Lumboperitoneal Shunt Research Articles

Surgical management of pseudotumor cerebri syndrome: A single center experience with endoscopic optic nerve decompression and CSF diversion procedures

ObjectivesPseudotumor cerebri syndrome (PTC) is a chronic disorder, which is initially treated by conservative measures, yet surgery is inevitable in case of progressive worsening of vision or headache despite medical treatment. The surgical management is controversial including CSF diversion procedures and optic decompression. The purpose of this study was to evaluate the efficacy of different surgeries in PTC and to present surgical outcomes in a single center. MethodsThis retrospective study included the patients with PTC who were operated by endoscopic optic nerve decompression (EOND), ventriculoperitoneal (VP) and lumboperitoneal (LP) shunting. Surgical outcomes, i.e. visual acuity, visual field, papilledema and headache were compared according to type of surgery. Surgical complications were noted. ResultsSeventeen of 36 patients were treated with shunting, 14 with EOND and 5 patients with both EOND and shunting. No statistical significance was observed between CSF diversion procedures and EOND concerning clinical outcomes. The improvement rate of papilledema was higher with VPS (p = 0574) while more patients benefitted from LPS regarding visual field and acuity (p = 0471 and p = 0718, respectively). The best treatment response for headache was in shunt implemented patients (VPS and LPS) with a rate of 88.2% followed by EOND (78.6%) and both surgeries (60%)(p = 0.294). Gender and BMI were significant predictors of improved papilledema (p = 0.034). ConclusionsOur study demonstrated comparable results between shunting and EOND, regarding the efficacy on surgical outcomes. EOND is quite effective for headache besides its advantage on treatment-refractory visual loss. Shunting may offer sustained relief of symptoms when compared with EOND.

Clinical, radiological profile and outcomes of patients with idiopathic intracranial hypertension: a prospective study in the South Indian population

Objective: To describe the clinical, radiological characteristics and outcomes of patients with Idiopathic intracranial hypertension (IIH) at 6 months in a cohort of South Indian patients. Methods: We did a prospective study on patients presented to our institute with the symptomatology of IIH. A detailed history regarding headache, visual symptoms were noted. A complete neurological examination including examination of the fundus, CSF opening pressure, MRI brain, and MR cerebral venography were performed for all subjects. The patients were followed-up for 6 months to assess treatment response. Results: We evaluated 49 patients, the majority were females, and 38.7% had grade 1 obesity. Headache was the most common clinical presentation. The most common MRI abnormality was empty sella turcica, noted in 47%. There was a significant positive correlation between CSF opening pressure and headache severity (R2= 0.165, p = 0.018), as well as between CSF opening pressure and the grade of papilledema (R2=0.245, p=0.001). Of the cases, 95% responded to medical management, and three patients of fulminant IIH underwent lumbar-peritoneal shunting. At 6 months, 60% had persistent headaches. Only 8.7% had persistent visual symptoms, and only one had optic atrophy. There was no significant correlation between the follow-up grade of papilledema and the patient’s BMI. No significant correlation was found between the amount of weight lost and the improvement in the Numerical Rating Scale (NRS) score at 6 months. Conclusion: Headache in IIH is multifactorial and a significant cause of disability. The overall prognosis for vision is good. IIH should be suspected in any obese woman with headaches since it is one of the preventable causes of blindness.

NCMP-19. OUTCOMES FOLLOWING PALLIATIVE CEREBROSPINAL FLUID DIVERSION FOR NEOPLASTIC LEPTOMENINGEAL DISEASE: A SYSTEMATIC REVIEW

