Permanent Ventriculoperitoneal Shunt Research Articles

Anterior interhemispheric vs. pterional approach in the microsurgical management of anterior communicating artery aneurysms: a comparative analysis employing a novel multidimensional matching-tool

The surgical management of anterior communicating artery aneurysms (AcomA) is challenging due to their deep midline position and proximity to complex skull base anatomy. This study compares the pterional craniotomy with the interhemispheric approach based on the specific aneurysm angulation. A total of 129 AcomA cases were analyzed, with 50 undergoing microsurgical clipping via either the pterional or interhemispheric approach. All selected cases had computed tomography-angiography with sagittal imaging slices and 2D-angiography. Using an interactive tool, 14 cases treated via the interhemispheric approach were matched with 14 cases approached pterionally based on clinical and morphological parameters, emphasizing intracranial aneurysm (IA) dome angulation relative to the frontal skull base. Outcomes included IA occlusion, temporary clipping incidence, intraoperative rupture, postoperative strokes, hemorrhages, hydrocephalus, vasospasm, and patient functionality. Matched cohorts had consistent demographics. Both approaches resulted in similar IA occlusion rates, but the interhemispheric approach led to improved clinical outcomes, measured by the modified Rankin Scale. It also had a lower incidence of hydrocephalus and reduced need for permanent ventriculoperitoneal shunt placement. Vasospasms and postoperative infarction rates were comparable between the groups. Our findings suggest potential advantages of the interhemispheric approach in managing AcomA, depending on aneurysm angulation. Despite a small sample size, the results highlight the importance of customized surgical decision-making based on the unique traits of each aneurysm and the surgeon's expertise.

An 11-month-old boy with tuberculous meningitis presenting as progressive limb weakness, fever, developmental retardation, and loss of consciousness: a case report

BackgroundTuberculous meningitis (TBM) accounts for about 1% of all tuberculosis cases and about 5% of extrapulmonary tuberculosis cases. However, it poses major importance because approximately half of those affected die or become severely disabled. Herein, the successful treatment of an 11-month-old boy with progressive limb weakness, fever, developmental retardation, and loss of consciousness due to tuberculosis, was reported.Case presentationAn 11-month-old (Iranian Turk) boy was referred to Loghman Hakim hospital for progressive limb weakness and loss of previously attained developmental milestones for the past 2 months. He also had persistent fever and loss of consciousness for about 14 to 21 days. Before being referred to our center, the patient had been diagnosed with hydrocephalus at another center due to possible acute bacterial meningitis based on a CT scan and MRI imaging. On physical examination, anterior fontanel bulging and neck stiffness were observed on the admission. His body temperature and heart rate were 38.1 C and 86 beats per minute (bpm), respectively. He had left 6 cranial nerve palsy and spastic quadriparesis with a power of grade 3/5. Other systemic examinations were normal. Endoscopic third ventriculostomy (ETV) (and leptomeningeal biopsy) revealed diffuse thickening of the floor and lateral walls of the 3rd ventricle and also a cobblestone appearance in the form of multiple white patchy lesions was detected on the floor of the 3rd ventricle. CSF analysis and polymerase chain reaction confirmed the TB meningitis. During hospitalization, a temporary EVD (external ventricular drain) was initially inserted. Eventually, defervescence was denoted 5–6 days after initiation of anti-TB medications, and a permanent ventriculoperitoneal shunt was inserted due to hydrocephalus. Gradually his truncal and limb tone and motor function improved, as did his emotional responses to his parents and ability to eat. The patient can walk without help in the 15th month following the operation and resolved hydrocephalus demonstrated on follow-up imaging.ConclusionOver half of treated TB meningitis patients die or suffer severe neurological sequelae, mainly due to late diagnosis. Hence, early diagnosis and prompt initiation of TB treatment offer the best chance of a good neurological outcome.

Early prediction of ventricular peritoneal shunt dependency in aneurysmal subarachnoid haemorrhage patients by recurrent neural network-based machine learning using routine intensive care unit data.

