Shunt Insertion Research Articles

Abdominal pseudocyst: a rare complication of ventriculoperitoneal shunt

Abstract Like any other surgical intervention, ventriculoperitoneal shunt (VPS) insertion is associated with multiple complications including bleeding, shunt infection, and shunt malfunction. Additionally, other complications involve the gastrointestinal tract, such as CSF pseudocyst or abdomen pseudocyst (APC) formation, have also been reported. The APC inhibits cerebrospinal fluid (CSF) absorption and causes shunt malfunction. Differential diagnosis might be difficult since APC can mimic other cystic abdominal diseases. This article aims to provide an updated review that summarize the most relevant findings available in the literature. This review can help clinicians in better understanding the clinical characteristics of this complication in order to develop a comprehensive approach that is associated with a lower incidence and recurrence rate of APC. Accurate history taking, precise clinical examination of signs and symptoms, abdominal imaging, and a high index of suspicion are key components of an APC diagnosis. Therefore, understanding predisposing factors and clinical features of such distinctive complication is essential for the adequate management of patients. Abdominal pseudocyst formation at the distal end of VPS can result in both features of shunt malfunction and abdominal signs and symptoms. Post-VPS APC, whenever suspected, should be assessed appropriately by imaging. The treatment of APC ranges from shunt removal and external drainage to various forms of shunt repositioning or conversion, and treatment decisions often depend on individual patient characteristics and surgeon preference.

The utility of routine intraoperative CSF during ventricular shunt insertion: a 10-year retrospective cohort study.

Ventricular shunt insertion is a common procedure in pediatric neurosurgical practice. In many areas of medicine there is a push toward rationalization of healthcare resources and a reduction in low-value tests or procedures. The intraoperative sampling of CSF at the time of shunt insertion is one traditional aspect of care that has not been rigorously evaluated. Additionally, the role of CSF cell counts and chemistry in predicting shunt dysfunction is often discussed but poorly studied. A recent meta-analysis found a correlation between elevated CSF protein levels and shunt failure in patients with tuberculous meningitis, but not other pathologies, which limits the generalizability of those findings to Western populations. The aims of this study were to assess the clinical utility of intraoperative CSF sampling during insertion of ventricular shunts and to describe any association of routine intraoperative CSF sample parameters with shunt failure or infection. A retrospective review of a prospectively maintained surgical database covering 10 years of consecutive cases from a quaternary Australian pediatric neurosurgical center serving a population of 5.3 million was conducted. Statewide electronic medical records were reviewed to collate data on demographics, postoperative imaging, CSF biochemistry, instances of shunt failure, shunt revisions, and mortality. Patients undergoing insertion of a new ventricular shunt were included, while all cases of shunt revision were excluded. During the study period, 1485 shunt procedures were performed, of which 427 involved the placement of a new ventriculoperitoneal shunt system. The mean patient age was 5.2 years (range premature-18 years). Of the 427 cases, 377 (88%) underwent routine CSF sampling. The most common indications for shunt revision were proximal catheter obstruction (51/173, 29%), followed by infection (29/173, 17%) and valve blockage (23/173, 13%). During the study period, 3 patients with existing intracranial hardware had overt ventriculitis identified at the time of intraoperative sampling, resulting in shunt removal. One patient with an existing ventricular reservoir had a delayed clinically significant infection identified on intraoperative cultures. Elevated CSF protein levels were associated with shunt failure during follow-up (area under the curve 0.625). The identified cutoff of 300 mg/L was significantly associated with a reduced time to shunt failure in both univariate and multivariate analyses. It may be reasonable to consider omission of routine intraoperative CSF sampling at the time of shunt insertion in patients without existing intracranial hardware. Elevated CSF protein levels are associated with a reduced time to shunt failure in a dose-dependent manner.

Insertion of a transjugular intrahepatic portosystemic shunt leads to sustained reversal of systemic inflammation in patients with decompensated liver cirrhosis.

