Patients Required Shunt Revision Research Articles

The outcome of surgical management of post-infectious hydrocephalus with multiple intraventricular septations

ObjectivesPost-infection hydrocephalus with multiple intraventricular septations is a complex issue in neurosurgery, with multiple treatment options available. The authors reviewed the results of neuroendoscopic cyst wall fenestration for managing this disease.Materials and MethodsMedical records of 76 patients with post-infection hydrocephalus and multiple intraventricular septations who underwent endoscopic treatment were collected and analyzed.ResultsThe patient group consisted of 40 males (52.6%) and 36 females (47.4%), with a mean age of 22.36 months (range: 4–132 months). Bacterial meningitis was the most common cause of hydrocephalus with multiple intraventricular septations in 37 patients (48.6%), while 24 patients had post-shunt infection (31.6%) that was complicated with multiloculated hydrocephalus. After confirming clearance of CSF infection, all patients underwent ventriculoscopic cyst fenestration and insertion of a ventriculoperitoneal shunt to create a single communicating system drained by one ventricular catheter. Fifty-five patients underwent De novo shunt implantation, while 20 patients required shunt revision. Endoscopy reduced the shunt revision rate from 3.4 per year before fenestration to 0.4 per year after fenestration. During the mean follow-up period of 7.7 months (range: 1–20 months), complications were reported in 13 patients (17.1%), including CSF leakage in eight (10.5%), VPS malfunction in five (6.5%), and two deaths (2.6%).ConclusionThe authors concluded that neuroendoscopic fenestration with the aid of CSF drainage by intraventricular catheter is an effective treatment for managing multiloculated post-infection hydrocephalus with much lower rates of morbidity and mortality than traditional procedures.

Risk of ventriculoperitoneal shunt malfunction in operatively treated early onset spinal deformity.

Ventriculoperitoneal (VP) shunt placement is a common neurosurgical procedure performed in patients with early onset scoliosis (EOS). To provide insight into the risks of spine lengthening operations, we investigate the rate of VP shunt complications in patients with EOS undergoing spinal deformity correction interventions. A retrospective review was performed of all patients with EOS at a single institution undergoing spinal deformity correction procedures from 2007 to 2018. Patients having undergone VP shunt implantation prior to deformity correction were included. A minimum of 2-year follow-up was required for inclusion. Clinical records and imaging studies were reviewed. Nineteen patients with VP shunts underwent Vertical Expandable Prosthetic Titanium Rib (VEPTR) implantation for treatment of early onset spinal deformity. The mean age at shunt placement and spine instrumentation surgery was 13.7months (1day to 13years) and 6.1years (0.5-15.1) respectively. The diagnoses associated with shunt implantation were: 12 spina bifida, 3 structural defects or obstructions, 2 intraventricular hemorrhage, 1 cerebral palsy, and 1 campomelic dwarfism. During the first 2years following rib-based insertion, there was a mean of 2.5 expansion/revision procedures (0-5) with no shunt-related complications. The mean length of follow-up in this series was 7.0years (2.6-13.2). A total of three (16%) patients required shunt revision following their rib-based device insertion, two patients with proximal shunt malfunctions and one with a mid-catheter breakage, at 2.4, 2.6, and 5.6years, respectively, after rod implantation (Fig.2). Each of these shunt revisions occurred more than 50days following an expansion procedure (1.9, 2.9, and 5.7months, respectively). Growing instrumentation procedures in EOS are associated with low risk for post-operative shunt complications in patients with ventriculoperitoneal shunts. There were no shunt revision procedures performed in the first 2years following rib-based device insertion. Sixteen percent of patients went on to require a shunt revision at some point during their follow-up, which is comparable to the baseline rate of shunt revision in non-EOS patients. IV, Case series.