Abstract BACKGROUND Leptomeningeal disease (LMD)—cancer involvement of meninges or disseminated through the cerebrospinal fluid (CSF) system—indicates widespread or advanced cancer. LMD leads to symptomatic hydrocephalus, for which palliative CSF diversion may be indicated. We conducted a systematic review exploring published literature on outcomes of permanent CSF diversion for hydrocephalus among pediatric and adult patients with LMD from primary brain tumor or systemic cancers. METHODS We searched PubMed, Embase, and Web of Science from database inception until 8/20/2022, using search terms including but not limited to ‘cancer’, ‘hydrocephalus’, and ‘shunt’. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed. Inclusion criteria were English-language, quantitative studies of patients with LMD and hydrocephalus, with at least five subjects. RESULTS We screened 2440 abstracts and 152 full-text articles to yield a final cohort of 23 articles. The retrospective studies reported outcomes for 2895 patients, among which 995 patients (34.3%) specifically had LMD on presentation. Fourteen studies reported proportions of patients with LMD and hydrocephalus who underwent surgery for permanent CSF diversion (range: 9.9-100%), including endoscopic third ventriculostomy, ventriculoperitoneal or lumboperitoneal shunts. Postoperative complication rates were 0-37.7% with no cases of extraneural metastases via shunt. Rates of symptomatic relief following CSF diversion ranged from 50-100% in studies that reported data. In 14 studies, median overall survival ranged from 2.1-17.1 months. Three studies reported median survival after shunt surgery for LMD (2-3.3 months). CONCLUSION A rare entity with dismal prognosis, LMD and disseminated tumor can present as symptomatic hydrocephalus in patients with cancer. Symptom relief can be achieved with palliative surgery for permanent CSF diversion with relatively low complication rates. Prospective studies are needed to further assess outcomes and needs of this patient population.

Patients of idiopathic normal-pressure hydrocephalus have small dural sac in cervical and upper thoracic levels: A supposed causal association.

Idiopathic normal pressure hydrocephalus (iNPH) is a neurological disorder presenting a triad including dementia and ventricular enlargement. The mechanism causing excessive cerebrospinal fluid (CSF) accumulation in the ventricles in iNPH is poorly understood. We hypothesized that the age-related degradation of the spinal shock-absorbing system composed of a spinal dural sac (SDS) and surrounding soft tissue, preventing ventricular enlargement caused by wide CSF pulsation driven by heartbeats, may be involved in the ventricular enlargement observed in iNPH. Sixty-four patients with iNPH in their seventies who underwent a lumboperitoneal shunt and a control group of 79 people in the same age group who underwent brain check-ups were included in the study. We compared the sizes of the cervical and upper parts of the thoracic SDS using magnetic resonance imaging between the two groups. The anterior-posterior distances of the dural sac at C5 were shorter in patients with iNPH of both sexes than those in the control group (P = 0.0008 in men and P = 0.0047 in women). The number of disc levels with disappeared CSF space surrounding the cervical cord was more in iNPH (P = 0.0176 and P = 0.0003). The midsagittal area of the upper part of the spinal sac, C2-Th4, was smaller in iNPH (P = 0.0057 and P = 0.0290). Narrowing of the cervical dural sac and midsagittal area in the upper part of the SDS in patients with iNPH may reflect the degradation of the shock-absorbing mechanism for CSF pressure pulsations, which may cause iNPH or at least aggravate iNPH by other unknown causes.

Lumboperitoneal Shunt Surgery under Spinal Anesthesia on Idiopathic Normal Pressure Hydrocephalus Patients.

Since the publication of guidelines for managing idiopathic normal pressure hydrocephalus (iNPH) in 2004, an increasing number of patients with iNPH have been undergoing shunt surgery in Japan. However, shunt surgeries for iNPH can be challenging because the procedures are performed on elderly patients. General anesthesia-related risks, such as postoperative pneumonia or delirium, are higher in the elderly. To decrease these risks, we applied spinal anesthesia on a lumboperitoneal shunt (LPS). Herein, we analyzed our methods focusing on the postoperative outcomes. We retrospectively analyzed 79 patients who underwent LPS at our institution with more than one year of follow-up. The patients were divided into two groups based on the anesthetic approach, that is, 1) general anesthesia and 2) spinal anesthesia, and were examined in terms of postoperative complications, delirium, and postoperative hospital stay. In the general anesthesia group, two patients had respiratory complications after the surgery. The postoperative delirium score using the intensive care delirium screening checklist (ICDSC) was 0 (2) (median [interquartile range]), and the length of postoperative hospital stay was 11 (4) days. In the spinal anesthesia group, no patients had respiratory complications. The postoperative mean ICDSC was 0 (1), and the length of postoperative hospital stay was 10 (3) days. Although there was no significant difference regarding postoperative delirium existed, LPS under spinal anesthesia decreased respiratory complications and significantly shortened the postoperative hospital stay. LPS under spinal anesthesia could be an alternative to general anesthesia in elderly patients with iNPH and possibly lessen the general anesthesia-related risks.