Systemic Inflammation (SI) is considered a key mechanism in disease progression and development of complications in decompensated liver cirrhosis. SI is mainly driven by portal hypertension and bacterial translocation. Transjugular intrahepatic portosystemic shunt (TIPS) insertion represents an effective treatment for portal hypertension. This study aims to investigate the impact of TIPS insertion on SI and bacterial translocation. We prospectively included 59 cirrhotic patients undergoing TIPS insertion. Blood samples were collected at TIPS insertion and follow-up (FU) 1, 3, 6, and 12 months thereafter. At all time points, we performed a comprehensive analysis of SI including 43 soluble inflammatory markers (SIMs), and surrogates of bacterial translocation (sCD14, sCD163). To investigate long-term kinetics of SI, C-reactive protein (CRP) and white blood cells (WBC) were retrospectively analyzed in a cohort of 177 patients up to 3 years after TIPS insertion. At TIPS insertion, 30/43 SIMs, sCD14, and sCD163 measured significantly higher in cirrhotic patients compared to healthy controls. By FU6 25 SIMs and sCD14 measured at significantly lower levels compared to baseline. Interestingly, in patients with TIPS indication of refractory ascites, IL-6 decreased to levels documented in earlier stages of cirrhosis. In long-term follow-up, CRP levels significantly decreased after TIPS insertion, which translated into lower mortality in Cox regression analysis (HR 0.968, p=0.042). Notably, patients with residual ascites post-TIPS showed significantly higher CRP and IL-6 levels across all follow-ups compared to patients with resolved ascites. Decreasing portal hypertension via TIPS insertion leads to a significant attenuation of SI and bacterial translocation over time.

Value of plasma ammonia levels to predict hepatic encephalopathy after transjugular intrahepatic portosystemic shunt insertion

Value of plasma ammonia levels to predict hepatic encephalopathy after transjugular intrahepatic portosystemic shunt insertion

Endocrinologic Dysfunctions and Neuropsychiatric Sequelae in Pediatric Patients With a History of Central Nervous System Infection (ENDLESS): A Prospective Monocentric Study.

Central nervous system (CNS) infections represent some of the most critical pediatric health challenges, characterized by high mortality rates and a notable risk of long-term complications. Despite their significance, standardized guidelines for endocrinological follow-up of CNS infection survivors are lacking, leading to reliance on the expertise of individual centers and clinicians. Prospective monocentric observational study conducted at the Fondazione Policlinico Universitario Agostino Gemelli in Rome, Italy. It included patients with a history of CNS infection, admitted to various pediatric departments of the hospital. The participants were selected based on a coded diagnosis of CNS infection and had completed their follow-up at the Pediatric Endocrinology Day Hospital after October 2019. Eighty participants were included, comprising 53 patients with a prior CNS infection and 27 healthy controls, with a median age of 7.4 years (range 3.6-12.3 years). Endocrinologic alterations were detected in 13 patients, with 8 cases in those who had meningitis, 4 in encephalitis survivors, and 1 in a patient with a cerebral abscess. Patients with a history of CNS infections were shorter compared with healthy controls (P = 0.027). Moreover, those who had meningitis exhibited an increased risk of developing epilepsy (P = 0.01), neurosensory disabilities (P = 0.034) and the need for ventriculoperitoneal shunt insertion (P = 0.006). Patients with bacterial CNS infections were more prone to neurosensory and endocrine dysfunctions compared to those with viral or other infections. Significant differences were observed in hormone levels between previously infected patients and controls, specifically in TSH (P < 0.001), ACTH (P = <0.001), and cortisol (P = 0.019). IGF-1 levels were considerably lower in the infection group, both in absolute terms and when adjusted for sex and age (P < 0.001). The regression analysis suggested that the reduction in IGF-1 was more pronounced the earlier the CNS infection occurred, irrespective of infection type. Our study found several endocrinologic imbalances in children who survived CNS infections.

Bilateral vocal cord paralysis following ventriculoatrial shunt placement for hydrocephalus after subarachnoid hemorrhage: illustrative case.

