Early Shunt Research Articles

An aberrant metabolic flow toward early shunt products in the granaticin biosynthetic machinery of Streptomyces vietnamensis GIMV4.0001.

A systematic study of the secondary metabolites of the wild granaticin-producing strain Streptomyces vietnamensis GIMV4.0001 led to the isolation of six known early shunt products related to actinorhodin, SEK34 (3), SEK34b (4), mutactin (5), dehydromutactin (7), EM18 (8) and GTRI-02 (9). While the other shunt products were minor or trace products, the production ratio of SEK34 (3) and SEK34b (4) to granaticins was strikingly high. Nearly 64% of the intermediate with the first ring closed went to the SEK34/SEK34b aberrant pathway. The high level of the aberrant metabolic flow toward the early shunt products SEK34 and SEK34b indicated that the second ring closure of the granaticin (1) biosynthesis is a key limiting step in the granaticin biosynthetic machinery of S. vietnamensis GIMV4.0001.

Utility of dynamic MRA in the evaluation of male erectile dysfunction.

To assess the efficacy of time-resolved MR angiography (MRA) in evaluating penile vasculature in patients with clinically suspected vascular anomalies contributing to their erectile dysfunction correlating with penile doppler ultrasound (PDUS) findings and clinical outcomes after surgical intervention. Men (n = 26) with signs of early vascular shunting on PDUS underwent time-resolved, contrast-enhanced (0.1mMol/kg gadobutrol at 1ml/s followed by saline flush) 3-dimensional spoiled gradient echo T1-weighted MRA sequence performed over 3min with 4.6s frame rate after intracavernosal injection of an erectogenic agent. Additional T1- and T2-weighted sequences were performed for anatomic co-localization and tissue characterization. MRA images were evaluated for early filling of draining veins as well as arteriovenous malformations and fistulas and correlated with findings at surgery. 29 MRA examinations on 26 patients (mean age 39years) demonstrated abnormal early venous drainage (n = 22) as well as diminutive/delayed cavernosal enhancement (n = 3), incomplete tumescence (n = 2), and combined arterial inflow/venous outflow disease (n = 1). The MRA had a concordance of 85.2% at determining the presence, or lack thereof of a shunt/AVM when compared to PDUS. Time-resolved MRA allows for both temporal and spatial resolution with visualization of both arterial and venous abnormalities which may be suggested with a screening PDUS examination. This technique allows us to provide detailed anatomic information prior to any surgical intervention.

Hemodynamic of the patent ductus arteriosus in neonates with modified Blalock-Taussig shunts

Background and objectiveStudying the hemodynamic effects of nonclosure of patent ductus arteriosus (PDA) on the modified Blalock-Taussig shunt (MBTS) is beneficial for surgical PDA management. In the present study, the effect of PDA on MBTS was investigated numerically. A series of parameters including energy loss, wall shear stress (WSS), and left/right Pulmonary artery (LPA/RPA) flow ratio were computed from simulations to analyze the hemodynamic effects of PDA on MBTS. MethodsTo ensure the universality of the research conclusions, three typical models, including models with a well-developed RPA, a symmetrically-developed pulmonary artery(PA) and a well-developed LPA, were constructed based on patient-specific pre-surgery clinical data sets. A commercial CFD solver ANSYS-Fluent software was adopted for this study. A pressure-based solver for incompressible Newtonian flows, the K-omega based shear-stress-transport model and a second-order accurate numerical discretization scheme were employed for simulation. ResultsOur results show that MBTS with nonclosure of PDA is accompanied by lower blood velocity, energy loss and WSS values at the MBT shunt; smaller vortex regions; higher oxygen content(Sao2) and PA flow; and more uniform velocity distribution in the LPA and RPA than MBTS with closure of PDA. If the PDA was not closed when performing primary MBTS, a series of hemodynamic changes occurs during PDA closure in postoperative recovery: the energy loss, PA flow and Sao2 decrease, while the oxygen delivery(Do2) and WSS values at the MBT shunt increase. ConclusionNonclosure of PDA could provide a better hemodynamic environment and play an active role in preventing early acute shunt failure. It could be preferred for cases with very low PA overflow risk and may benefit patients with an underdeveloped myocardium due to its lower energy dissipation than PDA closure. However, excessive PA flow induced by nonclosure of PDA may result in a series of complications. Surgeon's decision-making process with respect to PDA management should consider the individual patient to achieve optimal postoperative recovery.

