Hydrocephalus In Adult Patients Research Articles

Revision and Infection Rate in 728 Shunt-Treated Adult Hydrocephalus Patients—a Single-Center Retrospective Study

Hydrocephalus is a common diagnosis worldwide that is treated with shunts and is associated with potential life-threatening risks of shunt dysfunction and infection. We investigated differences in rates of shunt revisions and infections including various factors in patients with different causes of hydrocephalus. We also studied causes of infections and efficacy of perioperative antibiotic regimens. Our objective was to identify patients at risk of higher revision and infection rates after shunt treatment. We conducted a retrospective single-center cohort study including 728 adult patients who underwent shunt surgery between 2013 and 2019 at our center. Overall revision rate was 20.1%, and infection rate was 4.8%. Infection was detected in 24% of all revisions. The main location for a positive culture was cerebrospinal fluid (67.5%), frequently caused by Cutibacterium acnes (60%). Younger age and prior shunts were the only predictors confirmed in multivariate Cox regression as significantly increasing the risk of revision surgery. Multivariate Cox regression analysis of infection risk factors showed that obstructive hydrocephalus, prior shunt, and cloxacillin significantly increased risk of shunt infection. We found revision and infection rates in accordance with other studies. We showed a significantly increased risk in younger patients. Previous shunts also increased the risk of revisions and infections. We showed a small but significant effect of perioperative prophylaxis with broader-spectrum antibiotics compared with cloxacillin. Our study identified a group of younger patients with congenital hydrocephalus and prior implants with an increased risk of shunt infection in whom additional preventive measures should be employed.

Cerebrospinal fluid diversion prior to posterior fossa tumor resection in adults: A systematic review

Abstract Background Posterior fossa tumors (PFTs) comprise 15%–20% of adult brain tumors, with the reported frequency of hydrocephalus (HCP) ranging between 3.7% and 58%. Most HCP resolves after resection of PFTs, but studies report persistent or new-onset HCP occurring in between 2% and 7% of cases. Preoperative cerebrospinal fluid (CSF) diversion with a ventriculoperitoneal shunt (VPS), external ventricular drain (EVD), or endoscopic third ventriculostomy (ETV) has been shown to improve outcomes. Evidence regarding the efficacy of these techniques is limited. Methods A systematic literature search was performed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Data points were extracted from individual patient cohort data. A failure rate was determined by the number of patients requiring further postoperative CSF diversion. Results In total, 8863 records were identified. Thirteen studies consisting of 17 patient cohorts met our inclusion criteria. Across all individual cohort studies, 2976 patients underwent surgical resection of a PFT in whom the frequency of hydrocephalus at presentation was 22.98% (1.92%–100%), and persistent hydrocephalus following preoperative CSF diversion was 13.63% (0%–18%). Of the 684 hydrocephalic patients, 83.63% underwent CSF diversion in the form of ETV, EVD, or VPS. Between years 1992 and 2020, 1986 and 2021, and 1981and 2013, the pre-resection ETV, EVD, and VPS failure rates were 14.66% (17/116), 16.26% (60/369), and 0% (0/87), respectively. Conclusions This systematic review highlights that VPS has a better failure rate profile in minimizing postoperative hydrocephalus in adult patients with PFTs.

Ventriculoperitoneal shunting obstruction: a multicentre clinical audit for cerebrospinal fluid parameters and its prediction role.

