular drainage. Overall, complications were reported in 22% of patients, with CSF leak (8.6%) being the most common complication. Postshunt ETV was successful in treating hydrocephalus, without subsequent need for a CSF shunt, in 41% of patients, with a clear view of the basilar artery being the only variable significantly associated with success. Complications occurred in 22% of patients. ETV is an option for treatment of hydrocephalus in children who have previously undergone shunt placement, but with a lower than expected likelihood of success.

Memantine associated with ventricular-subcutaneous shunt promotes behavioral improvement, reduces reactive astrogliosis and cell death in juvenile hydrocephalic rats

Hydrocephalus is defined as the accumulation of cerebrospinal fluid in the brain ventricles. The usual treatment of hydrocephalus is surgical (shunt), but not all patients can undergo treatment immediately after diagnosis. Thus, neuroprotective measures were tested to minimize the tissue damage involved. Memantine is a non-competitive antagonist of the N-methyl-D-aspartate (NMDA) receptor, which has shown a neuroprotective action in neurodegenerative diseases. This study aimed to evaluate the neuroprotective response of memantine in animals treated with or without a ventricular-subcutaneous shunt. Seven-day-old male Wistar rats induced by intracisternal injection of kaolin were used, divided into five groups: intact control (n = 10), hydrocephalic (n = 10), hydrocephalic treated with memantine (20 mg/kg/day) (n = 10), hydrocephalic treated with shunt (n = 10), hydrocephalic treated with shunt and memantine (20 mg/kg/day) (n = 10). Memantine administration was started on the day after hydrocephalus induction and continued until the last day of the experimental period, totaling 21 consecutive days of drug application. The CSF shunt surgery was performed seven days after hydrocephalus induction. Behavioral tests (open field, and modified Morris water maze), histological, and immunohistochemical evaluations were performed. Treatment with memantine resulted in significant improvement (p < 0.05) in sensorimotor development, preservation of spatial memory, reduction of astrocytic reaction in the corpus callosum, cortex, and germinal matrix. When associated with the shunt, it has also been shown to reduce the cell death cascade. It is concluded that memantine is a promising adjuvant drug with beneficial potential for the treatment of lesions secondary to hydrocephalus.

Maneuver protocol for outpatient telemetric intracranial pressure monitoring in hydrocephalus patients

IntroductionTelemetric intracranial pressure measurement (tICPM) offers new opportunities to acquire objective information in shunted and non-shunted patients. The sensor reservoir (SR) provides tICPM modality at a decent sampling rate as an integrated component of the CSF shunt system. The aim of this study is to perform tICPM during a defined protocol of maneuvers in an outpatient setting as feasibility study including either shunt-dependent patients or candidates for possible shunt therapy.MethodsA total of 17 patients received a SR and were investigated within a protocol of maneuver measurements involving different body postures (90°, 10°, 0°, and − 10°), breathing patterns (hypo- and hyperventilation), and mild venous congestion (Valsalva, Jugular vein compression), while the latter two were performed in lying postures (10° and 0°). The cohort included 11 shunted and 6 non-shunted (stand-alone-SR) patients. All measurements were evaluated using an ICP-analysis software (ICPicture, Miethke, Germany) looking at ICP changes and amplitude (AMP) characteristics.ResultsThe shunted patient group consisted of 11 patients (median age: 15.8 years; range: 4–35.2 years) with either a primary shunt (n=9) and 2 patients received a shunt after stand-alone-SR tICPM. Six patients were enrolled with a stand-alone SR (median age 11.9 years, range 3.6–17.7 years). In the stand-alone SR group, maneuver related ICP and AMP changes were more sensitive compared to shunted patients. Postural maneuvers caused significant ICP changes in all body positions in both groups. The highest ICP values were seen during Valsalva maneuver, provoked by the patients themselves. In the stand-alone group, significant higher ICP values during hyperventilation were observed compared to shunted individuals. In shunted patients, a significant correlation between ICP and AMP was observed only during hyperventilation maneuver, while this correlation was additionally seen in Valsalva and jugular vein compression in stand-alone patients.ConclusionSR-related tICPM is helpful to objectify diagnostic evaluation in patients with CSF dynamic disturbances. The defined protocol did result in a wide range of ICP changes with promising potential for effective outpatient tICPM investigation. Since the correlation of ICP and AMP was observed during mild venous congestion maneuvers it appears to be specifically helpful for the evaluation of intracranial compliance. Further investigations of maneuver-related tICPM in a larger population, including variable pathologies, are needed to further establish the protocol in the clinical practice.