An Overview of Hydrocephalus and Shunts Used in The Clinical Management of Hydrocephalus

Hydrocephalus is a complex neurological condition characterized by an abnormal accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain, leading to increased intracranial pressure. The clinical management of hydrocephalus often involves the surgical placement of a shunt system to divert CSF and restore normal fluid dynamics. This article provides a comprehensive overview of hydrocephalus, its etiology, clinical presentation, and various types of shunts used in its management. The outline of this report encompasses the principles of shunt surgery, indications for shunt placement and primary types of shunts used in the clinical management of hydrocephalus, including ventriculoperitoneal (VP), ventriculoatrial (VA), ventriculopleural (VPL), lumboperitoneal (LP) and ventriculo-subgaleal (VS) shunts. Additionally, some non-conventional shunts such as ventriculo-osseous, ventriculo renal, ventriculo gall bladder, intraventricular (Aqueductal stents) and long-tunnelled external ventricular drains are also discussed. The distinct features of each shunt type, its associated advantages, limitations and complications are also outlined together with a comparison between pressure vs flow regulated valves. An understanding of the different shunt types and their specific characteristics is essential for clinicians to make informed decisions in tailoring treatment to individual patients. This review offers a comprehensive understanding of shunt characteristics which we believe will empower clinicians to make informed decisions tailored to individual patients, ensuring effective CSF diversion and long-term management of hydrocephalus.

Systemic Review: Neurological Deficits following Ventriculoperitoneal Shunt (VPS) Insertion.

A reduction in fluid absorption or an obstruction of normal outflow is a common cause of hydrocephalus. It typically requires medical attention, which frequently entails the placement of a ventriculoperitoneal shunt (VPS) to lower intracranial pressure. We intend to list the few, documented examples of neurological impairments resulting from the installation of a VPS in this systematic study. Two search engines (PubMed and Cochrane) were used to conduct a systematic review from 1975 to December 12, 2021. The following search terms were employed: neurological deficits or neurological injury or palsies or thalamus or tract or longitudinal fasciculus or somatotropy or fasciculus or hearing loss or hemisensory or cortico AND ventriculoperitoneal shunt or VPS AND hydrocephalus. The inclusion criteria included VPS, neurological deficits, and human participants. The exclusion criteria included ventriculoarterial shunt, lumboperitoneal shunt, nonhuman subjects, and infection. Twenty trials in total, including a total of 25 patients, were included. There were 17 case report studies. A total of 35/785 patients (4.46%) experienced neurological impairments. In 9/25 (36%) of shunt cases had one of the three recognized causes: trapped fourth ventricle, dandy walker, or syringomyelia. Most of the patients developed VI, VII nerve palsies 11/25 (44%) followed by weakness, cerebellar symptoms, and VI nerve palsy. The brainstem was seen to be the most often injured structure (15/25; 60%), followed by deep brain structures (thalamus, basal ganglia, and white matter tracts; 20%). Even though ventriculoperitoneal shunting is a routine and straightforward treatment, issues can still arise. Although rare, there have been reports of cranial nerve impairments, therefore care should be taken.

Coronavirus Disease 2019-Related Fulminant Idiopathic Intracranial Hypertension

AbstractIdiopathic intracranial hypertension or pseudotumor cerebri syndrome (PTCS) is defined as an increase in intracranial pressure (ICP) without an identifiable and/or structural cause or abnormal cerebrospinal fluid content. The most common symptoms of PTCS include headache, vomiting, pulsatile tinnitus, blurred vision, and diplopia. In 2 to 3% of PTCS patients, severe and rapidly progressive vision loss may develop within 1 month since symptoms begin; this clinical condition is usually defined as fulminant idiopathic intracranial hypertension (FIIH). This study presented a patient admitted to the hospital with headache and blurred vision, who also had high severe acute respiratory syndrome coronavirus 2 infections total antibody level and was treated with a lumboperitoneal shunt due to medical treatment-resistant increased ICP. We also reviewed similar cases previously reported in the literature. To the best of our knowledge, no children affected with coronavirus 2019 related to FIIH and requiring surgical treatment have been yet reported in the literature.

