Shunting For Normal Pressure Hydrocephalus Research Articles

Approaching an undetermined diagnosis in the aftermath of rhombencephalitis: A case report

A 49-year-old male patient manifested acute onset increased imbalance, quadriparesis, and speech impairment 1 month after undergoing ventricular-peritoneal shunt for normal pressure hydrocephalus (although magnetic resonance imaging [MRI] of the brain with contrast was otherwise normal), which showed improvement afterward. He had hypercalcemia and elevated erythrocyte sedimentation rate. Repeat brain MRI revealed pachymeningitis coupled with rhombencephalitis, while cerebrospinal fluid study unveiled only increased protein level without evidence of active infection. Given these findings, neurosarcoidosis was preliminarily considered a plausible cause of the recent clinical manifestations, and the patient was prescribed methylprednisolone, which led to significant improvement. However, the steroid treatment was discontinued on the revelation that the patient grappled with severe sepsis. Despite an initial improvement following a post-management of sepsis, his condition deteriorated, and he became lost to follow-up after 4 months of initial presentation. An infective etiology was ruled out since his condition improved with steroid. Precluding vasculitis or demyelinating disorder left the physicians with primary central nervous system (CNS) lymphoma or sarcoidosis as a proper diagnosis based on the fact that the patient experienced deterioration when steroid was excluded from the treatment regimen. This case study portrays a need to conduct a more specific and elaborate investigation, driven by a strong perception to both primary CNS lymphoma and sarcoidosis, to optimize clinical diagnosis, which facilitates the formulation of an appropriate treatment regimen.

Early Outcome of Ventriculoperitoneal (VP) Shunt in Terms of Improvement and Complications

Objective: To analyze the outcome of ventriculoperitoneal (VP) shunts in terms of improvement and complications.
 Material and Methods: This retrospective observational study is done in MTI Mardan medical complex and Prime teaching hospital from September 2017 to March 2020. The hospital record of all patients who underwent ventriculoperitoneal shunts was reviewed for improvement and complications. Patients undergoing ventriculoperitoneal shunt for normal pressure hydrocephalus were excluded from this study. Revision of ventriculoperitoneal shunt was the primary endpoint of the study.
 Results: A total of 167 patients were operated on for ventriculoperitoneal shunts with males 106 (63.47%) and females 61 (36.52%). Age ranged from 1 month to 75 years with a mean of 14 years. The most common indication for surgery was congenital hydrocephalus in 102 patients (61.1%) while brain tumors caused hydrocephalus in 25 (15%) patients. Common presenting symptoms were the increase in head size in 75 (44.9%), and headaches in 84 (50.2%) patients. Symptomatic (headache, vomiting, and increase in OFC) improvement occurred in 145 patients (86.82%). Shunt revision was needed in 50.29% (84 patients) in one year.
 Conclusion: VP shunt is a life-saving procedure and is an effective treatment of hydrocephalus but is not risk-free. Almost half of the shunted patients will need revision surgery in one year period.
 Keywords: Hydrocephalus, Ventriculoperitoneal Shunt, Occipitofrontal Circumference (OFC).

Indication and Technique of Ventriculo:Atrial Shunt for Normal Pressure Hydrocephalus

The type of shunt surgery with the best outcome and lowest complication rate has not been established. Ventriculo-atrial(V-A)shunts have almost been abandoned as the first choice of surgery. However, the V-A shunt has many advantages; the operative site is narrower than in other types of shunt surgery, and intra-atrial pressure is lower than intra-abdominal pressure, which may guarantee constant cerebrospinal fluid flow and less malfunction. Since this procedure has been neglected, devices of V-A shunt are scarce. Furthermore, the technique to insert an atrial catheter into the jugular vein is not commonly performed by general neurosurgeons. Herein, we introduce a simple method of V-A shunt for general neurosurgeons.