Hidrocefalijos revizinių operacijų priežastys

Darbo tikslasNustatyti pacientų, sergančių hidrocefalija, pakartotinių operacijų dažnį ir priežastis. Įvertinti šunto revizijos poreikio bei vožtuvo gedimo dažnio priklausomybę nuo hidrocefalijos etiologijos, likvoro priešoperacinio slėgio, implantuoto vožtuvo gamintojo bei drenuoto smegenų skilvelio rago.Ligoniai ir metodaiRetrospektyviai išanalizuoti operacijų protokolai bei epikrizės visų 130 pacientų, kuriems nuo 2007 m. vasario 1 d. iki 2014 m. sausio 31 d. VšĮ Respublikinės Vilniaus universitetinės ligoninės (RVUL) Neurochirurgijos skyriuje atlikta 214 ventrikuloperitoneostomijos (VPS) operacijų dėl hidrocefalijos (HC). Rinkti duomenys: HC etiologija, likvoro slėgis prieš operaciją, operacijų skaičius, pakartotinių operacijų priežastys, drenuotas ragas, implantuotas vožtuvas bei nustatytas vožtuvo atsidarymo slėgis. Tarpusavyje lyginant pacientus pagal implantuotus skirtingų gamintojų vožtuvus, HC priežastis ir likvoro slėgį prieš operaciją, ieškota statistiškai patikimų koreliacijų su vožtuvo gedimo ir revizijos poreikio dažniu. Duomenys statistiškai apdoroti SPSS 22.0 programa.RezultataiPasiskirstymas pagal lytį: 49 % vyrų, 51 % moterų. Amžius svyravo nuo 20 iki 83 metų, amžiaus vidurkis 55±15,0 metų. 55 metų amžiaus arba jaunesni buvo 61 (46,9 %) pacientas, vyresni nei 55 metų – 69 (53,1 %) pacientai. Aptariamuoju laikotarpiu atlikta 214 VPS operacijų. Vieną kartą operuoti 84 (64,6 %) pacientai, pakartotinai – 46 (35,4 %) pacientai, kai kurie po keletą kartų. Nustatytos pakartotinės operacijos priežastys – galvinio kateterio užsikimšimas konstatuotas 2,17 % atvejų, vožtuvo gedimas – 30,43 % atvejų, pilvinio kateterio užsikimšimas – 10,87 %, mišrus šunto sistemos blokas – 23,92 %, šunto migracija – 10,87 %, sistemos šalinimas dėl infekcijos – 19,57 %, tiksli priežastis nenustatyta – 2,17 %. Dažniausia pakartotinės operacijos priežastis – vožtuvo gedimas. Tarpusavyje lyginant implantuotų skirtingų gamintojų vožtuvų – „Codman“, „Sophysa“, „Medtronic“ – gedimo dažnį, statistiškai reikšmingo skirtumo nerasta (p>0,05). Taip pat vožtuvo gedimo dažnis nesiskyrė drenavus priekinį ar užpakalinį ragą (p>0,05). Tačiau 55 metų amžiaus ir jaunesniems pacientams šunto revizijos reikėjo dažniau nei vyresniems (p=0,047). Be to, vožtuvas gedo gerokai dažniau, kai likvoro slėgis prieš operaciją buvo žemas, palyginti su vidutiniu (p=0,035) ir aukštu (p=0,036) likvoro slėgiu prieš operaciją. Nustatyta patikima atvirkštinė koreliacija – likvoro takų stenozės atveju vožtuvas genda daug rečiau nei esant kitoms HC priežastims (p=0,012).IšvadosPakartotinės VPS operacijos prireikė 35,4 % pacientų. Dažniausia pakartotinės operacijos priežastis – vožtuvo gedimas. Pacientų amžius pirmosios operacijos metu, HC etiologija, likvoro slėgis prieš operaciją reikšmingai susiję su vožtuvo gedimo dažniu ir revizijos poreikio dažniu. Vožtuvo gedimo dažnis ir šunto revizijos poreikis nepriklauso nuo implantuoto šunto gamintojo ir drenuoto rago.