High prevalence of lumbar spinal stenosis in cases of idiopathic normal-pressure hydrocephalus affects improvements in gait disturbance after shunt operation

ObjectiveIdiopathic normal-pressure hydrocephalus (iNPH) is characterized by symptoms of dementia, urinary incontinence, and gait disturbance; however, gait disturbance tends to persist after shunt surgery. Gait disturbance and urinary dysfunction are also major symptoms of lumbar spinal stenosis (LSS). Currently, the epidemiology of the complications of LSS in iNPH is unclear. Here, we evaluated the coexistence rate of LSS in iNPH cases. MethodsThis was a retrospective case–control study. Between 2011 and 2017, 224 patients with a median age of 78 years, including 119 males, were diagnosed with iNPH and underwent lumboperitoneal shunts or ventriculoperitoneal shunts. LSS was diagnosed with magnetic resonance imaging by two spine surgeons. Age, sex, body mass index (BMI), Timed Up and Go (TUG) test, Mini Mental State Examination (MMSE) score, and urinary dysfunction were examined. We compared the changes in these variables in the group of patients with iNPH without LSS versus those with both iNPH and LSS. ResultsSeventy-three iNPH patients (32.6%) with LSS had significantly higher age and BMI. The existence of LSS did not alter the postoperative improvement rates of MMSE and urinary dysfunction; however, TUG improvement was significantly impaired in the LSS-positive group. ConclusionsLSS affects improvements in gait disturbance of iNPH patients after shunt operation. Because our results revealed that one-third of iNPH patients were associated with LSS, gait disturbance observed in iNPH patients should be considered a potential complication of LSS.

Syringopleural shunt for refractory syringomyelia: how I do it.

Surgical treatment of syringomyelia is directed at the reconstruction of the subarachnoid space and restoration normal cerebrospinal fluid flow. Direct intervention on the syrinx is a rescue procedure and should be offered to patients with refractory syringomyelia. We provide an overview on indications and technique of syringopleural shunt (SPS). The procedure involves the connection of syrinx with the pleural space using a lumboperitoneal shunt. The occurrence of a negative pressure inside the pleural compartment offers an appropriate gradient for drainage from the syrinx. The SPS allows for a safe and effective treatment of persistent syringomyelia when management of the underlying cause does not yield substantial improvement.

Optic disc vessel density changes after shunt surgery in idiopathic intracranial hypertension

AimTo detect the change in optic disc vessel density in patients with idiopathic intracranial hypertension (IIH) after shunt surgery. Patients and methodTwenty-one patients with IIH underwent shunt surgery. Patients were subjected to full ophthalmic and neurological examinations. Optic disc vessel density was measured using optical coherence tomography angiography (OCT-A) before and two months after surgery. ResultsThe age of patients ranged from 27 to 48 years old, with a mean of (34.85 ± 6.87). Visual acuity ranged between 0.2 and 0.9 by log Mar, with a mean of (0.64±o.20). The mean deviation (MD) of the perimeter ranged from -22.9 to 0 dB, with a mean of (-9.77 ± 7.23 dB). With respect to the grade of papilledema, 15 eyes (35.7%) were of grade II, 21 eyes (50.0%) were of grade III, and 6 eyes (14.3%) were grade IV.Intracranial pressure measured by lumbar puncture (LP) prior to surgery ranged from 30 to 40 cm, with a mean of 35.43 cm. Except for right transverse sinus hypoplasia in 6 patients (28.6%), MRV was normal. In 15 patients (71.4%), lumboperitoneal shunt was performed, while ventriculoperitoneal shunt was performed in 6 patients (28.6%).After surgery, the optical disc vessel density was decreased in all patients. This decrease was highly significant for the whole image, the inner disc, the peripapillary, superior, and inferior hemispheres. Moreover, this reduction affected both optic disc microvasculature (referred to as capillary vessel density) and macro vasculature (also known as all vessel density).There were positive correlations between the CSF opening pressures and the preoperative optic disc vessel density of the whole image and inside disc with a P-value (0.002, 0.009), respectively. In addition, there was a positive correlation between the opening CSF pressures and the reduction in whole image vessel density after surgery with a P-value of 0.000. ConclusionOptic disc vessel density decreased after shunt surgery in patients with IIH. Consequently, optic disc vessel density can be used as a biomarker for the reduction of CSF opening pressure.