Shunt obstruction is a type of ventriculoperitoneal shunt (VPS) failure. Whether changes in cerebrospinal fluid (CSF) parameters can influence shunt outcomes or not is debatable. In this study, we retrospectively included adult hydrocephalus patients who received VPS from 6 general hospitals in different provinces of China from November 2013 to September 2021. The inclusion criteria: Patients with hydrocephalus of all etiologies underwent shunt surgery from 6 general hospitals in different provinces of China were included in the study. The exclusion criteria: 1.Patients under the age of 18; 2.Patients who had previous shunt surgery; 3. Shunt failurefromother factors; 4.Patients died from other causes; 5. Patients with incomplete data. The CSF of shunt patients had been analyzed at the time of shunt insertion. The CSF samples were collected and analyzed when the shunt was implanted. The relationship between CSF parameters and the incidence rate of shunt obstruction in one year was analyzed. A total of 717 eligible patients from 6 hospitals were included, of whom 59(8.23%) experienced obstruction. Multivariate logistic regression analysis identified that protein level(odds ratio [OR] 1.161, 95% CI 1.005 ~ 1.341, p = 0.043), decreased glucose level(< 2.5 mmol/L)(odds ratio 3.784, 95% confidence interval 1.872 ~ 7.652, p = 0.001) and protein level increase(> 0.45 g/L) (odds ratio 3.653, 95% confidence interval 1.931 ~ 6.910, p = 0.001)were independent risk factors of shunt obstruction. This study suggested that increased protein level (> 0.45 g/L) and decreased glucose level (< 2.5 mmol/L) in CSF indicated an increased risk of shunt obstruction in a patient with hydrocephalus. Thus, shunt surgery should be more carefully considered when the CSF glucose and protein were abnormal.

Long-term follow-up and comparison of programmable and non-programmable ventricular cerebrospinal fluid shunts among adult patients with different hydrocephalus etiologies: a retrospective cohort study.

Programmable valve (PV) has been shown as a solution to the high revision rate in pediatric hydrocephalus patients, but it remains controversial among adults. This study is to compare the overall revision rate, revision cause, and revision-free survival between PV and non-programmable valve (NPV) in adult patients with different hydrocephalus etiologies. We reviewed the chart of all patients with hydrocephalus receiving index ventricular cerebrospinal fluid (CSF) shunt operations conducted at a single institution from January 2017 to December 2017. Patients included in the study were followed up for at least 5years. Statistical tests including independent t-test, chi-square test, and Fisher's exact test were used for comparative analysis, and Kaplan-Meier curve using log-rank test was performed to compare the revision-free survival between the PV and NPV groups. A total of 325 patients were included in the study, of which 181 patients were receiving PVs and 144 patients receiving NPV. There were 23 patients (12.8%) with PV and 22 patients (15.3%) with NPV receiving initial revision. No significant statistical difference in the initial revision rate was observed between the two groups (p = 0.52). No survival difference was found between the PV and NPV groups. However, better revision-free survival was noted in the PV group among idiopathic normal pressure hydrocephalus (iNPH) (p = 0.0274) and post-traumatic hydrocephalus (p = 0.017). The combination of the different etiologies of hydrocephalus and the features of PV and NPV results in different outcomes-revision rate and revision-free survival. PV use might be superior to NPV in iNPH and post-traumatic hydrocephalus patients. Further studies are needed to clarify the indications of PV use in adult hydrocephalus patients.

Correlation between cerebrospinal fluid abnormalities before ventriculoperitoneal shunt and postoperative intracranial infection in adult patients with hydrocephalus: A clinical study.