Subdural haematoma complicating shunting for normal pressure hydrocephalus in the setting of concomitant antiplatelet medication – a report of 11 cases

Objective: To report on the occurrence and management of subdural haematoma after shunt implantation for normal pressure hydrocephalus and to determine the risk of recurrence in the setting of antiplatelet medication. Methods: From a consecutive series of 80 patients implanted with a cerebrospinal fluid shunt for normal pressure hydrocephalus, records from 11 patients taking antiplatelet drugs, who subsequently had surgery for subdural haematoma were extracted and retrospectively reviewed. Results: Patients were followed up for a mean of 1819 days after shunt implantation. Subdural haematomas occurred at a median of 335 days after shunt implantation – four ipsilateral, five contralateral and two bilateral with respect to the ventricular catheter. Three patients had reoperations done within a week without having resumed antiplatelet medication in the interim. One of them had three further reoperations done before the subdural collection disappeared. Only one patient had a late recurrence almost 11 years after shunt implantation. Conclusions: Subdural haematoma in the setting of a ventriculoperitoneal implantation for normal pressure hydrocephalus and concomitant antiplatelet medication can be managed along usual lines. Antiplatelet medication can be recommenced in due course with a low risk of recurrence.

ABDOMINAL PAIN OF THE RIGHT UPPER QUADRANT

A 77-year-old woman, with a ventriculoperitoneal shunt for normal pressure hydrocephalus since August 2007, was referred for evaluation of constant abdominal pain in the right upper quadrant for 4 weeks. Clinical abdominal examination revealed pain in the right upper quadrant by palpation and percussion. Laboratory evaluation revealed a leucocytosis of 12890 per microliter, a serum γ-glutamyltransferase of 283 U per liter, a serum alkaline phosphatase level of 377 U per liter, an alanine aminotransferase level of 120 U per liter, an aspartate aminotransferase level of 78 U per liter and a C-reactive protein of 212 mg per liter. Abdominal radiographs showed a ventriculoperitoneal shunt in the right upper quadrant (fi gure 1). An abdominal ultrasonographic study revealed an organized hyporefl ective collection in the left lobe of the liver with a diameter of 10 cm and thickness of 5 cm. Computed tomography of the abdomen showed a perihepatic collection of 8 Hounsfi eld Units, consistent with the density of water. The ventriculoperitoneal shunt is located into this subcapsular collection (fi gure 2). We diagnosed a spontaneous shift of the ventriculoperitoneal shunt into the liver causing a subcapsular collection of cerebrospinal fl uid. The patient was transferred to the neurosurgical unit for repositioning. Figure 1 : Abdominal radiographs showed a ventriculoperitoneal shunt in the right upper quadrant (panel A). Panel B shows a radiograph of 2 months earlier with a normal position of the ventriculoperitoneal shunt.

Early onset tension pneumocephalus following ventriculoperitoneal shunt insertion for normal pressure hydrocephalus: A case report

The occurrence of tension pneumocephalus following ventriculoperitoneal (VP) shunt insertion is extremely rare, and is usually of delayed onset. We report a patient who developed an acute subdural tension pneumocephalus within 1 day following placement of a VP shunt for normal pressure hydrocephalus as a complication from shunt surgery.

Subdural Hematoma following Minor Head Trauma in Patients with Ventriculoperitoneal Shunts : Two Case Reports

*3 Abstract : Subdural hematoma or effusion is a common complication in ventriculoperitoneal shunts. However, the incidence of subdural hematoma in shunted patients requiring a surgical proce- dure has been decreasing recently, since it can be treated with a newly developed pressure-program- mable valve system. We treated two shunted patients with subdural hematomas caused by simple falls during gait training. The management was complicated, involving multiple surgical procedures. Case 1 : A 65-year-old woman, who had undergone ventriculoperitoneal shunting for normal pressure hydrocephalus after removal of a meningioma, suffered mild head trauma due to a fall during gait training and developed consciousness disturbance after 2 hours. Computed tomography revealed an acute subdural hematoma with marked midline shift. Emergency craniotomy and hematoma evacua- tion were performed. Case 2 : A 61-year-old man, who had previously undergone ventriculoperitoneal shunting for normal pressure hydrocephalus after subarachnoid hemorrhage, fell to the floor during gait training. Computed tomography demonstrated a thin subdural hematoma, thus the pressure-pro- grammable valve was adjusted to a higher pressure. However, the hematoma continued to enlarge and his level of consciousness deteriorated. Consequently, shunt ligation and irrigation of the chron- ic subdural hematoma were performed 6 days after the head trauma. Brain atrophy and a lowering of the intracranial pressure, which are both shunt-related complications, may have contributed to these patient' s subdural hematomas forming after such relatively minor head traumas. In conclusion, reha- bilitation physicians treating shunted patients must be aware of the possibility of a catastrophic intracranial hemorrhage following minor head trauma and of the various treatment-related difficulties arising in such a scenario including exacerbation of hydrocephalus, meningitis, and rebleeding. (Jpn J Rehabil Med 2008;45:193 ― 200)