Virulence Characteristics and Emerging Therapies for Biofilm-Forming Acinetobacter baumannii: A Review.

Simple SummaryAcinetobacter baumannii (A. baumannii) is one of the ESKAPE organisms and has the competency to build biofilms. These biofilms account for the most nosocomial infections all over the world. This review reflects on the various physicochemical and environmental factors such as adhesion, pili expression, growth surfaces, drug-resistant genes, and virulence factors that profoundly affect its resistant forte. Emerging drug-resistant issues and limitations to newer drugs are other factors affecting the hospital environment. Here, we discuss newer and alternative methods that can significantly enhance the susceptibility to Acinetobacter spp. Many new antibiotics are under trials, such as GSK-3342830, The Cefiderocol (S-649266), Fimsbactin, and similar. On the other hand, we can also see the impact of traditional medicine and the secondary metabolites of these natural products’ application in searching for new treatments. The field of nanoparticles has demonstrated effective antimicrobial actions and has exhibited encouraging results in the field of nanomedicine. The use of various phages such as vWUPSU and phage ISTD as an alternative treatment for its specificity and effectiveness is being investigated. Cathelicidins obtained synthetically or from natural sources can effectively produce antimicrobial activity in the micromolar range. Radioimmunotherapy and photodynamic therapy have boundless prospects if explored as a therapeutic antimicrobial strategy.Acinetobacter species is one of the most prevailing nosocomial pathogens with a potent ability to develop antimicrobial resistance. It commonly causes infections where there is a prolonged utilization of medical devices such as CSF shunts, catheters, endotracheal tubes, and similar. There are several strains of Acinetobacter (A) species (spp), among which the majority are pathogenic to humans, but A. baumannii are entirely resistant to several clinically available antibiotics. The crucial mechanism that renders them a multidrug-resistant strain is their potent ability to synthesize biofilms. Biofilms provide ample opportunity for the microorganisms to withstand the harsh environment and further cause chronic infections. Several studies have enumerated multiple physiological and virulence factors responsible for the production and maintenance of biofilms. To further enhance our understanding of this pathogen, in this review, we discuss its taxonomy, pathogenesis, current treatment options, global resistance rates, mechanisms of its resistance against various groups of antimicrobials, and future therapeutics.

Analysis of the management of ventriculitis cases at a UK neurosurgery centre

SummaryBackgroundVentriculitis is an infection of the ventricular system of the central nervous system associated with neurosurgery and/or indwelling medical devices mainly caused by coagulase-negative staphylococci and increasingly by Gram-negative bacilli and other Gram-positive bacteria. The Infectious Diseases Society of America (IDSA) and the neurosurgery department University Hospital Coventry and Warwickshire (UHCW) have treatment guidelines for ventriculitis which recommend antimicrobials and device removal.MethodsData on ventriculitis cases, their management and outcomes were collected from electronic laboratory and hospital records as well as patients' paper records from 2009 to 2019. Cases included patients with CSF shunts or external ventricular drainage. The management of the cases was then compared to both Infectious Diseases Society of America (IDSA) and UHCW guidelines. The data collected included the causative organisms and the use of inappropriate antimicrobials. The cost of inappropriate antimicrobials was calculated.Results99 patients with microbiologically confirmed ventriculitis were identified. Some cases had multiple devices and the total number of devices was 105.98% of cases had medical device removal as part of their care. Only 50% and 56% of cases had antimicrobial treatment which was compliant with local (UHCW) and IDSA guidelines, respectively. The most frequently inappropriate antimicrobials used were meropenem and linezolid, at an estimated cost of £201,172 over 10 years. The most frequently isolated organisms were coagulase negative staphylococci. Mortality rate was estimated at 14% of cases.ConclusionsWe report the first analysis of the management of ventriculitis cases at UHCW over a 10-year period and demonstrate the importance of antimicrobial stewardship. We also report the local epidemiology of causes of ventriculitis at UHCW which will guide the empirical treatment of ventriculitis at UHCW.