To identify the relationship between preoperative cerebrospinal fluid (CSF) leukocyte, chloride, glucose, aspartate aminotransferase, lactate dehydrogenase, adenosine deaminase, lactic acid and protein levels and ventriculoperitoneal shunt infection. Records of 671 consecutive adult patients who underwent ventriculoperitoneal shunt surgery for the treatment of hydrocephalus at Zhujiang Hospital affiliated with Southern Medical University from January 2011 to March 2022 were reviewed. The patients were divided into infection and non-infection groups based on the presence of postoperative infection. For all patients, we analyzed age; sex; primary disease; preoperative CSF leukocyte, chloride, glucose, aspartate aminotransferase, lactate dehydrogenase, adenosine deaminase, lactic acid and protein levels; postoperative temperature; and postoperative infection. A total of 397 patients were included, 28 (7.05%) of whom had an infection within 6 months of the operation and the remaining had no infection. There was no significant difference in age, sex, primary disease, leukocyte, chloride ion, aspartate aminotransferase, lactate dehydrogenase, adenosine deaminase and protein levels in CSF between infection group and non-infection group (p > 0.05). The postoperative infection rate of patients with CSF glucose < 2.8 mmol/L (x 2 = 11.650, p = 0.001) and CSF lactic acid >2.8 mmol/L (x 2 = 12.455, p < 0.001) was higher than that of patients with CSF glucose level ≥2.8 mmol/L and CSF lactic acid level in the range of (1-2.8) mmol/L, respectively, with statistical difference. Compared with the non-infection group, the level of CSF glucose (t = 4.113, p < 0.001) was significantly lower, and the level of CSF lactic acid (t = 6.651, p < 0.001) was significantly higher in the infection group. Multivariate logistic regression analysis showed that preoperative cerebrospinal fluid glucose < 2.8 mmol/L (OR = 3.911, 95% CI: 1.653~9.253, p = 0.002) and cerebrospinal fluid lactate >2.8 mmol/L (OR = 4.712, 95% CI: 1.892~11.734, p = 0.001) are risk factors for infection after ventriculoperitoneal shunt. ROC analysis revealed that the area under the curve (AUC) for CSF glucose and lactic acid level were 0.602 (95% CI: 0.492-0.713) and 0.818 (95% CI: 0.738-0.898), respectively. The infection group had higher rates of fever and body temperature on postoperative day 3-7 (p < 0.05). For adult hydrocephalus patients without clinical manifestations of intracranial infection but only with simple abnormality of cerebrospinal fluid, when the content of glucose in cerebrospinal fluid is < 2.8 mmol/L, and the content of lactic acid is >2.8 mmol/L, it is recommended to perform ventriculoperitoneal shunt after further improvement of cerebrospinal fluid indicators, otherwise, hasty operation will increase the postoperative infection rate. The postoperative fever rate of ventriculoperitoneal shunt surgery is high and the body temperature drops rapidly. If there is still fever after day 3 after surgery, whether there is intracranial infection should be considered.

Characteristics and management of hydrocephalus in adult patients with cerebellar glioblastoma: lessons from a French nationwide series of 118 cases.

The characteristics of hydrocephalus associated with cerebellar glioblastoma (cGB) remain poorly known. The objectives were to describe the occurence of hydrocephalus in a French nationwide series of adult patients with cGB, to identify the characteristics associated with hydrocephalus and to analyze the outcomes associated with the different surgical strategies, in order to propose practical guidelines. Consecutive cases of adult cGB patients prospectively recorded into the French Brain Tumor Database between 2003 and 2017 were screened. Diagnosis was confirmed by a centralized neuropathological review. Among 118 patients with cGB (mean age 55.9 years), 49 patients (41.5%) presented with pre-operative hydrocephalus. Thirteen patients (11.0%) developed acute (n=7) or delayed (n=6) hydrocephalus postoperatively. Compared to patients without hydrocephalus at admission, patients with hydrocephalus were younger (52.0 years vs 58.6 years, p=0.03) and underwent more frequently tumor resection (93.9% vs 73.9%, p=0.006). A total of 40 cerebrospinal-fluid diversion procedures were performed, including 18 endoscopic third ventriculostomies, 12 ventriculoperitoneal shunts and 10 external ventricular drains. The different cerebrospinal-fluid diversion options had comparable functional results and complication rates. Among the 89 patients surgically managed for cGB without prior cerebrospinal-fluid diversion, 7 (7.9%) were long-term shunt-dependant. Hydrocephalus is frequent in patients with cGB and has to be carefully managed in order not to interfere with adjuvant oncological treatments. In case of symptomatic hydrocephalus, a cerebrospinal-fluid diversion is mandatory, especially if surgical resection is not feasible. In case of asymptomatic hydrocephalus, a cerebrospinal-fluid diversion has to be discussed only if surgical resection is not feasible.