Epidural Labor Analgesia and Epidural Surgical Anesthesia in a Patient with Idiopathic Intracranial Pressure with Lumbo-peritoneal Shunt: a rare case report

Background: Idiopathic Intracranial Hypertension (IIH) is due to an increased intracranial pressure with no secondary cause of intracranial hypertension and normal Cerebrospinal fluid (CSF) composition. IIH’s prevalence is high among obese women of childbearing age and subsequently coincides with pregnancy. Symptoms vary among patients and commonly present headaches and visual impairment. If untreated, it may steer persistent headaches and lasting visual impairment such as diplopia and scotoma or even blindness. Case Report: We hereby present the uncommon case of an epidural anesthesia for cesarean section in a patient with idiopathic intracranial hypertension and Lumbo-peritoneal shunt that presented to our obstetrics department in labor. First, epidural labor anesthesia (ELA) with a catheter placed above the LP shunt scar was the chosen course of action. However, ELA was converted to an epidural surgical anesthesia (ESA) for acute fetal distress secondary to a placental abruption. Conclusion: IIH usually occurs in pregnant women at any trimester. If undiagnosed or poorly managed, it can lead to drastic complications. As uncommon as it may be, all medical practitioners should be familiar with this pathology even though its diagnostic and treatment are exacting. While the optimal anesthetic management is still controversial, epidural anesthesia proved to be very effective.

Fulminant Idiopathic Intracranial Hypertension Refractory to Treatment Associated to SARS-CoV-2: A Case Report (P14-4.004)

<h3>Objective:</h3> NA <h3>Background:</h3> Idiopathic Intracranial Hypertension (IIH) is characterized by increased intracranial pressure, which most frequently occurs in childbearing-age obese women. Scarce reports of COVID-19 infection associated IIH exist and have only described this in women and children. “Fulminant IIH” is defined as intracranial hypertension without secondary cause, with severe vision loss within 4 weeks of onset, and progressive vision loss over days. A 36-year-old man with obesity came to the Ophthalmology clinic for evaluation of vision loss and headache, the patient tested positive for SARS-CoV-2 one month before this. He was identified to have bilateral grade V papilledema, confirmed with optical coherence tomography (OCT), and admitted to Neurology for IIH management. The patient was started intravenous therapy with high-dose steroids and acetazolamide without relief of headache or vision improvement (20/100). Lumbar puncture was performed, revealing an opening pressure of ≥55 cm H20. The MRI only showed findings of increased intracranial hypertension, and the MRV ruled out thrombosis. The lack of improvement in his headaches and vision loss ultimately required ventriculoperitoneal shunt placement. The patient had immediate subjective visual improvement after this, with unchanged visual acuity. On follow-up 4 weeks later, the patient continued to have headaches and the opening pressure was 30 cm H20. Lumboperitoneal shunt was placed. Both optic nerves became completely atrophic. Despite finally reaching an opening pressure of 15 cm H20, headaches did not resolve, and the patient currently only perceives light. <h3>Design/Methods:</h3> NA <h3>Results:</h3> NA <h3>Conclusions:</h3> This case represents, to our best knowledge, the first description of fulminant IIH associated with SARS-CoV-2. The previous reports described mild to moderate cases in women and children with response to treatment. This occurred to an adult male who despite receiving promptly treatment, had a poor response. Further studies are needed to determine if atypical clinical phenotypes are associated with refractory forms. <b>Disclosure:</b> Dr. Murguia Fuentes has nothing to disclose. Mr. Murguia Fuentes has nothing to disclose. Dr. Adamu has nothing to disclose. Dr. Carvajal- Gonzalez has nothing to disclose. Dr. Arvas has nothing to disclose.

Lumboperitoneal shunt using fluoroscopy and a peel-away sheath

BackgroundAfter placement of the spinal catheter into the spinal canal during lumboperitoneal shunt (LPS) placement, the spinal catheter needs to be connected to the programmable valve. Although surgeons always try to secure the spinal catheter position during procedures, it may be accidentally pulled and displaced. This article aimed to introduce a “one-piece method” of LPS using fluoroscopy and peel-away sheath without connecting the spinal catheter to the programmable valve. MethodsAn abdominal shunt catheter, valve, and spinal shunt catheter were connected and tunneled to the back for insertion into the lumbar spinal subarachnoid space. The spinal catheter was cut to a length of 15 cm. Lumbar puncture was performed using a 14-gauge Tuohy needle inserted at the L2-3 intervertebral space using an image-guided paramedian technique, and a 0.035-inch guidewire was passed gently through the Tuohy needle under fluoroscopic guidance. The Tuohy needle was withdrawn, and a 5-Fr peel-away sheath was advanced over the wire. The dilator and guide wire were removed, the distal end of the 5-Fr peel-away sheath was checked to ensure that the cerebrospinal fluid flowed out, and the spinal shunt catheter was passed down the sheath. After confirming under fluoroscopic guidance that the catheter was properly positioned, the peel-away sheath was removed. ResultsLPS was performed using this method in seven patients without complications. ConclusionThis simple “one-piece method” using fluoroscopy and peel-away sheath is safe and effective for positioning the spinal catheter.