Rate and Risk Factors of Early Ventriculoperitoneal Shunt Revision: A Five-Year Retrospective Analysis of a Referral Center

Cerebral shunts are the mainstay treatment of hydrocephalus. Because most previous studies have focused on factors related to long-term outcomes of shunt surgery, we aimed to assess the rates and causes of 30-day ventriculoperitoneal shunt (VPS) failure in a single referral center over 5 years in both adult and pediatric patients. Patients who underwent VPS surgery from February 2012 to February 2017 in Ghaem Teaching Hospital, Mashhad, Iran were evaluated retrospectively through clinical history, operative reports, imaging studies, and follow-up notes. Data of 12 possible factors related to shunt failure were collected comprising age, gender, household income, level of education, cause of hydrocephalus, causes of revision, type of failure, anatomic site, duration of operation, time of surgery, surgeons' level of expertise, and Glasgow Coma Scale (GCS) score. Among 403 VPS placements, 121 VPS revisions were performed, and 82 eligible patients were included in the study (57.3% male and 42.7% female). The 30-day shunt failure rate was 24.4% among all revisions. Obstruction and malposition were the most common causes of early revisions. Six factors were statistically significant in the univariate analysis. After adjustment in a logistic regression model, 2 factors, namely surgeons' level of expertise (odds ratio, 10.33; 95% confidence interval, 1.08-98.80) and anatomic site of the shunt (odds ratio, 10.28; 95% confidence interval, 1.21-87.35) were associated with early shunt revision. Shunt surgeries performed by junior residents and shunts placed in the frontal site were associated with early shunt failure.

Progressive hydrocephalus despite early complete reversal of hindbrain herniation after prenatal open myelomeningocele repair.

Open prenatal myelomeningocele (MMC) repair is typically associated with reversal of in utero hindbrain herniation (HBH) and has been posited to be associated with a reduction in both postoperative prenatal and immediate postnatal hydrocephalus (HCP) risks. However, the long-term postnatal risk of HCP following HBH reversal in these cases has not been well defined. The authors describe the results of a long-term HCP surveillance in a cohort of patients who underwent prenatal MMC repair at their institution. A retrospective review of all prenatal MMC repair operations performed at the Mayo Clinic between 2012 and 2017 was conducted. Pertinent data regarding the clinical courses of these patients before and after MMC repair were summarized. Outcomes of interest were occurrences of HBH and HCP and the need for intervention. A total of 9 prenatal MMC repair cases were identified. There were 7 cases in which MRI clearly demonstrated prenatal HBH, and of these 86% (6/7) had evidence of HBH reversal after repair and prior to delivery. After a mean postnatal follow-up of 20 months, there were 3 cases of postnatal HCP requiring intervention. One case that failed to show complete HBH reversal after MMC repair required early ventriculoperitoneal shunting. The other 2 cases were of progressive, gradual-onset HCP despite complete prenatal HBH reversal, requiring endoscopic third ventriculostomy with choroid plexus cauterization at ages 5 and 7 months. Although prenatal MMC repair can achieve HBH reversal in a majority of well-selected cases, the prevention of postnatal HCP requiring intervention appears not to be predicated on this outcome alone. In fact, it appears that in a subset of cases in which HBH reversal is achieved, patients can experience a progressive, gradual-onset HCP within the 1st year of life. These findings support continued rigorous postnatal surveillance of all prenatal MMC repair patients, irrespective of postoperative HBH outcome.

Standardized Approach to Intervention for Intestinal Malrotation in Single Ventricle Patients with Heterotaxy Syndrome: Impact on Interstage Attrition and Time to Superior Cavopulmonary Connection.

