Preexisting Ventriculoperitoneal Shunt Research Articles

Approach to Cochlear Implantation in Patients With Ventriculoperitoneal Shunts.

To evaluate the safety and outcomes of cochlear implantation (CI) in patients with ventriculoperitoneal (VP) shunts to inform clinical practice. Historical cohort study. Tertiary referral centers. A multi-institutional historical cohort of patients with VP shunts and CI was identified and analyzed. A total of 46 patients (median age 8 years [interquratile range, IQR: 2-46]) with VP shunts and CI were identified. Of these, 41 (89%) patients had a VP shunt prior to CI. Based on institutional preference and individual patient factors, CI was performed contralateral to a pre-existing VP shunt in 24 of these 41 cases (59%) and ipsilateral in 17 (41%). Furthermore, pre-CI relocation of the VP shunt was performed in 3 cases (7%), and 2 patients (5%) underwent planned revision of their VP shunt concurrent with CI. In total, 2 of 27 pediatric patients (7%) required unanticipated revision shunt surgery, both contralateral to CI device placement, given VP shunt malfunction. One of 19 adult patients (5%) required shunt revision during CI due to shunt damage noted intraoperatively. Among 43 patients with available follow-up, 38 (88%) are regular CI users, with a median consonant-nucleus vowel-consonant word: score of 58% (IQR: 28-72). CI can be performed at low risk, either contralateral or ipsilateral, to a VP shunt, and does not mandate shunt revision in most cases. Additional considerations regarding CI receiver-stimulator placement are necessary with programmable shunts to mitigate device interaction. Preoperative planning, including coordination of care with neurosurgery, is important to achieving optimal outcomes.

Intraventricular haemorrhage due to re-ruptured arteriovenous malformation cleared with tissue plasminogen activator administered through a pre-existing ventriculoperitoneal shunt

In the context in intraventricular haemorrhage (IVH), intrathecal thrombolytic agents administered in conjunction with extraventricular drainage have been demonstrated to clear larger volumes of blood and reduce mortality rates. However, patients with arteriovenous malformations (AVM) have been mostly excluded from clinical trials. We describe a patient with hydrocephalus secondary to a ruptured AVM who was treated via external ventriculostomy, which was subsequently converted to a ventriculoperitoneal shunt (VPS). Eight months later, the AVM re-ruptured, causing IVH and rendering the patient comatose. Taking into consideration the patient’s poor outlook, a single dose of intraventricular tissue plasminogen activator (t-PA) was administered through the shunt reservoir. The shunt maintained its function and the patient's condition ultimately improved. This impressive case demonstrates the utility of t-PA administered through an existing VPS in the setting of IVH due to ruptured AVM, highlighting its lifesaving potential in the appropriate patient and overall decrease in the cost of care by mitigating the need for shunt revision.

Feasibility and Challenges of Microsurgical Resection of Colloid Cysts in Patients with Preexisting Ventriculoperitoneal Shunts

Colloid cysts are the most common third ventricular tumor and may present with symptoms related to obstructive hydrocephalus. Although definitive endoscopic or microsurgical resection is the standard of care, patients may receive temporizing ventriculoperitoneal shunts when definitive management is deferred. Subsequent definitive treatment can be challenging because of the ventricular collapse and narrowing of the operative corridor. There is currently no literature evaluating the feasibility of definitive colloid cyst resection in patients with preexisting ventriculoperitoneal shunts. We retrospectively reviewed records for patients undergoing colloid cyst resection between 2009 and 2019 to identify patients with preexisting shunts prior to surgery. Three patients had preexisting ventriculoperitoneal shunts. Two patients had been shunted at outside institutions where microsurgical or endoscopic resection was not available. One patient received a shunt from an outside surgeon when she was deemed a poor surgical candidate because of cardiac instability. All 3 patients underwent successful gross total colloid cyst resection via the transcallosal approach without recurrences during a mean follow-up of 4.2 years. All patients had intact cognitive and memory function and returned to work. Surgical resection of colloid cysts is possible despite a preexisting ventriculoperitoneal shunt. Because the ventricular space may be collapsed postoperatively because of cerebrospinal fluid diversion, a transcortical route (either endoscopic or microscopic) can be complicated by a small operative corridor with reduced visibility. The transcallosal approach was safe and feasible in these cases for providing midline access with adequate visualization for complete resection despite ventricular collapse.