Aneurysmal subarachnoid haemorrhage (aSAH) can lead to complications such as acute hydrocephalic congestion. Treatment of this acute condition often includes establishing an external ventricular drainage (EVD). However, chronic hydrocephalus develops in some patients, who then require placement of a permanent ventriculoperitoneal (VP) shunt. The aim of this study was to employ recurrent neural network (RNN)-based machine learning techniques to identify patients who require VP shunt placement at an early stage. This retrospective single-centre study included all patients who were diagnosed with aSAH and treated in the intensive care unit (ICU) between November 2010 and May 2020 (n = 602). More than 120 parameters were analysed, including routine neurocritical care data, vital signs and blood gas analyses. Various machine learning techniques, including RNNs and gradient boosting machines, were evaluated for their ability to predict VP shunt dependency. VP-shunt dependency could be predicted using an RNN after just one day of ICU stay, with an AUC-ROC of 0.77 (CI: 0.75-0.79). The accuracy of the prediction improved after four days of observation (Day 4: AUC-ROC 0.81, CI: 0.79-0.84). At that point, the accuracy of the prediction was 76% (CI: 75.98-83.09%), with a sensitivity of 85% (CI: 83-88%) and a specificity of 74% (CI: 71-78%). RNN-based machine learning has the potential to predict VP shunt dependency on Day 4 after ictus in aSAH patients using routine data collected in the ICU. The use of machine learning may allow early identification of patients with specific therapeutic needs and accelerate the execution of required procedures.

Role of EVD Placement in Patients with Hydrocephalus Secondary to Subarachnoid Hemorrhage and Need for Permanent Ventriculoperitoneal Shunt Placement

Background: Subarachnoid hemorrhage (SAH), often caused by aneurysm rupture, is a critical neurosurgical condition frequently leading to hydrocephalus. Management typically involves the use of an external ventricular drain (EVD) to reduce intracranial pressure and drain cerebrospinal fluid (CSF). The transition from EVD to permanent ventriculoperitoneal shunt (VPS) placement is a pivotal decision in patient management, influenced by various factors. Objective: This study aims to analyze the role of EVD placement in patients with hydrocephalus secondary to spontaneous SAH and the subsequent need for permanent VPS placement. Methods: Conducted at Jinnah Postgraduate Medical Center, Karachi, over six months, this retrospective study included 30 patients. After securing hospital ethical committee approval, several parameters were recorded: age, gender, Glasgow Coma Scale (GCS) score, aneurysm details (size and location), vasospasm occurrence, EVD placement in ICU, duration of EVD placement, CSF output, clamp trials, and wean failures. Results: Out of 30 patients, 8 (26.66%) required VPS placement. No significant difference was found in VPS placement regarding age, gender, GCS score, aneurysm treatment and location, vasospasm, and EVD placement in ICU. However, patients requiring VPS had statistically longer EVD duration (p=0.0001), larger aneurysm size, more wean trials, clamp trials, and instances of wean failure (p=0.0001). Conclusion: The study highlights the complexities in managing hydrocephalus post-SAH, particularly the significant association between the need for VPS installation and factors like EVD duration, aneurysm size, and wean trial outcomes. It underscores the need for future prospective studies with larger sample sizes to better identify patients who would benefit from shunt insertion post-SAH. Keywords: EVD, Hydrocephalus, SAH, Ventriculoperitoneal Shunt, Wean Trials.

Ventriculosubgaleal shunts in the management of neonatal post-haemorrhagic hydrocephalus: technical note.

Germinal matrix / intraventricular haemorrhage (GMIVH) remains a significant complication of prematurity. The more severe grades are associated with parenchymal haemorrhagic infarction (PHI) and hydrocephalus. A temporising procedure is usually the first line in management of neonatal post-haemorrhagic hydrocephalus (nPHH) as the risk of failure of a permanent cerebrospinal fluid (CSF) diversion is higher in the early stage. Our choice of temporising procedure is a ventriculosubgaleal shunt (VSGS). In this technical note, we describe a modification in technique whereby the pocket of the VSGS is fashioned away from the surgical wound. This resulted in lower CSF leak and subsequent infection rates in our centre. We conducted a retrospective analysis of all patients who underwent insertion of a VSGS between September 2014 and February 2023. Twenty children were included in our study with a mean gestational age of 31 weeks + 4 days. Post-operatively, 10% of patients did not need a tap, and 10%, 20%, 15%, 25% and 20% respectively had 1, 2, 3, 4 and 5 taps. Two patients experienced CSF leak from their wounds. In both these patients, the pocket was deemed too close to the wound. None of the patients without suspected pre-existing CNS infection at the time of insertion of VSGS had a subsequent VSGS-related infection. VSGS conversion to permanent ventriculoperitoneal shunts (VPS) was required in 15 (75%) of the patients with an average interval duration of 72 days. On reviewing the literature, the infection rate following VSGS is quoted up to 13.5%. In our own centre, 13 patients had undergone VSGS insertion between 2005 and 2013 with a 30.8% infection rate which seemed related to increased leak rates. Our modified surgical approach seems to be effective in reducing the risk of infection, which we postulate is a direct result of reduction in the risk of leak from the surgical wound.