Hydrodynamic comparison of shunt and endoscopic third ventriculostomy in adult hydrocephalus using in vitro models and fluid-structure interaction simulation

ObjectiveThe comparison of the efficiency of shunt placement and endoscopic third ventriculostomy (ETV) in treating of adult hydrocephalus patients with various intensities and different obstruction intensities in the aqueduct of Sylvius (AS). MethodsIn vitro models with separated ventricles were simulated and implemented for modeling shunt and ETV surgeries in one healthy subject and hydrocephalus patients with various intensities, as well as three different obstruction intensities in AS and under two cerebrospinal fluid (CSF) dynamic conditions. The fluid-structure interaction simulation was also carried out to validate in vitro results. ResultsThe efficiency of both methods in reducing the maximum CSF pressure in the subarachnoid space (MCPS) decreased by an increase in the patient's intensities. Contrary to shunting, the efficiency of ETV in reducing MCPS demonstrated a decline (8.3–16.4%) by an increase in obstruction levels in AS. Based on the findings, shunt efficiency in decreasing MCPS in patients with low intensity was more remarkable compared to ETV. However, ETV was more efficient than shunt in the patient with intracranial hypertension. Further, shunt placement and ETV led to a significant reduction in the amplitude of CSF pressure in the SAS (ACPS) in patients with sneezing, coughing, Valsalva maneuver, and exercising effects in contrast to other patients. Moreover, ACPS reduction was not related to the intensity of the disease in both treatment methods. In contrast to shunt, an increase in the obstruction level in AS led to a reduction in ACPS in ETV in both CSF dynamic conditions. ConclusionsThe noises from irregular disorders increased the discharging of CSF after shunt placement, and activities such as sneezing, coughing, Valsalva maneuvers, and exercising increased the risk of shunt overdrainage by 10.4~47.8%, especially in the patient with intracranial hypertension. Based on the proposed in vitro ETV and shunt models, an increase of head compliance was higher in ETV compared to the shunt. Eventually, an increase in the obstruction level of AS after ETV led to a decline in head compliance in contrast to shunt.

Prompt closure versus gradual weaning of external ventricular drainage for hydrocephalus in adult patients with aneurysmal subarachnoid haemorrhage: a systematic review

ObjectivesTo summarise the evidence on benefits and harms of prompt closure versus gradual weaning of external ventricular drainage (EVD) in patients with hydrocephalus following aneurysmal subarachnoid haemorrhage (aSAH) based on...

Can early cranioplasty reduce the incidence of hydrocephalus after decompressive craniectomy? A meta-analysis

Background: Do alterations of cerebrospinal fluid dynamics secondary to decompressive craniectomy (DC) lead to hydrocephalus, and can this effect be mitigated by early cranioplasty (CP)? In this meta-analysis, we evaluated whether the timing of CP decreased the incidence of postoperative hydrocephalus.Methods: We performed a systematic search of PubMed/MEDLINE, Scopus, and the Cochrane databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for English language articles (1990–2020). We included case series, case–control, and cohort studies, and clinical trials assessing the incidence of hydrocephalus in adult patients undergoing early CP (within 3 months) versus late CP (after 3 months) after DC.Results: Eleven studies matched the inclusion criteria. The rate of postoperative hydrocephalus was not significantly different between the early (=96/1063; 9.03%) and late CP (=65/966; 6.72%) group (P = 0.09). Only in the three studies specifically reporting on the rate of hydrocephalus after DC performed to address traumatic brain injury (TBI) alone was there a significantly lower incidence of hydrocephalus with early CP (P = 0.01).Conclusion: Early CP (within 90 days) after DC performed in TBI patients alone was associated with a lower incidence of hydrocephalus. However, this finding was not corroborated in the remaining eight studies involving CP for pathology exclusive of TBI.