A ventriculoatrial (VA) shunt is an alternative to a ventriculoperitoneal (VP) shunt for managing hydrocephalus, especially when VP shunt insertion is not feasible. Despite its decline in use, the VA shunt remains vital for certain patients. This report highlights a rare complication of bilateral vocal cord paralysis following VA shunt insertion for hydrocephalus secondary to subarachnoid hemorrhage. A woman in her 60s with a history of hypertension and giant liver cysts developed hydrocephalus after a subarachnoid hemorrhage. Because of her abdominal anatomical problems, VA shunt insertion assisted by transesophageal echocardiography (TEE) was chosen. Postoperatively, she experienced sudden dyspnea and upper airway stridor, diagnosed as bilateral vocal cord paralysis, necessitating an emergency tracheostomy. Gradual improvement was noted over the following month. Bilateral vocal cord paralysis can be a potential complication of TEE-assisted VA shunt procedures. To mitigate this risk, preoperative assessments of vocal cord function and swallowing are recommended. Alternatives to TEE, such as fluoroscopy or smaller probes, can be considered for patients with risk factors, including severe subarachnoid hemorrhage and prolonged intubation. https://thejns.org/doi/10.3171/CASE24518.

False alarms and the burden of shunt failure in pediatric patients with hydrocephalus: a longitudinal study.

This study aimed to investigate the burden of CSF shunt failure and false alarms on pediatric patients with hydrocephalus, their caregivers, and the healthcare system. This retrospective longitudinal study examined pediatric patients who underwent CSF shunt procedures at Auckland City Hospital from January 2014 to December 2019. The study included patients aged 18 years or younger living within the hospital's catchment area. Clinical encounters were recorded from the date of their first shunt insertion until November 1, 2023. Data collected included patient demographics, hospital admissions, acute and elective shunt-related imaging, clinic visits, surgery times, and symptom characteristics. Shunt-related admissions were categorized as either shunt failures or false alarms. The cohort comprised 73 patients with follow-up periods ranging from 4 to 18 years. By the 1st year, 71% had been rehospitalized for shunt-related concerns, with 59% experiencing at least 1 false alarm and 38% experiencing at least 1 shunt failure. By the 4th year, 88% of patients had been rehospitalized for shunt-related concerns, 42% had experienced at least 3 false alarms, 60% had at least 1 shunt failure, and 25% had at least 3 shunt failures. The average accumulated hospital stay was 1 month for shunt failures and 2 weeks for false alarms, compared with 22 days for all other admissions. Frequent clinic interactions from multiple specialties highlighted the complex care needs of these patients. The timing of shunt failure or false alarm, but not symptom duration, significantly predicted their overall frequency. This study details the chronic burden and complex care requirements for pediatric patients with CSF shunts. Shunt-related concerns significantly and disproportionately contribute to the patients' total hospital interactions. The findings highlight the immediate clinical need for novel technologies to enable long-term and accurate detection of shunt failure to optimize patient care. Future efforts should focus on improving shunt systems to lower failure rates.

Spontaneous cerebrospinal fluid rhinorrhea as a primary presentation of idiopathic intracranial hypertension, management strategies, and clinical outcome.

Causes of cerebrospinal fluid (CSF) rhinorrhea could be divided into primary (spontaneous) and secondary (head trauma and iatrogenic). Idiopathic intracranial hypertension (IIH) has emerged as a cause for spontaneous CSF rhinorrhea but is still underestimated, may be overlooked and needs special consideration in management. The objective of this study is to demonstrate spontaneous CSF rhinorrhea as the primary presentation of IIH and explore the algorithm of management. All patients with spontaneous (primary) CSF rhinorrhea were included with complete clinical and radiological assessment. We performed lumbar puncture and CSF pressure measurements in the lateral decubitus position for all included patients to detect those with intracranial hypertension. A pressure of 20 cmH2O in cases of CSF rhinorrhea is considered a cutoff for diagnosing raised intracranial pressure. When intracranial hypertension was diagnosed, patients were subjected immediately to lumboperitoneal shunt. If CSF leakage stopped after shunt insertion, we would not perform skull base repair, and the patient was sent for follow-up. However, if CSF leakage did not stop after shunt insertion despite normalization of intracranial tension or recurrence of CSF rhinorrhea despite shunt patency or there was intracranial pneumocephalus, skull base repair would be performed. During the period of the study, 293 cases of CSF rhinorrhea were seen. Only 42 (14.3%) patients were diagnosed with spontaneous CSF rhinorrhea, and the remaining were posttraumatic. Thirty-seven patients (88.1%) of 42 patients revealed high CSF pressure readings. All 37 patients received lumboperitoneal shunt followed by CSF rhinorrhea stoppage. Later, during follow-up, 7 patients developed recurrence of leakage; 3 of them revealed shunt obstruction, and rhinorrhea improved after shunt revision. The other 4 patients revealed patent shunt and needed skull base repair. Spontaneous CSF rhinorrhea is considered secondary to IIH until proven otherwise. Initial placement of lumboperitoneal shunt may provide an effective alternative to skull base repair for the treatment of patients with IIH presenting with CSF rhinorrhea.