Heterotaxy syndrome (HS) is a significant determinant of outcome in single ventricle (SV) physiology. Attrition rate and time-related events associated with intestinal malrotation (IM) are, yet, to be determined. We sought to evaluate hospital and interstage outcomes in relation with operative intervention for IM (IMO). Twelve SV/HS patients, who underwent IMO, from January 2004 to December 2016, were studied. Early shunt failure, time to superior cavopulmonary connection (SCPC) and interstage attrition were assessed. Since September 2014, based on a comprehensive standardized protocol, IMO was performed at the time of hospitalization for stage-I palliation (S1P) irrespective of clinical manifestations. Patients were assigned to Group A (n = 8): expectant /symptoms-driven versus Group B (n = 4): protocol-driven. At S1P 7 had systemic-to-pulmonary shunt (SPS), 1 SPS with anomalous pulmonary venous return (APVR) repair (Group A) compared to 2 SPS, 1 SPS with APVR repair and 1 Norwood operation (Group B). Median duration from S1P to IMO was 82days (range 57-336; Group A) compared to 14days (range 11-31; Group B); p < 0.05. Median age at IMO was 87days (range 8-345) [Group A: 99days (range 68-345) vs Group B: 25days (range 8-39)] (p < 0.05). Early SPS failure occurred in 25% (2 of 8) for Group A compared to none in Group B (p < 0.05). Hospital mortality following IMO was 25% [Group A: 37.5% (3 of 8) vs Group B: 0; p < 0.05]. Interstage survival was 67% [Group A: 50% (4 of 8) vs Group B: 100%; p < 0.05]. Time to SCPC following S1P was 186days (range 169-218) for Group A compared to 118days (range 97-161) (Group B); p < 0.05. Operative intervention for IM in SV/HS is associated with significant interstage attrition and might impact the time to SCPC. SPS is at risk for early failure after IMO. A comprehensive standardized concept can mitigate detrimental implications.

Child-Pugh Classification: Time to Abandon?

The Child-Pugh classification is one of the commonest and oldest bedside tools utilized in estimating prognosis in patients with cirrhosis. However, its usage as a risk prediction tool or indeed a decision-making tool should be revisited. In this review, we discuss some inherent issues with the Child-Pugh classification and present a few contexts in which the current usage of Child-Pugh warrants reassessment, elaborating on its utility in acute variceal bleeding, specifically its role in decision-making on early transjugular intrahepatic portosystemic shunt, as well as its use in the context of hepatocellular carcinoma and drug development and dose adjustment.

Introduction of a self-holding retractor for optimized abdominal visualization in ventriculoperitoneal shunt surgery: first experiences at a single center.

Ventriculoperitoneal shunt implantation is a common procedure in general neurosurgery. The patient population is often fragile, ranging from elderly to pediatric patients, and avoidance of perioperative complication is of utmost importance. Abdominal catheter dislocation has been found to be a common cause for early shunt dysfunction and needs to be avoided by optimal visualization of the abdominal catheter insertion zone. Here, we introduce a self-holding wound retractor system Alexis® and demonstrate its use for abdominal shunt surgery in a series of patients. We explain the use of the Alexis® self-holding wound retractor during open ventriculoperitoneal shunt surgery in a series of 16 patients operated at our institution. The self-holding retractor consists of two polymer rings connected by a polymer membrane. The deep ring is easily placed on the internal fascia of the straight muscle and circular retraction is achieved by twisting the upper ring. Free hand working can then be performed by a single surgeon with good abdominal exposure. No case of abdominal dislocation or infection occurred in our series, although no properly powered statistical analysis can be performed regarding the sample size. We demonstrate the Alexis® Wound Retractor, which is an easy tool for optimal visualization of the abdominal catheter insertion zone. We believe it can facilitate surgical practice of shunt surgery, especially in obese patients.

The Association between the Timing of Shunt Placement and Shunt Infection in Hydrocephalus Associated with Myelomeningocele.

To determine whether the timing of shunt placement affects shunt infection rate in hydrocephalus associated with myelomeningocele (MMC). The cases of 67 consecutive patients who underwent MMC repair and ventriculoperitoneal (VP) shunt placement between 2010 and 2017 were analyzed, retrospectively. Shunt infection rates were compared for three different approaches: simultaneous shunting (MMC repair and shunting in the same session; n=22), early shunting (shunting in the first week after MMC repair; n=21), and delayed shunting (shunting in the second week after MMC repair; n=24). Three patients in the simultaneous shunting group (13.6%) and two patients in the early shunting group (9.5%) developed shunt infection, whereas no such infections occurred in the delayed shunting group (p > 0.05). While the shunt infection rates for the simultaneous, early and delayed shunting groups were not significant, it is of interest that no shunt infections occurred in the delayed shunting group. Investigation with a larger number of patients is warranted to assess whether delayed shunting might reduce the risk of shunt infection.