Development of involuntary movements after ventriculoperitoneal shunting for normal pressure hydrocephalus in a patient with chronic-phase thalamic haemorrhage

Background: Delayed-onset involuntary movements have been described after thalamic stroke.Methods: We treated a patient with involuntary movements that increased after ventriculoperitoneal shunting (VPS) for normal pressure hydrocephalus (NPH) following thalamic haemorrage. One and one-half years after right thalamic and intraventricular haemorrhage, NPH suggested clinical evaluation and neuroimaging studies in a 56-year-old man.Results: Hemidystonia and pseudochoreoathetosis were evident in the left arm, leg and trunk. Proprioceptive impairment and mild cerebellar dysfunction affected the left upper and lower extremity. Yet the patient could walk unassisted and carry out activities of daily living (ADL) rated as 90 points according to the Barthel Index (BI). Lumbar puncture lessened both gait disturbance and cognitive impairment. After VPS, cognition and urinary continence improved, but involuntary movements worsened, precluding unaided ambulation and decreasing the BI score to 65 points. Computed tomography after VPS showed resolution of NPH, while single-photon emission computed tomography showed increased cerebral blood flow after VPS.Conclusion: Increased cerebral blood flow after VPS is suspected to have promoted development of abnormal neuronal circuitry.

Occurrence of subdural hematoma and resolution of gait disturbance in a patient treated with shunting for normal pressure hydrocephalus

A 66-year-old man with gait disturbance was diagnosed with normal pressure hydrocephalus (NPH) and treated with ventriculoperitoneal shunting using a programmable valve. The valve ultimately set at a pressure of 40 mmH 2O after higher settings no longer relieved symptoms. However, this pressure setting was excessively low and was associated with occurrence of bilateral subdural hematomas. Paradoxically, this event was associated with stable improvement of gait. Our patient's gait disturbance was unassociated with muscle weakness, spasticity, cerebellar ataxia, or Romberg's sign, and, therefore, was consistent with a frontal gait disorder. Cerebral cortical blood flow as measured after shunting by single photon emission computed tomography (SPECT) was slightly increased from the value before shunting, possibly because of intracranial hypotension related to the valve setting. Lasting improvement of gait in our case may be a result of increased blood flow in the supplementary motor area (SMA).

Recovery of stroke hemiplegia through neurosurgical intervention in the chronic stage

Objective: We evaluated quantitatively the further recovery from impairment and disability in the hemiplegic stroke survivors who required neurosurgical intervention, i.e. cranioplasty or ventriculoperitoneal (V-P) shunt, in chronic stage. Setting: Rehabilitation (RH) ward affiliated with university hospitals. Patients: Eleven first-ever stroke patients with hemiplegia (mean age, 56.3+/-2.5 years) out of 498 survivors required delayed (between 4 and 10 months after the onset) neurosurgical intervention during continuous RH therapy. Six patients received cranioplasty for preexisting hemicraniectomy, and five required V-P shunt for normal pressure hydrocephalus with later complications. Main outcome measures: Recovery grade (1--12) of hemiplegia and Barthel index were assessed monthly before (the 1st RH) and after the intervention (the 2nd RH). Results: The recovery grade of upper and lower extremity movements significantly increased both in the 1st and 2nd RH. Changes in the upper and lower extremity grades were significantly larger in the 2nd RH (0.5+/-0.3 in the 1st vs. 2.5+/-0.6 in the 2nd RH for upper extremity, p<0.005; 0.9+/-0.3 in the 1st vs. 3.4+/-0.5 in the 2nd RH for lower extremity, p<0.001). Barthel index increased significantly only in the 2nd RH (from 48+/-7 to 90+/-3, p<0.001); all patients regained the ability to walk independently. Conclusions: Significant recovery of functional grade and recovery from disability occurred after the neurosurgical intervention in the chronic stage (geq 4 months) of stroke.

Visual Environmental Rotation

A 70-year-old man experienced an unusual disorder of visual perception after undergoing a ventriculoperitoneal shunt for normal-pressure hydrocephalus. The disorder was characterized by transient episodes of 90 degrees rotation of the visual environment, rather than the retinotopic visual field. This phenomenon is different from standard visual allesthesia and may have been caused by disordered integration of vestibular and visual inputs to the posterior parietal cortex or perseveration of a pre-existing environmental memory trace.