Bone Regrowth After Frontal Burr Hole Craniostomy: Natural History of 14-mm and 20-mm Burr Holes and Implications for Postoperative Trans-Burr Hole Ultrasound

BACKGROUND AND OBJECTIVE: Burr hole craniostomy is performed for ventriculoperitoneal shunt insertion and endoscopic third ventriculostomy in patients with cerebrospinal fluid disorders. These burr holes are increasingly being used as windows for postoperative ultrasound, an investigational alternative to computed tomography or MRI for follow-up imaging of ventricular caliber. However, bone regrowth reduces ultrasound visibility, and little is known about burr hole regrowth rates in adults. Our study evaluates burr hole regrowth patterns and implications for transcranial ultrasound imaging. METHODS: We retrospectively analyzed 101 consecutive patients who had frontal burr hole craniostomy for new ventriculoperitoneal shunt insertion or endoscopic third ventriculostomy over a 3-year period. A mix of standard 14-mm burr holes and expanded 20-mm burr holes were used. Burr hole bone regrowth was assessed using serial follow-up computed tomography scans. Linear and logistic regression analyses examined if bone regrowth correlated with any clinical variables. RESULTS: There was wide variability in rate and degree of burr hole regrowth. The average percentage closure was 25% at 6 months, with minimal additional closure over the following 18 months. The mean residual diameter for 14-mm and 20-mm burr holes stabilized around 9.4 mm and 15.4 mm, respectively. Bone regrowth was not associated with patient characteristics, including age, sex, skull thickness, or etiology of cerebrospinal fluid disorder. Rate of bone regrowth was similar between both cohorts. CONCLUSION: Bone regrowth after burr hole craniostomy is common, even in elderly patients, occurring rapidly within the first 6 to 12 months and subsequently stabilizing. It is frequently severe enough to restrict ultrasound visualization. Regrowth could not be predicted with any investigated variables, so uniform techniques are needed to block regrowth to allow for longitudinal ultrasound imaging, such as full-thickness cylindrical burr hole implants.

Management of treatment-naïve Koos grade IV vestibular schwannomas using hypofractionated Gamma Knife radiosurgery: a retrospective single-institution study.

While single-fraction Gamma Knife radiosurgery (GKRS) has shown efficacy in managing vestibular schwannomas (VSs), some concerns have been raised regarding its safety profile, particularly in the context of hearing preservation. Hypofractionation has emerged as a promising approach to improving the safety profile. This retrospective, single-institution study evaluated patient outcomes following hypofractionated GKRS (hf-GKRS) for treatment-naïve Koos grade IV VSs. This study involved all patients with treatment-naïve Koos grade IV VSs who underwent hf-GKRS (3 or 5 fractions) between January 2018 and June 2021, with a follow-up period of ≥ 36 months. The outcomes assessed included local control (LC), the preservation of serviceable hearing as determined by the Gardner-Robertson hearing scale, and procedure-related adverse events. Twenty-nine patients (14 females, median age 49 years) were treated with three different dose regimens: 21 patients received 18Gy in 3 fractions, 6 patients received 20Gy in 5 fractions, and 2 patients received 25Gy in 5 fractions. Prior to treatment, 13 patients (44.8%) had serviceable hearing, one (3.4%) presented with facial palsy, and four (13.8%) had trigeminal nerve dysfunction. The median tumor volume was 10.8 cm3. During a median radiological follow-up period of 60 months (range, 36-78 months), LC was achieved in all patients. All 13 patients retained serviceable hearing at the last follow-up. Trigeminal nerve dysfunction occurred in one patient (3.4%), while another patient (3.4%) needed a ventriculoperitoneal shunt insertion due to new-onset hydrocephalus. No new-onset facial palsy was observed. hf-GKRS shows promise as an effective and safe primary or adjuvant treatment for Koos grade IV VSs with non-life-threatening or debilitating symptoms. Future studies with larger cohorts and extended follow-up periods are needed to validate these findings and to refine fractionation schemes.