Cerebrospinal fluid shunting protocol for idiopathic intracranial hypertension for an improved revision rate.

Cerebrospinal fluid (CSF) shunting in idiopathic intracranial hypertension (IIH) is associated with high complication rates, primarily because of the technical challenges that are related to small ventricles and a large body habitus. In this study, the authors report the benefits of a standardized protocol for CSF shunting in patients with IIH as relates to shunt revisions. This was a retrospective study of consecutive patients with IIH who had undergone primary insertion of a CSF shunt between January 2014 and December 2020 at the authors' hospital. In July 2019, they implemented a surgical protocol for shunting in IIH. This protocol recommended IIH shunt insertion by neurosurgeons with expertise in CSF disorders, a frontal ventriculoperitoneal (VP) shunt with an adjustable gravitational valve and integrated intracranial pressure monitoring device, frameless stereotactic insertion of the ventricular catheter, and laparoscopic insertion of the peritoneal catheter. Thirty-day revision rates before and after implementation of the protocol were compared in order to assess the impact of standardizing shunting for IIH on shunt complications. The 81 patients included in the study were predominantly female (93%), with a mean age of 31 years at primary surgery and mean body mass index (BMI) of 37 kg/m2. Forty-five patients underwent primary surgery prior to implementation of the protocol and 36 patients after. Overall, 12 (15%) of 81 patients needed CSF shunt revision in the first 30 days, 10 before and 2 after introduction of the protocol. This represented a significant reduction in the early revision rate from 22% to 6% after the protocol (p = 0.036). The most common cause of shunt revision for the whole cohort was migration or misplacement of the peritoneal catheter, occurring in 6 of the 12 patients. Patients with a higher BMI were significantly more likely to have a shunt revision within 30 days (p = 0.022). The Birmingham standardized IIH shunt protocol resulted in a significant reduction in revisions within 30 days of primary shunt surgery in patients with IIH. The authors recommend standardization for shunting in IIH as a method for improving surgical outcomes. They support the notion of subspecialization for IIH shunts, the use of a frontal VP shunt with sophisticated technology, and laparoscopic insertion of the peritoneal end.

The Hydrocephalus Clinical Research Network quality improvement initiative: the role of antibiotic-impregnated catheters and vancomycin wound irrigation.

Two previous Hydrocephalus Clinical Research Network (HCRN) studies have demonstrated that compliance with a standardized CSF shunt infection protocol reduces shunt infections. In this third iteration, a simplified protocol consisting of 5 steps was implemented. This analysis provides an updated evaluation of protocol compliance and evaluates modifiable shunt infection risk factors. The new simplified protocol was implemented at HCRN centers on November 1, 2016, for all shunt procedures, excluding external ventricular drains, ventricular reservoirs, and subgaleal shunts. Procedures performed through December 31, 2019, were included (38 months). Compliance with the protocol, use of antibiotic-impregnated catheters (AICs), and other variables of interest were collected at the index operation. Outcome events for a minimum of 6 months postoperatively were recorded. The definition of infection was unchanged from the authors' previous report. A total of 4913 procedures were performed at 13 HCRN centers. The overall infection rate was 5.1%. Surgeons were compliant with all 5 steps of the protocol in 79.4% of procedures. The infection rate for the protocol alone was 8.1% and dropped to 4.9% when AICs were added. Multivariate analysis identified having ≥ 2 complex chronic conditions (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.26-2.44, p = 0.01) and a history of prior shunt surgery within 12 weeks (OR 1.84, 95% CI 1.37-2.47, p < 0.01) as independent risk factors for shunt infection. The use of AICs (OR 0.70, 95% CI 0.50-0.97, p = 0.05) and vancomycin irrigation (OR 0.36, 95% CI 0.21-0.62, p < 0.01) were identified as independent factors protective against shunt infection. The authors report the third iteration of their quality improvement protocol to reduce the risk of shunt infection. Compliance with the protocol was high. These updated data suggest that the incorporation of AICs is an important, modifiable infection prevention measure. Vancomycin irrigation was also identified as a protective factor but requires further study to better understand its role in preventing shunt infection.