Pseudotumor cerebri controlled with ventriculo-peritoneal shunt as a rare complication of ROHHAD syndrome: a case report

Background: rapid-onset obesity with hypoventilation, hypothalamic dysfunction and autonomic dysregulation (ROHHAD) is a rare yet possibly fatal condition. It is similar to common obesity syndromes (whether exogenous or genetic) sideways with other endocrinopathy in early childhood. Objective of the study: this study aimed to present the clinical manifestations, laboratory and imaging results as well as complications and treatment particularly for ventriculo-peritoneal shunt for a ROHHAD patient with pseudotumor cerebri. Patient and methods: in this case report, a 10-year-old girl was presented to the emergency department with recurrent episodes of dyspnea, hypernatremia and cyanosis. Results: her obesity was controlled with sleeve surgery and hormonal evaluation showed high prolactin level and hypothyroidism. She continued to have symptomatic hypoventilation and severe Pseudo-Tumor Cerebri (PTC), idiopathic intracranial hypertension (IIH), in addition to significant reduction in her visual acuity. She was diagnosed with ROHHAD syndrome based on the clinical, laboratory and radiological findings. Brain and abdominal magnetic resonance imaging were performed to demonstrate a possible accompanying neural crest tumor, which was normal, but follow-up images were recommended. Conclusion: ROHHAD syndrome should be suspected in all cases of rapid onset obesity associated with hypothalamic-pituitary endocrine dysfunction. Also provided the high prevalence of cardiorespiratory arrest and potentially associated neural crest tumors, early recognition of ROHHAD syndrome is quite crucial to avert mortality and morbidity. Moreover, Early ventriculoperitoneal shunt insertion might be a lifesaving procedure to avoid visual impairment and subsequent blindness in severe pseudotumor cerebri.

Microarteriovenous Malformations-Value of Indocyanine Green Fluorescence and Nuances of Surgical Excision: 2-Dimensional Operative Video.

MicroAVMs (microarteriovenous malformation) are arteriovenous shunts with a nidus smaller than 1 centimeter.1 They are typically diagnosed after hemorrhage. When the nidus is very small, diagnosis can be challenging even on catheter angiography and careful examination of the arterial and capillary phases is required to identify the early shunt. Because of the very small size, identification and localization of the actual AV shunt can be problematic during surgical exploration. Advances in frameless stereotactic neuronavigation and the introduction of intraoperative indocyanine green (ICG) fluorescein provide useful adjuncts in the surgical treatment of these relatively uncommon lesions. In this video, we present 2 cases which document the value of intraoperative ICG fluorescein as well as some of the surgical pitfalls in the treatment of these lesions.

Model for end-stage liver disease score and hemodynamic instability as a predictor of poor outcome in early transjugular intrahepatic portosystemic shunt treatment for acute variceal hemorrhage.

To evaluate the outcome of early transjugular portosystemic shunt (TIPS) treatment in patients with a trial-compatible high-risk variceal bleeding and secondly to disclose other predictors of early mortality. A cohort study was conducted on patients referred for a TIPS procedure with or without combined variceal embolization to control acute esophageal variceal bleeding. A total of 32 patients with Child-Pugh C score less than 14 or Child-Pugh B plus active bleeding at endoscopy, admitted for early-TIPS treatment (<72 h), were included. We noted one (3.7%) failure to control bleeding and no rebleeding during 1-year follow-up. Ten (31.3%) patients died within 6 weeks after TIPS placement. Early mortality was associated with model for end-stage liver disease (MELD) score (P=0.025), MELD score of at least 19 (P=0.008) and hemodynamic instability at time of admission (P=0.001). If hemodynamic instability is associated with a high MELD score, the 6-week mortality peaks at 77.8% (P=0.000). This study confirms the excellent survival results of early-TIPS treatment for acute variceal bleeding in a selected patient group with a low MELD score. Poor survival in hemodynamically unstable patients with high MELD scores (≥19) contests the guidelines that patients with Child-Pugh class C cirrhosis or Child-Pugh class B with active bleeding on endoscopy should deliberately receive preemptive TIPS treatment after endoscopic haemostasis.