Arnold-Chiari Malformations in Pediatric Patients After Fetal Surgery for Meningomyelocele.

(1) Background: Fetal surgery for meningomyelocele (MMC) should reduce the occurrence of Arnold-Chiari malformations, hydrocephalus, the associated need for craniocervical decompression, and the need for cerebrospinal fluid shunt insertion. Fetal surgery should improve ambulatory status. (2) Methods: We used retrospective analysis of the documentation and descriptive statistics to summarize the clinical data and measured MRI parameters. The neurosurgical results are presented as the frequency of findings in percentages and compared with the results of the Management of Myelomeningocele Study (MOMS). (3) Results: A total of eight patients who underwent prenatal correction of MMC between 2016 and 2020 participated. MRI detected Chiari II malformation in all patients during prenatal imaging and in 87.5% of the patients at the age of 12 months. Craniocervical decompression was used in 25% of the patients. Shunt-dependent hydrocephalus occurred in 50% of the cases. In 87.5% of the cases, the functional level exceeded the expected ambulatory status. (4) Conclusions: We present the clinical status of our patients. Analysis of the complete cohort confirmed that prenatal surgery is associated with a reduced occurrence of Chiari malformations and reduced associated occurrence of hydrocephalus. Specific lesion levels are not associated with the need for craniocervical decompression. The results of our study are valuable in prenatal counseling and important for treatment planning.

Operative Factors Associated with Severe Hypotension in the Postoperative Setting in Patients with Carotid Artery Endarterectomy.

Carotid endarterectomy is a recognized method for preventing stroke for both symptomatic and asymptomatic hemodynamically carotid artery stenosis. Hemodynamic depression is more frequently associated with carotid artery stenting, while postoperative hypertension and cerebral hyperperfusion syndrome are known frequent complications after carotid endarterectomy. Severe hypotension after carotid revascularization is associated with a higher risk of perioperative stroke, myocardial infarction, and death, with limited data existing regarding risk factors. This study aims to investigate intraoperative risk factors for severe hypotension after carotid endarterectomy. A total of 160 patients who underwent carotid endarterectomy were included in this study. Patients with other cardiac conditions that required concomitant cardiac surgery, patients with incomplete medical records, and patients considered high risk for surgery were excluded. The incidence of severe hypotension was 30.6%. Patients with severe hypotension after carotid endarterectomy had a higher incidence of diabetes, moderate mitral valve regurgitation, a history of percutaneous coronary intervention, and higher operative times. Using logistic regression, temporary shunt insertion was independently associated with severe postoperative hypotension (OR = 2.26, 95% CI = 1.09-4.71, p = 0.029). This result favors the selective shunting strategy when performing carotid endarterectomies, especially for those patients with comorbidities predisposing to postoperative complications.

Laparoscopic-Assisted Peritoneal Access in Ventriculoperitoneal Shunt Placement: Systematic Review and Meta-Analysis.

The most common treatment of hydrocephalus is ventriculoperitoneal (VP) shunting. Peritoneal access is commonly conducted through an open laparotomy, but laparoscopic peritoneal access is gaining popularity. Many studies have reported the benefits of minimally invasive laparoscopic peritoneal access, but there is no consensus on its use. We conducted a systematic review and meta-analysis to compare open laparotomy vs laparoscopic peritoneal access in VP shunting. A systematic search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using 3 databases. Twelve studies included only adults, 3 included only pediatric patients, and 3 included both adults and pediatric patients. Compared with open laparotomy, laparoscopic peritoneal access was associated with a reduction in distal shunt failure (6.1% vs 2.2%, P = .01), operative time (69.4 vs 56.3 minutes, P < .001), and length of stay (LOS) (9.6 vs 7.3 days, P < .001). There were no differences in proximal shunt failure, total shunt failure, intraoperative complications, or infection rate. In the pediatric population, laparoscopic access was associated with a reduced LOS (7.8 vs 5.9 days, P < .001). Heterogeneity was high but explained by the varying study populations and techniques. Laparoscopic peritoneal access for VP shunt insertion is associated with improved outcomes, including reduced distal shunt failure, reduced operative time, and reduced hospital LOS, when compared with open laparotomy and should be considered for shunt insertion. Additional studies are necessary to further determine the benefit of laparoscopic access, especially in the pediatric population.