Abstract WP133: Assessing Aneurysmal Rupture Outcomes Using Automated Quantification Of Hemorrhage Volume

Introduction: Hemorrhage volume affects the risk of developing complications after aneurysmal subarachnoid hemorrhage (aSAH). This volume is quantified subjectively through the Fisher Scale. We developed an automated method to quantify intracranial hemorrhage and determine the risk of complications after aSAH. Methods: CT scans of patients with aSAH were analyzed. An image-processing algorithm was designed in MATLAB to quantify aSAH volume. The automated algorithm was developed with region-growing and 3D k-means clustering. Two independent raters manually measured hemorrhage volumes using PACS and correlated these measurements with the algorithm measurements in ten patients. Vasospasm and hydrocephalus were identified through chart and imaging review. Hydrocephalus was adjudicated as ventricular enlargement in the setting of aSAH. ROC analysis was performed to evaluate the association between blood volume and the incidence of vasospasm, hydrocephalus and need for a permanent ventriculoperitoneal (VP) shunt. Results: One hundred and forty-one patients were included in the analysis. The intraclass coefficient correlation (ICC) for inter-rater agreement in PACS was 0.988 (p < 0.001). The ICC for comparing automated versus manual volumes was 0.966 (p < 0.001). Bland-Altman analysis reported a mean difference of -3.14 mL between automated and manual measurements. Hemorrhage volume discriminated for the development of vasospasm (AUC = 0.692), hydrocephalus (AUC = 0.775), and need of permanent VP shunt (AUC = 0.669). Conclusion: Vasospasm and hydrocephalus were associated with higher volume of aSAH. Patients with higher volume of aSAH at presentation were more likely to require a permanent VP shunt. An objective method to automatically measure aSAH volume can aid in assessing risk of complications among patients with aSAH.

Per-Operative External Ventricular Drainage Results in Children with Posterior Fossa Tumors and Hydrocephalus

Objective: We determined the outcome of per operational external ventricular drainage in pediatric patients with posterior fossa tumors and hydrocephalus.
 Material And Methods: 54 patients included presenting with posterior fossa tumors and mild to moderate hydrocephalous were considered for per operative external ventricular drainage. The external ventricular drain was then weaned off in one week. If it cannot be removed due to persistent hydrocephalous it was converted into a permanent ventriculoperitoneal shunt.
 Results: In the study, the mean age was 7 years. Twenty-seven children had ependymoma, 19% of children had medulloblastoma, and 54% of children had pilocytic astrocytoma. Moreover, 67% of children had weaned off and 33% of children had converted to VP shunt. There existed an insignificant difference in the outcome (yes/ no) concerning age groups, gender, and tumor type.
 Conclusion: Our study concludes that the outcome of per operative external ventricular drainage was weaned off (67%) and converted to VP shunt (33%) in pediatrics with posterior fossa tumors and hydrocephalous.

Development of an integrated risk scale for prediction of shunt placement after neonatal intraventricular hemorrhage.

Neonatal intraventricular hemorrhage (IVH) is a major cause of mortality and morbidity, particularly following premature birth. Even after the acute phase, posthemorrhagic hydrocephalus is a long-term complication, frequently requiring permanent ventriculoperitoneal shunt (VPS) placement. Currently, there are no risk classification methods integrating the constellation of clinical data to predict short- and long-term prognosis in neonatal IVH. To address this need, the authors developed a two-part machine learning approach for predicting short- and long-term outcomes after diagnosis of neonatal IVH. Integrating both maternal and neonatal characteristics, they developed a binary classifier to predict short-term mortality risk and a clinical scale to predict the long-term risk of VPS placement. Neonates with IVH were identified from the Optum Clinformatics Data Mart administrative claims database. Matched maternal and childbirth characteristics were obtained for all patients. The primary endpoints of interest were short-term (30 day) mortality and long-term VPS placement. Classification of short-term mortality risk was evaluated using 5 different machine learning approaches and the best-performing method was validated using a withheld validation subset. Prediction of long-term shunt risk was performed using a multivariable Cox regression model with stepwise variable selection, which was subsequently converted to an easily applied integer risk scale. A total of 5926 neonates with IVH were identified. Most patients were born before 32 weeks' gestation (67.2%) and with low birth weight (81.2%). Empirical 30-day mortality risk was 10.9% across all IVH grades and highest among grade IV IVH (34.3%). Among the neonates who survived > 30 days, actuarial 12-month postdiagnosis risk of shunt placement was 5.4% across all IVH grades and 31.3% for grade IV IVH. The optimal short-term risk classifier was a random forest model achieving an area under the receiver operating characteristic curve of 0.882 with important predictors ranging from gestational age to diverse comorbid medical conditions. Selected features for long-term shunt risk stratification were IVH grade, respiratory distress syndrome, disseminated intravascular coagulation, and maternal preeclampsia or eclampsia. An integer risk scale, termed the Shunt Prediction After IVH in Neonates (SPAIN) scale, was developed from these 4 features, which, evaluated on withheld cases, demonstrated improved risk stratification compared with IVH grade alone (Harrell's concordance index 0.869 vs 0.852). In a large cohort of neonates with IVH, the authors developed a two-pronged, integrated, risk classification approach to anticipate short-term mortality and long-term shunt risk. The application of such approaches may improve the prognostication of outcomes and identification of higher-risk individuals who warrant careful surveillance and early intervention.