Investigation of The Improvement Rate Regarding The Herniation of Cerebellar Tonsils Following Shunting Procedures in Patients with Chiari Malformation and Associated Hydrocephalus

Introduction and Aim: Chiari malformation is a congenital anomaly formed as the result of the herniation of posterior fossa structures through the foramen magnum toward the spinal canal. In this study, we aimed to present the improvement rate regarding the herniation in cerebellar tonsils following shunting procedures in patients with Chiari malformation and associated hydrocephalus. Method: We measured in mm the improvement rate regarding the herniation in cerebellar tonsils in postoperative cervical MRI images obtained following ventriculoperitoneal shunting procedures for hydrocephalus in adult patients with symptoms of Chiari malformation such as balance disorder, dizziness, numbness and loss of muscular strength at the hands who were diagnosed with Chiari malformation and hydrocephalus following cranial and cervical magnetic resonance imaging MRI . Results: A total of fifteen adult patients in whom the cerebellar tonsillar herniation was over 5 mm and accompanied by hydrocephalus were included in our study. The measure of herniation in the patients involved in the study was between 1.11 cm and 8 mm. The amount of improvement in herniation following the shunting procedure was between 7.76 mm and 2.2 mm. Conclusion: In patients with Chiari malformation associated with hydrocephalus, cerebellar tonsillar herniation can regress to 5 mm, which is considered as physiological, and the symptoms related to Chiari malformation can disappear. When Chiari malformation is associated with hydrocephalus, the tonsillar herniation may improve, and symptoms may disappear following the ventriculoperitoneal shunting procedure for hydrocephalus without necessitating posterior decompression for Chiari-related herniation.

Prompt closure versus gradual weaning of extraventricular drainage for hydrocephalus in adult patients with aneurysmal subarachnoid haemorrhage: a systematic review protocol with meta-analysis and trial sequential analysis

IntroductionIn Neuro Intensive Care Units (NICU) and neurosurgical units, patients with an external ventricular drain (EVD) due to hydrocephalus following aneurysmal subarachnoid haemorrhage (SAH) are commonly seen. Cessation of the...

Ventriculoatrial shunt in adults. A case series, with emphasis on atrial catheter migration

Abstract Objectives Few studies have described retrograde migration of the atrial catheter tip in ventriculoatrial shunt to treat adult hydrocephalus. Methods We placed ventriculoatrial shunts in 25 selected adult patients with a previous complicated abdominal surgery or concurrent bowel disease and in patients with persistent symptoms after a ventriculoperitoneal, potentially due to conflicting internal abdominal pressure. Clinical and radiological follow-ups were performed at least 18 months postoperatively. Results No mortality or early or late infection occurred in the series of patients. At the long-term clinical and radiological follow-up (mean 4.5 years), eight patients died due to causes unrelated to shunt surgery. All other patients were able to live independently but some experienced neurological decline related to their neurodegenerative disease. In five patients (20%), atrial catheter migration was detected on a control chest x-ray; in four patients, it was associated with worsening of their clinical condition. These patients underwent surgical substitution of the atrial catheter. The remaining asymptomatic patient was managed conservatively. Conclusions The ventriculoatrial shunt was a safe, effective procedure for treating hydrocephalus in adult patients. Retrograde migration of the atrial catheter tip in symptomatic patients required surgical substitution of the atrial catheter.