Dorsal third ventricular cysts revisited

We have previously argued that the clinical entity of dorsal third ventricular cyst in association with agenesis of the corpus callosum is a developmentally, radiologically, and clinically distinct and separate entity from the dorsal cyst of alobar holoprosencephaly. Herein, we describe seven patients who underwent treatment of their dorsal third ventricular cyst with fluid diversion and shunting and report their long-term follow-up. The authors reviewed the literature and discrepancies identified in differentiating dorsal third ventricular cysts and holoprosencephaly. Postoperative scans showed evidence of cyst decompression and stabilization of head circumference. Two patients required shunt revision surgery for delayed malfunction while the remainder has had no revision surgery since initial placement. Given the good clinical outcome in comparison to alobar holoprosencephaly patients, we recommend fluid diversion in this population of patients.

Is cerebrospinal fluid shunting in idiopathic intracranial hypertension worthwhile? A 10-year review

The role of cerebrospinal fluid (CSF) diversion in treating idiopathic intracranial hypertension (IIH) is disputed. We conducted a 10-year, retrospective case note review to evaluate the effects of CSF diversion in IIH. Symptoms, signs and details of shunt type, complications and revisions were documented at baseline, 6, 12 and 24 months post-operatively. Fifty-three IIH patients were shunted [predominantly lumboperitoneal (92%)]. The most common symptom pre-surgery was headache (96%). Post-operatively, significantly fewer patients experienced declining vision and visual acuity improved at 6 (p = 0.001) and 12 months (p = 0.016). Headache continued in 68% at 6 months, 77% at 12 months and 79% at 2 years post-operatively. Additionally, post-operative low-pressure headache occurred in 28%. Shunt revision occurred in 51% of patients, with 30% requiring multiple revisions. We conclude that CSF diversion reduces visual decline and improves visual acuity. Unfortunately, headache remained in the majority of patients and low-pressure headache frequently complicated surgery. Over half of the patients required shunt revision with the majority of these requiring multiple revisions. We suggest that CSF shunting should be conducted as a last resort in those with otherwise untreatable, rapidly declining vision. Alternative treatments, such as weight reduction, may be more effective with less associated morbidity.

Transjugular intrahepatic portosystemic shunt for refractory ascites: results in 50 patients

In this prospective cohort study, we evaluated the use of transjugular intrahepatic portosystemic shunt (TIPS) in 50 patients with refractory ascites and a Child-Pugh score of 9.8. The mean duration of follow-up was 592 days. Ascites improved in 96% at 1 year and in 93% at 2 years. The cumulative survival rate was 71%, 52% and 18% at 1, 2 and 5 years. The Child-Pugh score and the performance status score improved significantly after TIPS. Thirty six patients required shunt revision during follow-up, due to shunt stenosis. Hepatic encephalopathy which was able to be controlled medically occurred in 26 patients. Our results suggest that although shunt revision may be needed, TIPS can control refractory ascites in most survival cases and improve QOL. However, the 5-year survival rate is still low in our TIPS-treated patients with refractory ascites.

Myelomeningocele: long-term neurosurgical treatment and follow-up in 202 patients

In this paper the authors focus on the long-term management of myelomeningocele (MMC) and its associated conditions. During a 25-year period, 220 consecutive patients with MMC underwent surgical repair. There were 203 cases (92%) of enlarged ventricles, but only 171 cases (78%) of hydrocephalus. Seven infants (3%) presented with early brainstem dysfunction; two improved after ventricular drainage, whereas five required craniocervical decompression. Overall, five neonates (2%) died; 215 patients (98%) were eventually discharged from the hospital and of these, 202 (94%) remained in the authors' outpatient program. During the follow-up (range 1-25 years, mean 9.3 years), 96 patients required shunt revision (63% of shunts); 16 patients (8%) experienced late brainstem dysfunction that was treated by shunt placement in eight and by craniocervical decompression in the other eight; 137 patients (68%) harbored hydrosyringomyelia, but only six required surgical treatment; 40 patients (20%) presented symptoms of tethered cord, but surgical detethering was indicated in just 22 patients (11%). There were five deaths (2%), and severe adjunctive neurological morbidity was reported in 18 patients (9%) (owing to various causes). "Social" results have been evaluated by extrapolating 38 patients older than 15 years of age whose initial lesions were below L-2: 37 (97%) of these patients were fully independent, had "social urinary continence," and attended normal schools. Currently, many patients with MMC reach adulthood and social continence; self-care may be expected in a large percentage of cases. Nevertheless, there are many associated neurological conditions that have to be faced, and a coordinated network of care remains necessary throughout the patient's life. Moreover, these patients often present with so many peculiarities that indications for treatment, choice of proper techniques, and results are not always clear and evident.