Duration of Antibiotic Therapy and Timing of Shunt Reimplantation in Pediatric CSF Shunt Infections: A Retrospective Multicenter Case Series.

In this retrospective multicenter series of 154 children with cerebrospinal fluid shunt infections, the median (interquartile range) duration of antibiotic therapy was 18 (14-26) days. The time to shunt replacement was 14 (10-19) days. Management appeared to potentially differ according to the targeted pathogen and site.

Neurosurgical management of patients with neurocutaneous melanosis: a systematic review.

Neurocutaneous melanocytosis (NCM), also referred to as neurocutaneous melanosis, is a rare neurocutaneous disorder characterized by excess melanocytic proliferation in the skin, leptomeninges, and cranial parenchyma. NCM most often presents in pediatric patients within the first 2 years of life and is associated with high mortality due to proliferation of melanocytes in the brain. Prognosis is poor, as patients typically die within 3 years of symptom onset. Due to the rarity of NCM, there are no specific guidelines for management. The aims of this systematic review were to investigate approaches toward diagnosis and examine modern neurosurgical management of NCM. A systematic review was performed using the PubMed database between April and December 2021 to identify relevant articles using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Search criteria were created and checked independently among the authors. Inclusion criteria specified unique studies and case reports of NCM patients in which relevant neurosurgical management was considered and/or applied. Exclusion criteria included studies that did not report associated neurological diagnoses and neuroimaging findings, clinical reports without novel observations, and those unavailable in the English language. All articles that met the study inclusion criteria were included and analyzed. A total of 26 extracted articles met inclusion criteria and were used for quantitative analysis, yielding a cumulative of 74 patients with NCM. These included 21 case reports, 1 case series, 2 retrospective cohort studies, 1 prospective cohort study, and 1 review. The mean patient age was 16.66 years (range 0.25-67 years), and most were male (76%). Seizures were the most frequently reported symptom (55%, 41/74 cases). Neurological diagnoses associated with NCM included epilepsy (45%, 33/74 cases), hydrocephalus (24%, 18/74 cases), Dandy-Walker malformation (24%, 18/74 cases), and primary CNS melanocytic tumors (23%, 17/74 cases). The most common surgical technique was CSF shunting (43%, 24/56 operations), with tethered cord release (4%, 2/56 operations) being the least frequently performed. Current management of NCM includes CSF shunting to reduce intracranial pressure, surgery, chemotherapy, radiotherapy, immunotherapy, and palliative care. Neurosurgical intervention can aid in the diagnosis of NCM through tissue biopsy and resection of lesions with surgical decompression. Further evidence is required to establish the clinical outcomes of this rare entity and to describe the diverse spectrum of intracranial and intraspinal abnormalities present.

Number of surgeries performed during the lifetime of patients with myelomeningocele.