Observations from Social Media Regarding the Symptomatology of Adult Hydrocephalus Patients

Patients with hydrocephalus experience symptoms related to hydrocephalus in an age-dependent manner. However, prevalence estimates of hydrocephalus symptoms in young and middle-aged (YMA) adult patients are rare and variable. Highlighting the importance of hydrocephalus symptom management, the persistence and intensity of headache or gait disturbance have been associated with signs of brain white matter integrity loss, including in treated YMA adult patients. Thus, it is important to ascertain which symptoms adult patients with hydrocephalus report most to confirm their relative importance. Observations of symptom complaints were made from publicly viewable online responses to an inquiry posted by the Hydrocephalus Association to 2 Facebook webpages. Within 7 days of inquiry posting, 381 complaints of signs and symptoms were identified in 82 online responses. Headache, cognitive deficits (cognition and memory), and mobility issues (dizziness, balance, or gait problems) were most commonly reported by 63%, 45%, and 40% of respondents, respectively. Results were highly similar for the subgroup of 53 patients reported as treated. For self-identified YMA patients (<60 years old), results were similar, but with fewer mobility complaints. Not previously reported, hypersensitivity to external stimuli was reported by one-half of the patients that reported headache. The current results provide further quantitative support for the prioritization of study of headache, cognitive deficits, and mobility issues in YMA adult patients with hydrocephalus. Warranting further study, cranial hypersensitivity to external stimuli may represent a novel outcome measure, and treated YMA adult hydrocephalus patients continue to report symptoms associated with signs of brain damage.

The effect of tumor removal via craniotomies on preoperative hydrocephalus in adult patients with intracranial tumors.

The efficacy of tumor removal via craniotomies on preoperative hydrocephalus (HC) in adult patients with intracranial tumors is largely unknown. Therefore, we sought to evaluate the effect of tumor resection in patients with preoperative HC and identify the incidence and risk factors for postoperative VP shunt dependency. All craniotomies for intracranial tumors at Oslo University Hospital in patients ≥ 18years old during a 10-year period (2004-2013) were reviewed. Patients with radiologically confirmed HC requiring surgery and subsequent development of shunt dependency were identified by cross-linking our prospectively collected tumor database to surgical procedure codes for hydrocephalus treatment (AAF). Patients with preexisting ventriculoperitoneal (VP) shunts (N = 41) were excluded. From 4774 craniotomies performed on 4204 patients, a total of 373 patients (7.8%) with HC preoperatively were identified. Median age was 54.4years (range 18.1-83.9years). None were lost to follow-up. Of these, 10.5% (39/373) required permanent CSF shunting due to persisting postoperative HC. The risk of becoming VP shunt dependent in patients with preexisting HC was 7.0% (26/373) within 30days and 8.9% (33/373) within 90days. Only secondary (repeat) surgery was a significant risk factor for VP shunt dependency. In this large, contemporary, single-institution consecutive series, 10.5% of intracranial tumor patients with preoperative HC became shunt-dependent post-craniotomy, yielding a surgical cure rate for HC of 89.5%. To the best of our knowledge, this is the first and largest study regarding postoperative shunt dependency after craniotomies for intracranial tumors, and can serve as benchmark for future studies.

Comparison between Ventriculosubgaleal Shunt and Extraventricular Drainage to Treat Acute Hydrocephalus in Adults.

Context:Hydrocephalus, due to subarachnoid or intraventricular hemorrhage (IVH), meningitis, or tumor compression, is usually transient and may resolve after treatment. There are several temporary methods of cerebrospinal fluid (CSF) diversion, none of it is superior to the other, and the decision is based on its various etiologies and factors. Ventriculosubgaleal shunt (VSGS) is one of those temporary measures, which is a simple and rapid CSF decompression method without causing electrolyte and nutritional losses.Aims:The aim is to study the efficacy of VSGS for temporary CSF diversion, compared to extraventricular drainage (EVD) in adult hydrocephalus patients; to evaluate the outcome in terms of avoiding a permanent shunt, and to look for incidences of their complications.Settings and Design:This was a retrospective observational study.Subjects and Methods:The data were acquired from case notes of fifty patients with acute hydrocephalus: 26 secondary to IVH, 10 from aneurysm rupture, 8 posttrauma, and 6 from infection. All these patients had undergone CSF diversion in Hospital Queen Elizabeth II, Sabah, Malaysia, between 2013 and 2015. The patients were followed up from the date of treatment until the resolution of hydrocephalus, where parameters such as shunt dependency and complications were documented.Statistical Analysis Used:All analyses were carried out using Statistical Packages for the Social Sciences Version 22.0. Chi-squared test or Fisher's exact test is used for univariate analysis of categorical variables.Results:A total of 21 (42%) patients underwent EVD insertion and 29 (58%) underwent VSGS insertion. Thirty-seven (74%) patients did not require a permanent shunt; 24 (64.8%) of them were from the VSGS group (P = 0.097). EVD had more intracranial complications (44.1%) compared with VSGS (23.5%), with a statistically significant P = 0.026.Conclusions:VSGS is a safe and viable option for adult hydrocephalus patients, with the possibility of continuation of the treatment for such patients in nonneurosurgical centers, as opposed to patients with EVDs. Furthermore, even though this method had no statistical difference in avoiding a permanent ventriculoperitoneal shunt, VSGS has statistically significant less intracranial complications compared with EVD.