Retrospective Review of Multilevel Spinal Fusion Combined With Spinal Cord Transection for Treatment of Kyphoscoliosis in Pediatric Myelomeningocele Patients

Retrospective review of cases at a single institution from 1998 to 2005. The authors present their surgical experience, complications, and learned insight in 9 myelomeningocele children with kyphoscoliosis treated with combined spinal cord transection and spinal fusion. Complication rates in spinal fusion for treatment of kyphoscoliosis in myelomeningocele patients are high. Spinal cord transection in combination with fusion can be an appropriate strategy in selected patients, but changes in cerebrospinal fluid (CSF) dynamics that may accompany ligation of the distal CSF circulation are not well characterized. Demographic, clinical, and radiologic data were examined in 9 children with myelomeningocele level at or above T12 and no residual urologic function treated at our institution with spinal cord detethering and transection, and multilevel spinal fusion. Seven children underwent kyphectomy with posterior fusion only for severe gibbus deformities, while 2 had anterior and posterior fusions for severe kyphoscoliosis. Follow-up of patients ranged from 4 to 92 months (mean, 37.8 months). Eight children (89%) experienced postoperative complications involving wound infection or skin breakdown. One child presented with a CSF leak. Two children (22%) required revision of their ventriculoperitoneal shunts. The average angle of kyphosis before surgery was 122.3 (range, 48 degrees -180 degrees ), and the average postoperative angle was 38.2 (range, 4 degrees -113 degrees ), with average correction being 81.9 degrees (range, 29 degrees -124). Average correction of scoliosis, if present, was 59.5 degrees (range, 35 degrees -92 degrees ). Combined spinal cord transection and spinal fusion allowed an average correction of kyphosis by 81.9 degrees . The complication rate was 89%, with wound concerns being the most significant. Additionally, 22% of patients required shunt revision within 6 weeks of surgery. We attribute this to alteration of CSF dynamics resulting from loss of CSF absorption and flow-buffering capacity below the level of the spinal cord transection.

Budd-Chiari syndrome: current management options.

To assess the outcomes of current treatment strategies for Budd-Chiari syndrome. Budd-Chiari syndrome, occlusion or obstruction of hepatic venous outflow, is a disease traditionally managed by portal or mesenteric-systemic shunting. The development of other treatment options, such as catheter-directed thrombolysis, transjugular portosystemic shunting (TIPS), and liver transplantation, has expanded the therapeutic algorithm. The authors reviewed the medical records of all patients diagnosed with Budd-Chiari syndrome at the Johns Hopkins Hospital during the past 20 years. A total of 54 patients were identified: 13 (24%) male patients and 41 (76%) female patients, ranging in age from 2 to 76 years (median 33 years). Twenty-one (39%) had polycythemia vera, 3 (5.6%) used estrogens, 11 (20%) had a myeloproliferative or coagulation disorder, and in 7 (13%) the cause remained unknown. Forty-three patients were treated with surgical shunting, 24 mesocaval and 19 mesoatrial. Actuarial survival rates at 1, 3, and 5 years after shunting were 83%, 78%, and 75%, respectively. Of 33 patients surviving more than 4 years, 28 (85%) had relief of clinical symptoms. Five patients required shunt revision and eight had radiologic procedures to maintain shunt patency. Primary and secondary shunt patency rates were 46% and 69% respectively for mesoatrial shunts and 70% and 85% respectively for mesocaval shunts. Clot lysis was successful as primary treatment in seven patients. TIPS was performed in three patients, one after a failed mesocaval shunt. During an average of 4 years of follow-up, these patients required multiple procedures to maintain TIPS patency. Six patients underwent liver transplantation. Of these, three had previous shunt procedures. Five of the transplant recipients are alive with follow-up of 2 to 9 years (median 6). Both shunting and transplantation can result in a 5-year survival rate of at least 75%, and other treatment modalities may be appropriate for highly selected patients. Optimal management requires that treatment be directed by the predominant clinical symptom (liver failure or portal hypertension) and anatomical considerations and be tempered by careful assessment of surgical risk.