Complications in Patients Undergoing Microsurgical Clipping of Intracranial Aneurysms with Pre-existing Ventriculoperitoneal Shunts Following a Cranial Procedure

Introduction: Patients with ventriculoperitoneal/pleural (VP) shunts occasionally must undergo subsequent craniotomy, craniectomy, or cranioplasty. Due to changes in pressure dynamics following shunt placement, we hypothesized that such patients may have an increased risk of developing symptomatic collections of extra-axial blood, fluid, and/or air postoperatively, leading to longer stays and worse outcomes compared to those undergoing cranial operations without a VP shunt.Methods: From a retrospective cohort of patients who underwent cranial operations for management of cerebral aneurysms in 2005-2014, we identified patients who previously had a VP shunt placed, determined the temporal relationship between shunt placement and cranial operation, and investigated outcomes in those with and without a shunt.Results: Of 818 patients who underwent cranial operations, 28 (3.4%) had a VP shunt. Four of these 28 (14.3%, 95% confidence interval [CI] 4.0%-32.7%) developed postoperative complications, compared to 42 of 790 (5.3%, 95% CI 4.0%-7.1%) without a history of VP shunt (P = .07). In addition, patients with a shunt were more likely to have longer cranial procedures (P = .04), longer hospital stays (P = .05), and more computed tomography scans during their craniotomy-associated admission (P = .002). Multivariate analysis, though not significant, demonstrated that the presence of a shunt contributed to the development of complications (odds ratio [OR] 2.24, 95% CI .70-7.13, P = .17). Length of surgery (OR 1.17, 95% CI 1.04-1.31, P = .01) and length of stay (OR 1.04, 95% CI 1.01-1.07, P = .01) were significantly longer in those with a postoperative complication.Conclusion: We found a nonsignificant trend toward increased postoperative complications in patients with a VP shunt who underwent a subsequent cranial operation.

Treatment of medial clavicle fractures . A case report and review of the literature.

Medial clavicle fractures are seen rarely and can be associated with injuries to the adjacent vital structures. Herein, we described a 15-year-old boy who had a preexisting ventriculoperitoneal shunt and a displaced medial clavicle fracture. We performed a successful surgical treatment using a distal radius locking plate. We discussed the mechanism of injury and treatment options with literature review.

Transcranial Doppler monitoring of middle cerebral flow velocity in a patient with a ventriculoperitoneal shunt undergoing laparoscopy

Laparoscopic surgery is possibly associated with a risk of intracranial pressure (ICP) increase due to pneumoperitoneum in patients with ventriculoperitoneal shunts (VPS). Invasive techniques for shunt pressure monitoring are not routinely used because of the possible complications. Transcranial Doppler (TCD) is a non-invasive, safe method which gives accurate information about blood-flow velocities in basal cerebral arteries and indirectly about the ICP. Moreover it is inexpensive and simple in use. We report the use of TCD for middle cerebral flow velocity monitoring in a patient with a VPS who underwent laparoscopic surgery. In the case we present, during 60 min of pneumoperitoneum, TCD showed a sustained, but not clinically significant increase of the Pulsatility Index, with a recorded maximum change of 31 %. We consider that the use of TCD may increase the safety of laparoscopic procedures in patients with preexisting VPS.

Management of pediatric colloid cysts of anterior third ventricle: A review of five cases