Patients with myelomeningocele often require multiple surgeries, but no study has clarified the kind of treatment given to these patients throughout their lives. The authors analyzed the type of surgery that was performed and at what age for Japanese patients with myelomeningoceles. The Japanese health claims data of 556 patients with myelomeningocele for the period from January 2005 to March 2020 provided by the Japan Medical Data Center Co., Ltd., were examined to investigate the number of surgeries performed and the patient age at surgery for each specialty. The patients were divided into two groups (those ≤ 18 years old [group A] and those > 18 years old [group B]), and the way in which the types of surgery and the percentage of surgeries changed between these two groups was examined. The mean follow-up period was 4.4 years. The mean age at the end of the overall follow-up was 18.6 years (range 0-70.5 years), and 1033 surgeries were performed on 294 patients (0.42 surgeries performed per patient per year) during this period. The number of surgeries for patients in group A was 818 in 192 patients, with 0.62 surgeries per patient per year, and for patients in group B it was 215 in 102 patients, with 0.19 surgeries per patient per year. The number of surgeries and the mean age at the time of surgery were as follows: 313 neurosurgeries, 5.16 years; 280 orthopedic surgeries, 11.36 years; 70 urological surgeries, 14.57 years; and 202 dermatological/plastic surgeries, 16.19 years. In the surgeries related to myelomeningocele, the rates of CSF shunt placement, tethered cord release, muscle and tendon surgery, and other bone and joint surgery decreased significantly in group B, but they continued to undergo these surgeries. In group B, the rates of skin surgery, nephrostomy, ureterostomy, and cystostomy were significantly higher. A significant number of surgeries in multiple specialties related to myelomeningocele continue to be performed in adulthood, indicating that these patients require continuous care throughout their lives.

Endoscopic ultrasonic aspiration as alternative to more invasive surgery in initial management of optic pathway gliomas in children.

Optic pathway gliomas (OPGs) presenting with acute hydrocephalus represent a true neurosurgical and neurooncological challenge. Two main strategies are currently used: microsurgical removal of the tumor, restoring CSF pathways, and endoscopic biopsy associated with ventriculo-peritoneal shunt implantation. Since the availability of an ultrasonic aspirator handpiece, that can be used inside the working channel of a neuroendoscope, a different less invasive surgical strategy can be used. Four pediatric patients were treated by endoscopic ultrasonic aspiration, in order to remove the upper pole of the tumor, obtaining tissue for diagnosis and restoring CSF pathways as initial treatment of OPG invading the third ventricle and causing hydrocephalus due to simultaneous blockage of both Monro foramina and of the Sylvian aqueduct. Surgical technique is described. Pre-operative and post-operative volumes were calculated on magnetic resonance imaging. In all cases, the surgical procedure was uneventful, the biopsy was diagnostic, and CSF pathways were restored. The amount of tumor removed ranged between 31 and 76%. All patients underwent oncological treatment of their tumors. One patient received V-P shunt only 1year after endoscopic decompression due to tumor progression. Our preliminary results show that the use of endoscopic cavitron aspirator is safe and effective to obtain CSF flow restoration and tumor biopsy (for histological and molecular purposes), avoiding CSF shunt implant in the acute phase and offering the chance to obtain a consistent tumor debulking in a minimally invasive fashion. Neuroendoscopic approach together with modern target therapy offers the opportunity to avoid or delay major surgery.

Anterior versus posterior entry site for ventriculoperitoneal shunt insertion: a randomized controlled trial by the Hydrocephalus Clinical Research Network.