130 Development of an Integrated Risk Scale for Prediction of Shunt Placement After Neonatal Intraventricular Hemorrhage

INTRODUCTION: Neonatal intraventricular hemorrhage (IVH) is a major source of mortality and morbidity in infants, particularly following premature birth. Even after the acute phase, post-hemorrhagic hydrocephalus is a long-term complication, frequently requiring permanent ventriculoperitoneal shunt placement (VPS). Currently, there are no risk classification methods integrating the constellation of clinical data to predict short- and long-term prognosis in neonatal IVH. METHODS: Neonates with IVH were identified from the Optum Clinformatics DataMart administrative claims database using ICD-9/10 codes. Matched maternal-childbirth characteristics were obtained. Primary endpoints were short-term (30-day) mortality and long-term VPS placement. Classification of short-term mortality risk was evaluated using five different machine learning approaches and the best-performing method was validated using a withheld validation subset. Prediction of long-term shunt risk was performed using a multivariable Cox regression model with stepwise variable selection, which was subsequently converted to an easily applied integer risk scale. RESULTS: A total of 5,926 neonate-maternal pairs were included. Empiric 30-day neonatal mortality risk was 10.9% across all IVH grades and highest among grade IV IVH (34.3%). Among those surviving beyond 30 days, actuarial 12-month risk of shunt placement was 5.4% across all IVH grades and 31.3% for grade IV IVH. The optimal short-term risk classifier was a random forest model achieving an AUROC of 0.882 with important predictors ranging from gestational age to diverse comorbid medical conditions. The final multivariable Cox regression model for long-term shunt risk stratification following stepwise feature selection included IVH grade, respiratory distress syndrome, disseminated intravascular coagulation, and maternal preeclampsia/eclampsia. An integer risk scale termed the Shunt Prediction After IVH in Neonates (SPAIN) scale was developed from these four features which, evaluated on withheld validation cases, demonstrated improved risk stratification compared to IVH grade alone (Harrell’s concordance index 0.869 vs 0.852). CONCLUSION: We developed an integrated risk classification approach to anticipate short-term mortality and long-term shunt risk. Application of such approaches may improve outcome prognostication and identification of higher risk individuals warranting careful surveillance and early intervention.

Outcome of Childhood Cerebellar Pilocytic Astrocytoma: A Series With 20 Years of Follow Up.

Background: Cerebellar pilocytic astrocytoma (PCA) is one of the few CNS tumors that can be cured with gross-total removal (GTR). In this series, we had 39 patients diagnosed with cerebellar PCA, 27 patients (70%) had GTR, and mean follow-up period was 62 months with no tumor recurrence.Objective: To assess the long-term outcome of childhood cerebellar PCA treated at our institute during the period 2000-2020 and to highlight our surgical protocol.Methodology: Retrospective review of all patients under 18 years of age who were diagnosed with cerebellar PCA and had surgical excision between 2000 and 2020 at the Medical City of King Saud University.Results: The study included 39 patients: 17 males and 22 females, the mean age was 8.4 years. Radiologically, the tumor was solid in eight patients, cystic in 15 patients, and mixed components were found in 16 patients. The lesion was located in the right cerebellar hemisphere in 12 patients, left cerebellar hemisphere in five patients, and midline 22 patients. The tumor size ranged from 2 to 7 cm in its greatest diameter, it was <5 cm in 13 patients and >5 cm in 26 patients. Thirty-one patients had preoperative hydrocephalus. GTR of the tumor was achieved in 27 patients and subtotal resection (STR) was done in 12 patients, 18 patients required permanent ventriculoperitoneal (V-P) shunt, and five patients had postoperative radiotherapy. Postoperative complications included infection in two patients, cerebellar mutism in two patients, and significant neurologic disability in four patients. The duration of follow-up ranged from 0 to 240 months (mean follow-up period: 62.0 months). The outcome at 10 years was good in 30 patients, fair in four patients, poor in four patients, and one patient died. Recurrence was documented in nine patients, seven of them had GTR and two had STR.Conclusion: GTR, if achievable, is curative for childhood cerebellar PCA. Many posterior fossa surgical complications could be avoided with watertight dural closure. Although new dural substitutes are available we prefer using autologous grafts (pericranium). It is easy to harvest pericranial graft from the external ventricular drain (EVD) site. The insertion of EVD synchronously with GTR of the tumor and gradual weaning of EVD could avoid the insertion of V-P shunt.