Safety of laparoscopic cholecystectomy in patients with a cerebrospinal fluid shunt in the peritoneal cavity.

The management of patients with a cerebrospinal fluid (CSF) shunt located in the peritoneal cavity undergoing laparoscopic surgery is an issue that has not yet been settled. These patients are at risk of increased intracranial pressure caused by peritoneal insufflation, shunt dysfunction, and shunt infection/retrograde meningitis. This study aimed to determine the need for perioperative shunt intervention in CSF shunt patients undergoing laparoscopic cholecystectomy. We reviewed and analyzed five shunt patients who underwent laparoscopic cholecystectomy in our institution between 2012 and 2022, as well as 17 patients described in previous reports. Among the 22 patients, shunt type was ventriculoperitoneal in 14 and lumboperitoneal in eight. The most common indication for CSF shunt was hydrocephalus caused by cerebral vascular accident (50.0%). Laparoscopic cholecystectomy was performed for cholecystolithiasis in 13 patients (59.1%), acute cholecystitis in eight (36.4%), and gallbladder polyp in one (4.5%). Shunt clamping or externalization was performed in six patients. Two patients in the group that did not undergo shunt clamping or externalization experienced complications (intra abdominal abscess and subcutaneous emphysema). However, the incidence of short-term complications (both overall and shunt-related) and median length of hospital stay did not significantly differ between the two groups. Routine shunt clamping, externalization, or removal might not be necessarily required in patients with a ventriculoperitoneal or lumboperitoneal shunt undergoing laparoscopic cholecystectomy.

Clinical Outcome and Safety of Lumboperitoneal Shunt in the Treatment of Non-Obstructive Hydrocephalus.

This study aimed to evaluate the functional outcomes of lumboperitoneal (LP) shunt for the treatment of non-obstructive hydrocephalus. We retrospectively studied the clinical surgical results of 172 adult patients with hydrocephalus who underwent LP shunt surgery between June 2014 and June 2019. Data regarding the following were collected: pre- and postoperative symptom status, third ventricle width changes, Evans index, and postoperative complications. Additionally, the baseline and follow-up Glasgow Coma Scale (GCS) score, Glasgow Outcome Scale (GOS), and Modified Rankin Scale (mRS) scores were investigated. All patients were followed up for ≥12 months using clinical interview and braining imaging using computed tomography (CT) scan or magnetic resonance imaging (MRI). Majority of patients presented with normal pressure hydrocephalus as the etiology of their disease (48.8%), followed by cardiovascular accident (28.5%), trauma (19.7%), and brain tumor (3%). The mean GCS, GOS, and mRS improved postoperatively. The average period from symptomatic onset to surgery was 402 days. The average width of the third ventricle on CT scan or MRI was 11.43 mm preoperatively and 10.8 mm postoperatively (P<0.001). The Evans index improved from 0.258 to 0.222 after operation. The symptomatic improvement score was 7.0, with a complication rate of 7%. Significant improvement was observed in the functional score and brain image after LP shunt placement. Moreover, the satisfaction with symptomatic improvement after surgery remains high. LP shunt operation is a viable alternative in the treatment of non-obstructive hydrocephalus due to the low complication rate, fast recovery, and high satisfaction.