Transjugular intrahepatic portosystemic shunt for treatment of bleeding ectopic varices with portal hypertension.

In the setting of hepatic failure and portal hypertension, hemorrhage from stomal and rectal varices is a well-described problem. It has recently been suggested that transjugular intrahepatic portosystemic shunting may be useful in the therapy of bleeding from parastomal or anorectal varices in patients unresponsive to conservative therapy. We retrospectively review our institution's experience of five patients with parastomal varices and seven patients with anorectal varices who underwent transjugular intrahepatic portosystemic shunting for hemorrhage refractory to conservative management between 1994 and 1998. The study group consisted of four Child's A, five Child's B, and three Child's C patients. The mean age of the patients was 60.3 (range, 37-85) years. Mean follow-up was 15 (range, 5-27) months. The mean portosystemic pressure gradient before transjugular intrahepatic portosystemic shunting was 17.4+/-3.1 mm Hg. After transjugular intrahepatic portosystemic shunting, the mean portosystemic pressure gradient was reduced to 5.8+/-1.8 mm Hg (P<0.05). Transjugular intrahepatic portosystemic shunting were successful in complete resolution of bleeding in all patients. Three patients had encephalopathic changes after transjugular intrahepatic portosystemic shunting. Two patients died within 30 days of transjugular intrahepatic portosystemic shunting of causes unrelated to the procedure. Four patients required shunt revision within one year of placement. The transjugular intrahepatic portosystemic shunting procedure is an effective modality in the therapy of cirrhotic patients with bleeding stomal or anorectal varices unresponsive to conservative management. There is an acceptable procedure-related morbidity and mortality.

Ventricular CSF Shunt Infections Associated With Corynebacterium jeikeium: Report of Three Cases and Review

Ventricular CSF shunt infections due to Corynebacterium jeikeium are rare. Such infections may become manifest weeks to months after surgery. They are difficult to eradicate and often recur. We report three cases of C. jeikeium ventricular CSF shunt infections, all of which occurred in patients who received long-term prophylactic therapy with antibiotics and had protracted hospitalizations. Two patients had multiple recurrences, and all patients required shunt revision. Additional therapy with intrathecal vancomycin for 6-10 days after surgery was effective for this unusual cause of ventricular CSF shunt infection. On the basis of our experience and a review of six previously published case reports, we recommend CSF sterilization with intravenous and intrathecal vancomycin, followed by replacement of shunt hardware.

Ventricle to sagittal sinus shunt for hydrocephalus.

A technique of shunting the lateral ventricle to the superior sagittal sinus is described. It has been used in 36 adult patients; infection occured in 2 patients (5.6%), and 2 patients required shunt revision (5.6%). The outcome of 18 patients with high pressure hydrocephalus could be validly evaluated, and successful control was achieved in 15 (83%). One of the 3 failures could have been avoided because shunting was undertaken before the ventricular fluid had cleared of blood. Four patients with normal or low pressure hydrocephalus were treated; only 1 had a successful result. This technique is suitable for patients with high pressure hydrocephalus and is of particular value in very ill or debilitated patients because of the rapidity with which it can be performed under local analgesia. Its use in normal or low pressure hydrocephalus must still be evaluated. In any event, the sagittal sinus is certainly a feasible alternate receptor site for ventricular shunting.