Outcomes after placement of a SX‐ELLA oesophageal stent for refractory variceal bleeding—A national multicentre study

BackgroundCurrent guidelines favour the use of bleeding stents over balloon tamponade (BT) for refractory variceal bleeding (VB) from oesophageal varices. However, data on the efficacy and safety of self‐expandable metal SX‐ELLA Danis stents (SEMS) are limited.MethodsCirrhotic patients receiving SEMS for VB at four tertiary care centres were included in this retrospective multicentre study. Rates of failure‐to‐control bleeding (within 5 days) and bleeding‐related mortality (6 weeks) were assessed.ResultsSEMS controlled VB in 79.4% (27/34) of patients. In the rest of patients, other rescue treatments including endoscopic band ligation (EBL, n = 3), SEMS renewed (n = 2) or Linton (n = 2) were applied; however, VB was only controlled in one patient. Early rebleeding within six weeks occurred in 17.6% (6/34) patients. Median SEMS dwell time was three (IQR:6) days. Overall n = 13/34 (38.2%) patients died with SEMS in situ. After SEMS removal, rebleeding and bleeding‐related death occurred in n = 7 (35%) and n = 5 (14.7%) patients respectively. Only 32.4% (10/34) patients did not experience any rebleeding within six weeks after SEMS removal. Bleeding‐related mortality was 47.1% (n = 16/34) and the median survival after SEMS placement was 2.1 months. Notably, no patient received an early transjugular intrahepatic portosystemic shunt (TIPS). The most common adverse events were stent dislocations (n = 13; 38.2%), while ulcers/necrosis of the oesophageal mucosa was seen in only four (11.8%) patients.ConclusionSEMS controlled refractory VB in most patients. However, bleeding‐related mortality remained high. While SEMS dislocations were frequent, ulcers/necrosis of the oesophagus was rare. Further studies should investigate whether the wider use of early TIPS reduces bleeding‐related mortality after SEMS placement.

Early Transjugular Intrahepatic Portosystemic Shunt Creation Compared to Endoscopy With Pharmacotherapy in the Management of Variceal Rebleeding in Cirrhotic Patients: A Comprehensive Systematic Review and Meta-Analysis: Presidential Poster Award

Introduction: The use of early or rescue transjugular intrahepatic portosystemic shunt (TIPS) has been evaluated in cirrhotic patients with a history of variceal bleeding. In this study, we aimed to perform a systematic review and meta-analysis of studies investigating the efficacy and safety of early TIPS in the management of variceal bleeding as well as comparing the use of early compared to rescue TIPS. Methods: Medical electronic databases were queried for clinical studies in which TIPS creation was compared with endoscopy and pharmacotherapy treatment in cirrhotic patients with a history of variceal bleeding. Search results were screened against predefined eligibility criteria and data were extracted to a standard data extraction form. Meta-analysis was performed using Comprehensive Meta-Analysis software and the risk of bias of included studies was assessed using the Cochrane tool and modified Newcastle-Ottawa scale Results: Thirty-four studies that enrolled 2876 cirrhotic patients (n=1453 in the TIPS group and n=1423 in the endoscopy with pharmacotherapy group) were included. Overall analysis displayed significantly reduced re-bleeding, odds ratio (OR) = 0.29, 95% confidence interval (CI) [0.22-0.38], p< 0.0001) and bleeding-related death (OR= 0.28, 95% CI [0.18-0.44], p< 0.0001) in the TIPS group. There was no significant difference in all-cause mortality between all TIPS and endoscopy with pharmacotherapy (OR= 0.93, 95% CI [0.74-1.16], p= 0.52) and there was an increased incidence of hepatic encephalopathy (OR= 1.80, 95% CI [1.41-2.28], p< 0.0001) in the TIPS group (pooled analysis of both early and rescue TIPS). Early use of TIPS did not reveal any differences in hepatic encephalopathy (OR= 1.27, 95% CI [0.9-1.7], p= 0.13) and showed a decreased mortality in high risk patients (Child-Pugh class C, Child-Pugh class B with active bleeding at endoscopy, and hepatic venous pressure gradient [HVPG] ≥20 mm Hg) when compared to rescue TIPS. Conclusion: TIPS creation decreases rebleeding at the cost of increased hepatic encephalopathy with no survival benefit. Early TIPS creation may confer better clinical outcomes in terms of comparable hepatic encephalopathy and improved survival in high-risk patients when compared to rescue TIPS.

Citrofulvicin, an Antiosteoporotic Polyketide from Penicillium velutinum.