Using external lumbar CSF drainage to treat communicating external hydrocephalus in adult patients after acute traumatic or non-traumatic brain injury.

Despite various treatments to control intracranial pressure (ICP) after brain injury, patients may present a late onset of high ICP or a poor response to medications. External lumbar drainage (ELD) can be considered a therapeutic option if high ICP is due to communicating external hydrocephalus. We aimed at describing the efficacy and safety of ELD used in a cohort of traumatic or non-traumatic brain-injured patients. In this multicentre retrospective analysis, patients had a delayed onset of high ICP after the initial injury and/or a poor response to ICP treatments. ELD was considered in the presence of radiological signs of communicating external hydrocephalus. Changes in ICP values and side effects following the ELD procedure were reported. Thirty-three patients with a median age of 51years (25-75th percentile: 34-61years) were admitted after traumatic (n=22) or non-traumatic (n=11) brain injuries. Their initial Glasgow Coma Scale score was 8 (4-11). Eight patients underwent external ventricular drainage prior to ELD. Median time to ELD insertion was 5days (4-8) after brain insult. In all patients, ELD was dramatically effective in lowering ICP: 25mmHg (20-31) before versus 7mmHg (3-10) after (p<0.001). None of the patients showed adverse effects such as pupil changes or intracranial bleeding after the procedure. One patient developed an ELD-related infection. These findings indicate that ELD may be considered potentially effective in controlling ICP, remaining safe if a firm diagnosis of communicating external hydrocephalus has been made.

Incidence and outcome of surgery for adult hydrocephalus patients in Sweden

Object: To present population-based and age related incidence of surgery and clinical outcome for adult patients operated for hydrocephalus, registered in the Swedish Hydrocephalus Quality Registry (SHQR).Methods: All patients registered in SHQR during 2004–2011 were included. Data on age, gender, type of hydrocephalus and type of surgery were extracted as well as three months outcome for patients with idiopathic normal pressure hydrocephalus (iNPH).Results: The material consisted of 2360 patients, 1229 men and 1131 women, age 63.8 ± 14.4 years (mean ± standard deviation (SD)). The mean total incidence of surgery was 5.1 ± 0.9 surgeries/100,000/year; 4.7 ± 0.9 shunt surgeries and 0.4 ± 0.1 endoscopic third ventriculostomies. For iNPH, secondary communicating hydrocephalus and obstructive hydrocephalus, the incidence of surgery was 2.2 ± 0.8, 1.9 ± 0.3 and 0.8 ± 0.1/100,000/year, respectively. During 2004–2011, the incidence of surgery increased in total (p = .044), especially in age groups 70–79 years and ≥80 years (p = .012 and p = .031). After surgery, 253 of 652 iNPH patients (38.8%) improved at least one step on the modified Rankin scale (mRS). Number needed to treat was 3.0 for improving one patient from unfavourable (mRS 3–5) to favourable (mRS 0–2). The mean score of a modified iNPH scale increased from 54 ± 23 preoperatively to 63 ± 25 postoperatively (p < .0001, n = 704), and 58% improved. No significant regional differences in incidence, surgical techniques or outcome were found.Conclusions: Incidence of hydrocephalus surgery increased significantly during 2004–2011, specifically in elderly patients. Surgical treatment of iNPH markedly improved functional independence, but the improvement rate was low compared to recent single- and multicentre studies. Thus, the potential for surgical improvement is likely lower than generally reported when treating patients as part of everyday clinical care.