Perioptic cerebro-spinal fluid transudation: case report of an unusual finding of optic hydrops in idiopathic intracranial hypertension

BackgroundIdiopathic intracranial hypertension (IIH) has well-described imaging findings, typically reversible with the adequate treatment. We hereby report a case of IIH with a peculiar imaging finding, that to our knowledge and by the research conducted, has never been described before—cerebro-spinal fluid (CSF) transudation across the optic nerve sheath.Case presentationA 15-year-old girl with a 2-week history of occipital headache, nausea and vomiting, diplopia, blurred vision and tinnitus in her right ear, was admitted in the neuropediatric department and after extensive diagnostic work-up was diagnosed with IIH. The MRI showed typical signs of idiopathic intracranial hypertension, including enlargement of the perioptic CSF spaces associated with a peculiar finding described as a blurred hyperintensity T2/FLAIR of the perioptic fat, which was likely related to transudation of CSF. The adequate medical therapy (including corticosteroids and acetazolamide) for 2 weeks didn’t revert the signs and symptoms and so a lumboperitoneal shunt was placed with complete resolution of the clinical picture and the imaging findings described.ConclusionsThe documentation of CSF transudation around the optic nerve in the setting of hydrops has never been reported before and should be recognized by the neuroradiologist. It seems to be reversible, like the other findings of IIH and its physiopathology is not clear.

Freehand Ventriculoperitoneal Shunt for Idiopathic Intracranial Hypertension: Technical Note for Slit-Like Ventricle Puncture.

Idiopathic intracranial hypertension (IIH) is a syndrome characterized by elevated intracranial pressure, headache, and papilledema. It is frequently associated with obese women and can result in irreversible vision loss. The ventriculoperitoneal (VP) shunt has been proven to be superior to the lumboperitoneal (LP) shunt in IIH patients, with better clinical outcomes. It has been reported that the accurate placement of the ventricular catheter is highly important for shunt survival. However, a slit-like ventricle pattern, typically seen in the disease, has been considered a great concern and challenge for ventricular catheter placement, primarily for freehand technique. Frameless stereotaxy, ultrasound, and endoscopy have been described to improve the accuracy of catheter insertion. However, intraoperative image guidance is not widely accessible, especially in lower-resource countries, due to the high costs associated with its use. Techniques to improve the accuracy of the freehand VP shunt in IIH are scarce in the literature, and any effort to contribute to its development is valuable and helpful.

Laparoscopic-assisted intraperitoneal placement of lumboperitoneal shunt in patients with idiopathic intracranial hypertension

BackgroundLumboperitoneal (LP) shunting is an effective treatment option aiming at cerebrospinal fluid diversion in cases of idiopathic intracranial hypertension. Confirming the distal end position, on the other hand, could be technically difficult, especially in obese people. With minimal invasive procedures, laparoscopic-assisted placement of the peritoneal side of the LP shunt became a valid treatment option. In this study, we aim to evaluate the operation duration, possible complications, and patient outcomes after the placement of a peritoneal catheter using the laparoscopically assisted technique.MethodsA retrospective analysis of clinical, preoperative, and postoperative data for 18 patients diagnosed with idiopathic intracranial hypertension and undergoing LP shunt surgery using the laparoscopic-assisted technique for intraperitoneal catheter placement between 2019 and 2021 was performed.ResultsThe average operating time was 93.89 min, and the average hospital stay was 2.3 days. There was no mortality among cases treated with the described technique, and no intraoperative complication occurred. Seven patients (38.9%) had LP shunt failure, with a median duration to failure of 212 days; three cases for slippage, two cases had over drainage, one case had peritoneal adhesions around the shunt tip, and one case had Arnold Chiari malformation.ConclusionsThe laparoscopic assisted technique is safe and feasible. It allowed a direct vision of the shunt tip position within the peritoneal cavity which helped in confirming position and assessing function, resulting in a superior option over classic surgical options. Short hospital stay, minimal postoperative pain, and low failure rates are the main advantages of described technique.

Oblique Angled Retractor for Lumboperitoneal Shunt Implantation via Lateral Abdominal Laparotomy.

A normal retractor often interferes with the ribs and/or thighs of the ipsilateral side when the skin and abdominal muscles are towed while performing the lumboperitoneal shunt (LPS) procedure in the lateral position. To overcome this, we developed an obtuse-angled retractor. We modified the traditional retractors into oblique-angled retractors. The blade of the new retractors was bent to 60 degrees, the entire blade was thinned, and the tip of the blade was tapered. To date, we have performed approximately 30 LPS procedures in the lateral position using the new oblique-angled retractor and confirmed its usefulness. An oblique-angled retractor helps confirm the accurate placement of the tip of the retractor blades, even in obese patients in whom the retractor often interferes with the ribs and/or thighs.