Object:Colloid cysts are congenital benign lesions, associated with more aggressive clinical and radiological picture in children than in adults. We present our experience in management of five pediatric patients with colloid cyst of the anterior third ventricle. They have an excellent chance of surgical cure, or they can be devastating and even fatal, if not recognized on time and treated.Materials and Methods:Five pediatric patients (aged 16 years or less) who were surgically treated for a colloid cyst, between 1987 and 2011 were analyzed. The clinical features included raised intracranial pressure in all five cases, of which one patient was brought unconscious with decerebrate posturing. Computed Tomography (CT) scan of the brain was done in all patients. The density of the lesion, enhancement with contrast and the presence of hydrocephalus were analyzed. Four patients underwent a detailed postoperative neurological assessment.Results:Three patients underwent the transcallosal-transforaminal approach and total excision of the lesion. One patient underwent revision of the pre-existing ventriculoperitoneal shunt. One patient who was brought in an unconscious state, an external ventricular drain was inserted and she was ventilated. She died 4 hours after the admission. On follow-up, none of the three patients who underwent the transcallosal-transforaminal approach had disconnection syndromes or behavioral disturbances.Conclusion:Colloid cysts in children are rarer and more aggressive than their adult counterparts. It is surgically curable. Early detection and total excision of the lesion is a permanent cure with minimum morbidity, when compared with the natural history of the disease. The limited anterior callosotomy does not result in disconnection syndromes or behavioral disturbance.

Cholecystectomy in patients with prior ventriculoperitoneal shunts

Background There is little published evidence regarding intraoperative and postoperative complications in patients with ventriculoperitoneal shunts who undergo cholecystectomy. Methods Nationwide Department of Veterans Affairs databases were searched to identify patients with International Classification of Diseases, 9th revision, Clinical Modification codes for a VP shunt who later had a cholecystectomy during fiscal years 1994 to 2003. Charts on these patients were obtained and reviewed. Results Twenty-three patients were deemed evaluable. Of these, 8 had laparoscopic converted to open cholecystectomies. All conversions were owing to dense adhesions. There were 2 cases of postoperative shunt infection that required shunt removal and replacement. Conclusions The rate of conversion from laparoscopic to open cholecystectomy was 57% in this study, significantly higher than the reported rate of conversion for patients without shunts in Department of Veterans Affairs Medical Centers (5%). Cholecystectomy in adult patients with a preexisting ventriculoperitoneal shunt appears to result in a shunt infection rate similar to that reported after shunt insertion or revision.

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY AND VENTRICULOPERITONEAL SHUNTS: A DANGEROUS COMBINATION?

We report the largest European series of patients in whom both ventriculoperitoneal shunts (VPS) and percutaneous endoscopic gastrostomies (PEG) have been inserted with the aim of determining if this combination is safe or if there is an increased risk of VPS infection. The paper and electronic records of 302 patients who had a ventriculoperitoneal (VP) shunt inserted in the regional Neurosciences unit at Salford Royal NHS Foundation Trust between 2002 and 2007 were reviewed. A total of 24 patients with VP shunts had 26 PEG inserted. Thirteen PEG were inserted in 11 patients with a pre-existing VP shunt. The median age was 58 years (21-77 Yrs) with seven male and 17 female patients. In total, five patients developed a shunt infection (20.8%) compared to the overall rate of VP shunt infection for Salford Royal NHS Foundation Trust of 7% (P = 0.017). The increase in number of VP shunt infections when the procedures were done more than 10 days apart (2/14) was not significant (P = 0.25). In patients who need long-term enteral feeding following a VP shunt insertion it may be prudent to delay insertion of a PEG for at least 10 days to reduce VPS infection. In stable patients who have had a VP shunt inserted on previous hospital admissions PEG insertion need not be avoided because of concern regarding cerebrospinal fluid or shunt infection.

Risk of Ventriculoperitoneal Shunt Infections After Laparoscopic Placement of Chait Trapdoor™ Cecostomy Catheters in Children

Laparoscopic placement of Chait Trapdoor (Cook, Bloomington, IN) cecosotomy catheters has been practiced in our institution since 1999. Chait cecostomy catheters allow antegrade irrigation of the colon without the complications associated with appendicostomies. Although the use of laparoscopy allows precise placement of these catheters into the cecum under direct vision, the presence of a concomitant ventriculoperitoneal (VP) shunt raises concerns for the potential for a shunt infection. This is a retrospective review of all patients with VP shunts who underwent laparoscopic placement of a Chait cecostomy catheter from 1999 to 2008. We recorded patient demographics, indication for VP shunt placement, the date of the most recent shunt operation, the method of cecal fixation, follow-up duration, and episodes of shunt infection. Sixteen patients with spina bifida and VP shunts who underwent laparoscopic placement of a Chait cecostomy catheter were identified. There were 12 males. Mean follow-up was 46 +/- 27 months (range, 3-87). Two patients (12.5%) developed a VP shunt infection related to the placement of their cecostomy catheter. One shunt infection occurred 5 days postoperatively and the other occurred several years later, when the shunt and cecostomy catheter tracts merged in the subcutaneous tissue. Both patients underwent shunt externalization. Cecostomy catheter placement in patients with preexisting VP shunts may increase the risk of shunt infections. Our series illustrates two different mechanisms by which a VP shunt can become infected after this procedure. In the first case, leakage of enteric content from a poorly sealed tract probably resulted in the shunt infection. More secure fixation of the cecum to the abdominal wall, using intracorporeal sutures rather than T-fasteners, may avoid this complication. The second complication could have been avoided if the cecostomy catheter had been placed further away from the VP shunt.