Citrofulvicin (1), along with its early shunt product fulvionol (2), was characterized as a skeletally unprecedented antiosteoporotic agent from a human sputum-derived fungus Penicillium velutinum. The unique citrofulvicin framework is likely formed by a nonenzymatic intermolecular Diels-Alder cycloaddition between heptaketide-based intermediates. Citrofulvicin and fulvionol were demonstrated to be osteogenic at 0.1 μM in the prednisolone-induced osteoporotic zebrafish.

Predictors of hydrocephalus as a complication of non-traumatic subarachnoid hemorrhage: a retrospective observational cohort study in 107 patients

BackgroundThe predictors of shunt dependency such as amount of subarachnoid blood, acute hydrocephalus (HC), mode of aneurysm repair, clinical grade at admission and cerebro spinal fluid (CSF) drainage in excess of 1500 ml during the 1st week after the subarachnoid hemorrhage (SAH) have been identified as predictors of shunt dependency. Therefore our main objective is to identify predictors of CSF shunt dependency following non-traumatic subarachnoid hemorrhage.MethodsWe performed a retrospective study including patients from January 1st 2012 to September 30th 2014 between 16 and 89 years old and had a non-traumatic subarachnoid hemorrhage in cranial computed tomography (CCT). We excluded patients with the following characteristics: Patients who died 3 days after admittance, lesions in brainstem, previous surgical treatment in another clinic, traumatic brain injury, pregnancy and disability prior to SAH.We performed a descriptive and comparative analysis as well as a logistic regression with the variables that showed a significant difference (p < 0.05). Hence we identified the variables concerning HC after non traumatic SAH and its correlation.ResultsOne hundred and seven clinical files of patients with non-traumatic SAH were analyzed. Twenty one (48%) later underwent shunt treatment. Shunt patients had significantly clinical and corroborated with doppler ultrasonography vasospasmus (p = 0.015), OR = 5.2. The amount of subarachnoidal blood according to modified Fisher grade was (p = 0.008) OR = 10.9. Endovascularly treated patients were less often shunted as compared with those undergoing surgical aneurysm repair (p = 0.004).ConclusionVasospasmus and a large amount of ventricular blood seem to be a predictor concerning hydrocephalus after non-traumatic SAH. Hence according to our results the presence of these two variables could alert the treating physician in the decision whether an early shunt implantation < 7 days after SAH should be necessary.

Cardiopulmonary Bypass Reduces Early Thrombosis of Systemic-to-Pulmonary Artery Shunts.

Shunt thrombosis is a significant cause of morbidity and mortality after systemic-to-pulmonary artery shunt (SPS) placement. Concurrent procedures with placement of SPS may require cardiopulmonary bypass (CPB). Cardiopulmonary bypass is known to cause bleeding and platelet dysfunction in infants, which may protect from early shunt thrombosis. We hypothesized that infants undergoing SPS placement on CPB have a lower incidence of early shunt thrombosis. Retrospective cohort study of infants undergoing SPS placement from January 2008 to December 2014 was performed. Patients with and without early shunt thrombosis and on or off CPB were compared using the Mann-Whitney U test or Fisher exact test. Multivariable regression analysis was performed to identify independent predictors of early shunt thrombosis and to assess effect of CPB independent of other factors. Seventy-five infants underwent SPS placement during the study period (on CPB, n = 25; off CPB, n = 50). Operative mortality was 11% (8/75). Nine (12%) patients developed early shunt thrombosis, all of whom had shunt placement off CPB. Independent risk factors for early shunt thrombosis were identified to be SPS placement off CPB ( P = .011), prematurity ( P = .034), and competitive antegrade pulmonary blood flow ( P = .038). Prematurity, competitive antegrade pulmonary blood flow, and shunt placement off CPB lead to higher risk of early shunt thrombosis. We speculate that the protection offered by use of CPB may be accounted for by the associated complex coagulopathy and platelet dysfunction associated with CPB.

Factors associated with 30-day ventriculoperitoneal shunt failure in pediatric and adult patients.