External ventricular drainage for posthemorrhagic ventricular dilatation in preterm infants: insights on efficacy and failure.

The objective of this study was to describe the clinical and neuroradiological characteristics of a cohort of preterm infants who had undergone external ventricular drain insertion as a temporary measure to treat posthemorrhagic ventricular dilatation. In addition, the authors investigated the factors predicting permanent shunt dependency. The authors retrospectively reviewed the medical records of a cohort of preterm infants who had undergone external ventricular drain insertion at Gaslini Children's Hospital (Genoa, Italy) between March 2012 and February 2018. They also analyzed clinical characteristics and magnetic resonance imaging data, including diffusion- and susceptibility-weighted imaging studies, which were obtained before both catheter insertion and removal. Twenty-eight infants were included in the study. The mean gestational age was 28.2 ± 2.7 weeks, and the mean birth weight was 1209 ± 476 g. A permanent ventriculoperitoneal shunt was inserted in 15/28 (53.6%) infants because of the failure of external ventricular drainage as a temporary treatment option. Compared with the shunt-free group, the shunt-dependent group had a significantly lower gestational age (29.3 ± 2.3 vs 27.2 ± 2.7 weeks, p = 0.035) and tended toward a lower birth weight (p = 0.056). None of the clinical and neuroradiological characteristics significantly differed between the shunt-free and shunt-dependent groups at the time of catheter insertion. As expected, ventricular parameters as well as the intraventricular extension of intracerebral hemorrhage, as assessed using the intraventricular hemorrhage score, were reportedly higher in the shunt-dependent group than in the shunt-free group before catheter removal. External ventricular drainage is a reliable first-line treatment for posthemorrhagic hydrocephalus. However, predicting its efficacy as a unique treatment remains challenging. A lower gestational age is associated with a higher risk of posthemorrhagic hydrocephalus progression, suggesting that the more undeveloped the mechanisms for the clearance of blood degradation products, the greater the risk of requiring permanent cerebrospinal fluid diversion, although sophisticated MRI investigations are currently unable to corroborate this hypothesis.

Association of External Ventricular Drain Wean Strategy with Shunt Placement and Length of Stay in Subarachnoid Hemorrhage: A Prospective Multicenter Study.

Survivors of aneurysmal subarachnoid hemorrhage (SAH) face a protracted intensive care unit (ICU) course and are at risk for developing refractory hydrocephalus with the need for a permanent ventriculoperitoneal shunt (VPS). Management of the external ventricular drain (EVD) used to provide temporary cerebrospinal fluid diversion may influence the need for a VPS, ICU length of stay (LOS), and drain complications, but the optimal EVD management approach is unknown. Therefore, we sought to determine the effect of EVD discontinuation strategy on VPS rate. This was a prospective multicenter observational study at six neurocritical care units in the United States. The target population included adults with suspected aneurysmal SAH who required an EVD. Patients were preassigned to rapid or gradual EVD weans based on their treating center. The primary outcome was the rate of VPS placement. Secondary outcomes were EVD duration, ICU LOS, hospital LOS, and drain complications. A rapid EVD wean protocol was associated with a lower rate of VPS placement, including a delayed posthospitalization shunt, in an adjusted Cox proportional analysis (hazard ratio 0.52 [p = 0.041]) and adjusted logistic regression model (odds ratio 0.43 [95% confidence interval 0.18-1.03], p = 0.057). A rapid wean was also associated with 2.1 fewer EVD days (p = 0.007) and saved an estimated 2.5 ICU days (p = 0.049), as compared with a gradual wean protocol. There were fewer nonfunctioning EVDs in the rapid group (odds ratio 0.32 [95% confidence interval 0.11-0.92]). Furthermore, we found that the time to first wean and the number of weaning attempts were important independent covariates that affected the likelihood of receiving a VPS and the duration of ICU admission. A rapid EVD wean was associated with decreased rates of VPS placement, decreased ICU LOS, and decreased drain complications in survivors of aneurysmal SAH. These findings suggest that a randomized multicentered controlled study comparingrapid vs. gradual EVDweaning protocols is justified.