The primary objective of this trial was to determine if shunt entry site affects the risk of shunt failure. The authors performed a parallel-design randomized controlled trial with an equal allocation of patients who received shunt placement via the anterior entry site and patients who received shunt placement via the posterior entry site. All patients were children with symptoms or signs of hydrocephalus and ventriculomegaly. Patients were ineligible if they had a prior history of shunt insertion. Patients received a ventriculoperitoneal shunt after randomization; randomization was stratified by surgeon. The primary outcome was shunt failure. The planned minimum follow-up was 18 months. The trial was designed to achieve high power to detect a 10% or greater absolute difference in the shunt failure rate at 1 year. An independent, blinded adjudication committee determined eligibility and the primary outcome. The study was conducted by the Hydrocephalus Clinical Research Network. The study randomized 467 pediatric patients at 14 tertiary care pediatric hospitals in North America from April 2015 to January 2019. The adjudication committee, blinded to intervention, excluded 7 patients in each group for not meeting the study inclusion criteria. For the primary analysis, there were 229 patients in the posterior group and 224 patients in the anterior group. The median patient age was 1.3 months, and the most common etiologies of hydrocephalus were postintraventricular hemorrhage secondary to prematurity (32.7%), myelomeningocele (16.8%), and aqueductal stenosis (10.8%). There was no significant difference in the time to shunt failure between the entry sites (log-rank test, stratified by age < 6 months and ≥ 6 months; p = 0.061). The hazard ratio (HR) of a posterior shunt relative to an anterior shunt was calculated using a univariable Cox regression model and was nonsignificant (HR 1.35, 95% CI, 0.98-1.85; p = 0.062). No significant difference was found between entry sites for the surgery duration, number of ventricular catheter passes, ventricular catheter location, and hospital length of stay. There were no significant differences between entry sites for intraoperative complications, postoperative CSF leaks, pseudomeningoceles, shunt infections, skull fractures, postoperative seizures, new-onset epilepsy, or intracranial hemorrhages. This randomized controlled trial comparing the anterior and posterior shunt entry sites has demonstrated no significant difference in the time to shunt failure. Anterior and posterior entry site surgeries were found to have similar outcomes and similar complication rates.

135 Natural History of Midline Brain Shift Following Hemispherectomy and its Association with Cerebral Spinal Fluid Diversion in Pediatric Epilepsy

INTRODUCTION: Hemispherectomy and its modern variants are effective surgical treatments for medically intractable unihemispheric epilepsy. While complications of hemispherectomy such as postoperative hydrocephalus are well documented, a less-studied phenomenon of postoperative midline brain shift (MLBS) has only been described anecdotally and never formally studied. METHODS: A retrospective review of consecutive pediatric patients who underwent hemispherectomy for medically refractory epilepsy at UCLA between 1994 and 2018 was performed. Patients were stratified by severity of MLBS, shunt placement, type of shunt valve, and opening pressure. MLBS progression was evaluated within groups using repeated measures ANOVA and compared between groups using ANCOVA while adjusting for follow-up time and baseline postoperative MLBS. RESULTS: In total, 97 patients with a median follow-up of 17.7 months were analyzed in this study. Of these patients, 27 (28%) required CSF diversion via shunt placement in the ipsilateral cavity for post-hemispherectomy hydrocephalus. In non-shunted patients, average MLBS immediately following hemispherectomy and at last follow-up was 4.8 ± 4.7 and 8.3±6.4 mm, respectively. In shunted patients, average MLBS immediately after hemispherectomy and at latest follow-up following shunt placement was 6.5 ± 3.3 and 14.6 ± 9.5 mm, respectively. MLBS increased for both shunted and non-shunted patients between first and last follow-up. However, MLBS progression between first and last follow-up was significantly greater in the shunted cohort than the non-shunted cohort [F (1,92) = 5.33, p = 0.023]. Placement of valves with higher opening pressure settings did not significantly increase MLBS relative to non-shunted patients [F (1,73) = 0.1, p = 0.765], whereas MLBS was significantly greater with low opening pressure settings [F (1,85) = 8.5, p = 0.004]. Furthermore, severe MLBS was significantly associated with debilitating headaches (p = 0.042). CONCLUSION: Patients undergoing hemispherectomy often develop postoperative MLBS. The progression of MLBS is significantly exacerbated by CSF shunting of the ipsilateral post-surgical cavity, specifically when accomplished with lower opening pressure settings. Severe MLBS is associated with severe headaches, suggesting that MLBS exacerbation may be related to overshunting.