Endoscopic third ventriculostomy (ETV) for treatment of adult hydrocephalus: long-term followup with 163 patients

Introduction: Treatment of specific patterns of symptomatic hydrocephalus in the adult patient may be accomplished with endoscopic third ventriculostomy (ETV) as an alternative to insertion of a ventriculoperitoneal (VP) shunt. This review examines a single center experience with ETV to treat hydrocephalus in symptomatic adult patients. Methods: Adult patients (≥18 years) with a diagnosis of hydrocephalus who were treated with ETV in Calgary between January 1994 and July 2014 were reviewed using a clinic database and registry. Results: 163 patients were identified (male=92; female=71). Mean age at the time of ETV was 46.5 years (range 18-83.4 years). 118 underwent ETV as a primary treatment and 45 patients underwent treatment after presenting with VP shunt failure (secondary ETV). 113/163 patients had a diagnosis of aqueductal stenosis, 22/163 had a diagnosis of tumor. Mean followup was 8.2 years (range 0.3-18.4 years). Symptoms in 149/163 (91.4%) of ETV patients were better or unchanged at last followup. 104/118 (88.1%) of primary ETV patients were shunt free at last followup. 39/45 (86.7%) of secondary ETV patients were shunt free at last followup. Conclusion: Endoscopic (ETV) treatment is an effective long-term treatment for a select population of adult patients with hydrocephalus.

Endoscopic third ventriculostomy (ETV) for treatment of adult hydrocephalus: long-term followup with 163 patients

Treatment of specific patterns of symptomatic hydrocephalus in the adult patient may be accomplished with endoscopic third ventriculostomy (ETV) as an alternative to insertion of a ventriculoperitoneal (VP) shunt or when VP shunt failure occurs. Treatment of hydrocephalus with a VP shunt, while effective, is associated with a significant shunt failure rate that results in VP shunt revision surgery. This review examines a single center experience with ETV to treat hydrocephalus in symptomatic adult patients.

Overcoming CSF overdrainage with the adjustable gravitational valve proSA

Despite progress in shunt valve technology, CSF overdrainage is still one of the most frequent complications in shunt-treated hydrocephalus. Particularly with regard to young and adolescent patients, treatment of manifest overdrainage is complicated by several hardly influenceable factors such as increasing height and mobility. Therefore, the aim of this study was to evaluate the therapeutic efficiency of the new adjustable gravitational valve, proSA. Sixty-four shunt-treated young hydrocephalus patients aged 1.8-41.4 years (15.5 ± 10.5 years) suffering from clinical and/or radiological overdrainage underwent shunt revision surgery with the implantation of the new proSA valve. Clinical outcome after a 1-year follow-up period, pumping function of the valve chambers as well as the number of necessary postoperative valve adjustments were examined. Fifty-five patients completed the study as planned. All reported a significant improvement of their clinical condition; 91 % described a complete resolution in symptoms related to overdrainage. Preoperatively, more than 85 % of the valve chambers showed no or very slow refilling with CSF. After a year of proSA treatment, more than 90 % exhibited a normal valve chamber function. During the follow-up period, a total of 136 valve adjustments were necessary. None of the proSA valves had to be surgically revised. The postoperative adjustability of the opening pressure level is the advantage of the new gravitational valve. The good clinical outcome is attributed to the new valve technology. The proSA appears to be a promising shunt valve to overcome overdrainage in adolescent and adult hydrocephalus patients.