Surgical management of the fourth ventricular tumors using telovelar approach and the role of neuroendoscopy: Post-operative outcome and long-term results in a series of 52 cases

ObjectivesThe telovelar approach is a surgical method performed through natural corridors of the brain to access the fourth ventricle. The aim of this study is to assess the results of this approach as well as the role of neuroendoscopy in surgical management of fourth ventricle tumors. Material and MethodsA retrospective study was designed, and a series of 52 consecutive patients (32 male, 20 female) with fourth ventricle tumor undergoing telovelar approach was undertaken. In 10 patients (19 %) with a tumor invading the rostral fourth ventricle, an adjustable angle endoscope was also used to ensure total resection of the tumor. ResultsComplete resection was obtained in majority of patients (94 %). 30 patients (57 %) required insertion of an external ventricular drain which was discontinued in all patients after 72 h. 2 patients (4 %) underwent permanent ventriculoperitoneal shunt. The postoperative complications included meningitis (8 %), transient facial nerve paralysis (8 %), transient sixth cranial nerve paralysis (6 %) and transient unilateral absence of the gag reflex (4 %). No patient experienced mutism and there was a mortality rate of 2 % (1 case) in current study. ConclusionIn our experience, a high rate of total resection of the fourth ventricle tumors could be achieved with the telovelar approach associated with a low risk of surgical morbidity and mortality. Moreover, the use of an adjustable angle endoscope could be useful in patients with a tumor involving the rostral fourth ventricle to ensure total resection of the tumor and also to minimize the extent of telovelar dissection.

SURG-02. INITIAL MANAGEMENT OF HYDROCEPHALUS IN THE PEDIATRIC AND YOUNG-ADULT PATIENTS WITH BRAIN TUMORS; THE EFFICACY OF LONG-TERM INDWELLING EXTERNAL VENTRICULAR DRAINAGE

BACKGROUNDPediatric and Young-Adult (AYA) brain tumors often present with hydrocephalus. As temporary cerebrospinal fluid (CSF) diversion procedure, we perform long-term indwelling external ventricular drainage (EVD) in the case of the management of CSF diversion more than two weeks presumably. The aim of this study is to investigate the initial management for hydrocephalus in pediatric /AYA patients with brain tumor, especially about long-term EVD.MATERIALS AND METHODSThe patients less than 30 years of age diagnosed with brain tumor between 2005 and 2019 were retrospectively analyzed. Procedures of long-term EVD were similar to that of ventriculoperitoneal shunt (VPS) operation. Using flow-control VPS system, peritoneal catheter passed out of the body at the anterior chest, and distal end of the catheter was connected to standard EVD system.RESULTSIn total of 345 patients with brain tumor, 109 had hydrocephalus at presentation. Among them, 25 patients (23%) underwent long-term EVD. The main reasons for selecting long-term EVD were to avoid intraperitoneal dissemination (n=13), and to maintain longer period of CSF diversion for the treatment of tumor (n=12). The median of long-term EVD was 38 days (range: 12 – 222 days). Although one case suffered from drainage tube occlusion at 59 days, there were no other complications such as infection or accidental evulsion. Eventually, 3 cases required permanent VPS for persistent hydrocephalus.CONCLUSIONLong-term EVD is safe and effective option for CSF diversion. This procedure should be taken into consideration if patients have a risk of dissemination and may elude permanent VPS.

Retrospective Analytic Study of Neurosurgical Patients Who Developed Postoperative Hydrocephalus

Abstract Objective This article discusses the causes, primary pathologies, management, and prognosis of patients who did not have hydrocephalus in preoperative stage, underwent definitive surgical procedure, and developed postoperative hydrocephalus requiring cerebrospinal fluid (CSF) diversion procedures. Methods Retrospective data collection was done from operation theatre (OT) department database and patient records were obtained for the patients after, related literature was searched, all possible risk factors were analyzed, and our results were compared with other studies. Results A total of 80 cases were found eligible for the study. Decompressive craniectomy was the most common cause followed by aneurysmal subarachnoid hemorrhage (SAH), intraventricular, and cerebellopontine angle (CPA) tumors. Rate of postsurgical hydrocephalus was 15 to 16%. Cases of decompressive craniectomy presented late, only few cases required diversion procedures during the immediate postop period, mostly aneurysm cases and tumors bed bleed. Out of total 6 mortalities, none of them were directly attributable to hydrocephalus. Since most patient presented after initial stabilization, permanent ventriculoperitoneal shunting was found to be the best option. Conclusion Cases of decompression surgery should be under vigilant follow-up after discharge and even after cranioplasty for risk of development of hydrocephalus and requirement of permanent shunting. Cases with intraventricular hemorrhage or SAH should be considered as future candidate with risk of developing hydrocephalus. Lamina terminalis opening whenever possible results in favorable outcome in cases of anterior circulation aneurysms. CSF protein analysis in cases of intraventricular and CPA tumors should be done whenever possible, preferably routinely.