OBJECTIVE The aim of this study was to provide a comprehensive benchmark of 30-day ventriculoperitoneal (VP) shunt failure rates for a single institution over a 5-year study period for both adult and pediatric patients, to compare this with the results in previously published literature, and to establish factors associated with shunt failure. METHODS A retrospective database search was undertaken to identify all VP shunt operations performed in a single, regional neurosurgical unit during a 5-year period. Data were collected regarding patient age, sex, origin of hydrocephalus, and whether the shunt was a primary or secondary shunt. Operative notes were used to ascertain the type of valve inserted, which components of the shunt were adjusted/replaced (in revision cases), level of seniority of the most senior surgeon who participated in the operation, and number of surgeons involved in the operation. Where appropriate and where available, postoperative imaging was assessed for grade of shunt placement, using a recognized grading system. Univariate and multivariate models were used to establish factors associated with early (30-day) shunt failure. RESULTS Six hundred eighty-three VP shunt operations were performed, of which 321 were pediatric and 362 were adult. The median duration of postoperative follow-up for nonfailed shunts (excluding deaths) was 1263 days (range 525-2226 days). The pediatric 30-day shunt failure rates in the authors' institution were 8.8% for primary shunts and 23.4% for revisions. In adults, the 30-day shunt failure rates are 17.7% for primary shunts and 25.6% for revisions. In pediatric procedures, the number of surgeons involved in the operating theater was significantly associated with shunt failure rate. In adults, the origin of hydrocephalus was a statistically significant variable. Primary shunts lasted longer than revision shunts, irrespective of patient age. CONCLUSIONS A benchmark of 30-day failures is presented and is consistent with current national databases and previously published data by other groups. The number of surgeons involved in shunt operations and the origin of the patient's hydrocephalus should be described in future studies and should be controlled for in any prospective work. The choice of shunt valve was not a significant predictor of shunt failure. Most previous studies on shunts have concentrated on primary shunts, but the high rate of early shunt failure in revision cases (in both adults and children) is perhaps where future research efforts should be concentrated.

Clinical and Arterial Spin Labeling Brain MRI Features of Transitional Venous Anomalies.

Transitional venous anomalies (TVAs) are rare cerebrovascular lesions that resemble developmental venous anomalies (DVAs), but demonstrate early arteriovenous shunting on digital subtraction angiography (DSA) without the parenchymal nidus of arteriovenous malformations (AVMs). We investigate whether arterial spin labeling (ASL) magnetic resonance imaging (MRI) can distinguish brain TVAs from DVAs and guide their clinical management. We conducted a single-center retrospective review of patients with brain parenchymal DVA-like lesions with increased ASL signal on MRI. Clinical histories and follow-up information were obtained. Two readers assessed ASL signal location relative to the vascular lesion on MRI and, if available, the presence of arteriovenous shunting on DSA. Thirty patients with DVA-like lesions with increased ASL signal were identified. Clinical symptoms prompted MRI evaluation in 83%. Symptoms did not localize to the venous anomaly in 90%. Ten percent presented with acute symptoms, only one of whom presented with hemorrhage. ASL signal in relation to the venous anomaly was identified in: 50% in the adjacent parenchyma, 33% in the lesion, 7% in a distal draining vein/sinus, and 10% in at least two of these sites. Follow-up DSA confirmed arteriovenous shunting in 71% of ASL-positive venous anomalies. Interrater agreement was very good (κ = .81-1.0, P < .001). A DVA-like lesion with increased ASL signal likely represents a TVA with arteriovenous shunting. Our study indicates that these lesions are usually incidentally detected and have a lower risk of hemorrhage than AVMs. ASL-MRI may be a useful tool to identify TVAs and guide further management of patients with TVAs.

Early Transjugular Intrahepatic Portosystemic Shunt (TIPS) Placement in Patients with Cirrhosis and Variceal Bleeding

AbstractThe placement of a transjugular intrahepatic portosystemic shunt (TIPS) has been traditionally used as a rescue treatment for uncontrolled or recurrent acute variceal bleeding (AVB) in patients with cirrhosis. However, more contemporary studies are revealing that early or ‘pre-emptive’ TIPS placement (performed within 24–72 h of AVB presentation) significantly controls bleeding, prevents rebleeding, and improves survival in selected patients when compared with standard pharmacological and endoscopic therapies. Furthermore, the use of early TIPS did not translate to an increased risk of hepatic encephalopathy (HE) for this population. Proper patient selection for early TIPS is paramount, as the procedure is unlikely to benefit patients with advanced decompensated cirrhosis (Child–Turcotte–Pugh [CTP] class C, score &gt; 13) or patients who do not carry high risk with only mild hepatic dysfunction (Child-Turcotte-Pugh class A). Finally, while the current results for early TIPS are promising, further prospective studies are needed to confirm these findings before early TIPS can be widely adopted.