Is percutaneous endoscopic gastrostomy tube placement safe in patients with ventriculoperitoneal shunts?

To investigate whether percutaneous endoscopic gastrostomy (PEG) tube placement is safe in patients with ventriculoperitoneal (VP) shunts. This was a retrospective study of all patients undergoing PEG insertion at our institution between June 1999 and June 2006. Post-PEG complications were compared between two groups according to the presence or absence of VP shunts. VP shunt infection rates, the interval between PEG placement and VP shunt catheter insertion, and long-term follow-up were also investigated. Fifty-five patients qualified for the study. Seven patients (12.7%) had pre-existing VP shunts. All patients received prophylactic antibiotics. The complication rate did not differ between VP shunt patients undergoing PEG (PEG/VP group) and non-VP shunt patients undergoing PEG (control group) [1 (14.3%) vs 6 (12.5%), P = 1.000]. All patients in the PEG/VP group had undergone VP shunt insertion prior to PEG placement. The mean interval between VP shunt insertion and PEG placement was 308.7 d (range, 65-831 d). The mean follow-up duration in the PEG/VP group was 6.4 mo (range, 1-15 mo). There were no VP shunt infections, although one patient in the PEG/VP group developed a minor peristomal infection during follow-up. Complications following PEG placement in patients with VP shunts were infrequent in this study.

Endoscopic Third Ventriculostomy for the Treatment of Obstructive Hydrocephalus During Pregnancy

Endoscopic third ventriculostomy is an effective procedure for treating obstructive (noncommunicating) hydrocephalus as an alternative to ventricular shunt placement. Five pregnant women undergoing endoscopic third ventriculostomy as treatment for newly diagnosed acute obstructive hydrocephalus (n=2) or in cases of malfunction of a preexisting ventriculoperitoneal shunt (n=3) are presented. Endoscopic third ventriculostomy may be preferred to ventricular shunt placement as the initial mode of treatment for pregnant patients with newly diagnosed obstructive hydrocephalus as well as in cases of malfunction of a preexisting shunt.

Sterile ascites from a ventriculoperitoneal shunt: a case report and review of the literature

Symptomatic, sterile cerebrospinal fluid (CSF) ascites is a rare complication of ventriculoperitoneal (VP) shunt surgery. To date, reports in the literature have linked this unusual circumstance to various intra-abdominal, CNS, or nonspecific inflammatory causes. We present the case of a four-year-old boy with a recently fenestrated arachnoid cyst and VP shunt, who presented with sudden-onset, sterile CSF ascites. The ascites resolved with conversion of the preexisting VP shunt to a ventriculoatrial shunt.

Percutaneous gastrostomy in patients with a ventriculoperitoneal shunt: case series and review

Background There are few data on the safety of PEG in patients with a ventriculoperitoneal shunt. Methods Medical records for patients seen in 3 tertiary care, university-affiliated hospitals between January 1, 1991, and January 1, 1999, were reviewed. Observations Six patients underwent PEG after ventriculoperitoneal shunt placement during the study period. There was no immediate complication. One patient died of pneumonia 2 months after PEG insertion. There was no instance of shunt malfunction, intra-abdominal complication, or wound infection in the study group. There was no long-term complication, with either the ventriculoperitoneal shunt or the PEG. Conclusions Although the number of cases was small, PEG placement with prophylactic administration of antibiotics appears to be safe in patients with a pre-existing ventriculoperitoneal shunt.