The Burden of Neurocysticercosis at a Single New York Hospital.

Neurocysticercosis (NCC), a disease caused by the larval pork tapeworm Taenia solium, has emerged as an important infection in the United States. In this study, we describe the spectrum of NCC infection in eastern Long Island, where there is a growing population of immigrants from endemic countries. A retrospective study was designed to identify patients diagnosed with NCC using ICD-9 and ICD-10 codes in the electronic medical records at Stony Brook University Hospital between 2005 and 2016. We identified 52 patients (56% male, median age: 35 years) diagnosed with NCC in the only tertiary medical center in Suffolk County. Twenty-five cases were reported in the last three years of the study. Forty-eight (94%) patients self-identified as Hispanic or Latino in the electronic medical record. Twenty-two (44%) and 28 (56%) patients had parenchymal and extraparenchymal lesions, respectively. Nineteen (41.3%) patients presented with seizures to the emergency department. Six patients (11.7%) had hydrocephalus, and five of them required frequent hospitalizations and neurosurgical interventions, including permanent ventriculoperitoneal shunts or temporary external ventricular drains. No deaths were reported. The minimum accumulated estimated cost of NCC hospitalizations during the study period for all patients was approximately 1.4 million United States dollars (USD). In conclusion, NCC predominantly affects young, Hispanic immigrants in Eastern Long Island, particularly in zip codes correlating to predominantly Hispanic communities. The number of cases diagnosed increased at an alarming rate during the study period. Our study suggests a growing need for screening high-risk patients and connecting patients to care in hopes of providing early intervention and treatment to avoid potentially detrimental neurological sequelae.

Long-Term Complications and Influence on Outcome in Patients Surviving Spontaneous Subarachnoid Hemorrhage

Background: While the short-term clinical outcome of patients with subarachnoid hemorrhage (SAH) is well described, there are limited data on long-term complications and their impact on social reintegration. This study aimed to assess the frequency of complications post-SAH and to investigate whether these complications attribute to functional and self-reported outcomes as well as the ability to return to work in these patients. Methods: This retrospective single-center study included patients with atraumatic SAH over a 5-year period at a tertiary care center. Patients received a clinical follow-up for 12 months. In addition to demographics, imaging data, and parameters of acute treatment, the rate and extent of long-term complications after SAH were recorded. The functional outcome was assessed using the modified Rankin Scale (mRS; favorable outcome defined as mRS = 0–2). Further outcomes comprised self-reported subjective health measured by the EQ-5D and return to work for SAH patients with appropriate age. Multivariable analyses including in-hospital parameters and long-term complications were conducted to identify parameters independently associated with outcomes in SAH survivors. Results: This study cohort consisted of 505 SAH patients of whom 405 survived the follow-up period of 12 months (i.e., mortality rate of 19.8%). Outcome data were available in 359/405 (88.6%) patients surviving SAH. At 12 months, a favorable functional outcome was achieved in 287/359 (79.9%) and 145/251 (57.8%) SAH patients returned to work. The rates of post-acute complications were headache (32.3%), chronic hydrocephalus requiring permanent ventriculoperitoneal shunting (VP shunt 25.4%) and epileptic seizures (9.5%). Despite patient’s and clinical characteristics, both presence of epilepsy and need for VP shunt were independently and negatively associated with a favorable functional outcome (epilepsy: adjusted odds ratio [aOR] (95% confidence interval [95% CI]): 0.125 [0.050–0.315]; VP shunt: 0.279 [0.132–0.588]; both p < 0.001) as well as with return to work (aOR [95% CI]: epilepsy 0.195 [0.065–0.584], p = 0.003; VP shunt 0.412 [0.188–0.903], p = 0.027). Multivariable analyses revealed presence of headache, VP shunt, or epilepsy to be significantly related to subjective health impairment (aOR [95% CI]: headache 0.248 [0.143–0.430]; epilepsy 0.223 [0.085–0.585]; VP shunt 0.434 [0.231–0.816]; all p < 0.01). Conclusions: Long-term complications occur frequently after SAH and are associated with an impairment of functional and social outcomes. Further studies are warranted to investigate if treatment strategies specifically targeting these complications, including preventive aspects, may improve the outcomes after SAH.

Endoscopic Third Ventriculostomy for Hydrocephalus in Infants: A Single-center Experience.

Introduction:Hydrocephalus remains one of the more common pathologies managed in pediatric neurosurgery. Endoscopic third ventriculostomy (ETV) has become the procedure of choice for the treatment of hydrocephalus due to aqueductal stenosis with high success rate. It has an advantage over ventriculoperitoneal (VP) shunting, as it enables patients to remain device free.Objective:The purpose of this study is to assess the role of ETV in the treatment of hydrocephalus in children under 1 year of age, including preterm low birth weight infants.Materials and Methods:A prospective study of 30 infants undergoing ETV in our institution between January 2014 and December 2018 was carried out. There were 25 cases of congenital hydrocephalus with aqueductal stenosis, two cases of Dandy–Walker cyst, two cases of cerebellopontine angle arachnoid cyst, and one case of posttubercular meningitis. ETV success score was calculated preoperatively to evaluate the percentage of success of ETV.Results:The overall success rate was 76.66% (23), with highest success rate of 84% in aqueductal stenosis. The mean age was 6.75 months (range: 1.5–12 months). Five infants were born preterm, four of them required a permanent VP shunt. There were two cases of intraoperative bleeding, four cases of cerebrospinal fluid leak from the wound, and one case of meningitis.Conclusion:ETV can be considered a safe and effective modality for the initial treatment of hydrocephalus in full-term normal birth weight infants, while the success of ETV in preterm low birth weight infants need further study of maturity at birth and birth weight as the determinant factors for the success of ETV in this special group.

Associations between Features of External Ventricular Drain Management, Disposition, and Shunt Dependence

Abstract Background In the United States, nearly 25,000 patients annually undergo percutaneous ventriculostomy for the management of increased intracranial pressure with little consensus on extraventricular drain management. To characterize relationships between external ventricular drain management, permanent ventriculoperitoneal shunt placement, and hospital disposition, we hypothesized that patients requiring extended drainage would have greater association with ventriculoperitoneal shunt placement and unfavorable disposition. Methods Adult patients admitted to the Duke University Hospital Neuroscience Intensive Care Unit between 2008 and 2010 with extraventricular drains were analyzed. A total of 115 patient encounters were assessed to determine relative impact of age, sex, days of extraventricular placement, weaning attempts, cerebrospinal fluid drainage volumes, Glasgow Coma Scale, and physician’s experience on disposition at discharge and ventriculoperitoneal shunt placement. Univariate logistic regression was first used to test the effect of each variable on the outcome, followed by backward selection to determine a final multivariable logistic regression. Variables in the final model meeting p &lt; 0.05 were declared as significant factors for the outcome. Results Increased extraventricular drain duration (odds ratio [OR] = 1.17, confidence interval [CI] = 1.05–1.30, p = 0.0049) was associated with ventriculoperitoneal shunt placement, while older age (OR = 1.05, CI = 1.02–1.08, p = 0.0027) and less physician extraventricular drain management experience (OR = 4.04, CI = 1.67–9.79, p = 0.0020) were associated with unfavorable disposition. Conclusion In a small cohort, exploratory analyses demonstrate potentially modifiable factors are associated with important clinical outcomes. These findings warrant further study to refine how such factors affect patient outcomes.

Hydrocephalus in children with ruptured cerebral arteriovenous malformation.

Hydrocephalus is a strong determinant of poor neurological outcome after intracerebral hemorrhage (ICH). In children, ruptured brain arteriovenous malformations (bAVMs) are the dominant cause of ICH. In a large prospective cohort of pediatric patients with ruptured bAVMs, the authors analyzed the rates and predictive factors of hydrocephalus requiring acute external ventricular drainage (EVD) or ventriculoperitoneal shunt (VPS). The authors performed a single-center retrospective analysis of the data from a prospectively maintained database of children admitted for a ruptured bAVM since 2002. Admission clinical and imaging predictors of EVD and VPS placement were analyzed using univariate and multivariate statistical models. Among 114 patients (mean age 9.8 years) with 125 distinct ICHs due to ruptured bAVM, EVD and VPS were placed for 55/125 (44%) hemorrhagic events and 5/114 patients (4.4%), respectively. A multivariate nominal logistic regression model identified low initial Glasgow Coma Scale (iGCS) score, hydrocephalus on initial CT scan, the presence of intraventicular hemorrhage (IVH), and higher modified Graeb Scale (mGS) score as strongly associated with subsequent need for EVD (all p < 0.001). All children who needed a VPS had initial hydrocephalus requiring EVD and tended to have higher mGS scores. In a large cohort of pediatric patients with ruptured bAVM, almost half of the patients required EVD and 4.4% required permanent VPS. Use of a low iGCS score and a semiquantitative mGS score as indicators of the IVH burden may be helpful for decision making in the emergency setting and thus improve treatment.