Adult-onset neuronal ceroid lipofuscinosis misdiagnosed as autoimmune encephalitis and normal-pressure hydrocephalus: A 10-year case report and case-based review.

Neuronal ceroid lipofuscinoses (NCLs) are rare, fatal, inherited neurodegenerative disorders characterized by myoclonic epilepsy, cognitive decline, brain atrophy, and retinopathy. The pathogenesis and clinical manifestations of NCL are not well understood and frequently result in misdiagnosis and overtreatment. The aim of this case report and review is to improve our understanding of the clinical features and management of NCL. A 36-year-old woman initially presented with refractory epilepsy. Initially diagnosed with autoimmune encephalitis, the patient was later diagnosed with normal-pressure hydrocephalus. A definitive diagnosis of adult-onset neuronal ceroid lipofuscinosis (ANCL) was established after 10 years of observation, utilizing biopsy and genetic testing. High-dose intravenous immunoglobulin and methylprednisolone were administered, along with the insertion of a ventriculoperitoneal shunt. Despite various treatments, the patient's condition did not improve. ANCL typically presents with the clinical triad of refractory seizures, progressive cognitive decline, and movement disorders. Neuroimaging often reveals progressive brain atrophy on magnetic resonance imaging, while electroencephalograms frequently show epileptiform discharges. The prognosis is generally poor. Improved understanding of ANCL from both clinical and radiological perspectives, coupled with early consideration of differential diagnoses, could minimize unnecessary interventions and optimize patient care.

Are variations in ventricular catheter placement related to design of the catheter? A single-center cohort study.

The use of intracranial catheters is a common procedure used for neurosurgical patients with a variety of pathologies. Despite its frequency of use, shunt failure and revision have been reported to be a common problem. Given that depth of insertion can significantly affect the catheter tip position, a single institution retrospective chart review was performed to examine the accuracy of shunt and external ventricular drain (EVD) placement. Computed tomography (CT) images of the head following shunt or ventriculostomy insertion were analyzed to determine the delta between the final length of the intracranial catheter and the intended depth described in the operative notes. We found that there was a statistically significant difference in the accuracy of placement when comparing EVDs to shunts. The most used EVDs at our institution are marked with a solid black line in increments spaced 2 cm apart. The most used ventricular shunt catheter has a marking at 5 cm and 10 cm from the tip of the catheter. We believe that the visual confirmation that is afforded by metric unit markings on the EVD allows for better final placement of the catheter at the outer table of the calvarium. The addition of regular millimeter metric unit markings by the manufacturer is imperative in decreasing the chances of error in the insertion of ventricular catheters and preventing potential neurovascular injury to the surrounding structures.

Clinical and radiographic outcomes after subduro-peritoneal shunt insertion in adults

BackgroundSubdural collections consist amongst others of cerebrospinal, inflammatory, haemorrhagic or infective fluid. While these accumulations can be treated with conservative or surgical measures, such as burr hole evacuation or craniotomy, clinicians may resort to implantation of a subduro-peritoneal shunt, due to their high recurrence rates. While this treatment option is widely used in the pediatric population, its efficacy and safety in adults is scarcely reported. MethodsThis project is a retrospective case series of 25 adult patients, who underwent subduro-peritoneal shunt (SDPS) implantation between December 2008 and June 2021. The indications included symptomatic subdural collections following trauma, tumor resection or bone flap reimplantation. In general, adjustable valves were used. All patients received a pre- and postoperative computed tomography (CT) scan. We evaluated patients’ postoperative clinical outcomes as well as radiographic criteria, including midline shift, frontal horn width and collection volume. Additionally, we analyzed shunt-related complications. ResultsImpaired consciousness was the commonest presenting symptom. We report a significant reduction in volume and width of the subdural collection after SDP shunt implantation. Furthermore, the midline shift decreased significantly. While 60 % (N=15) of the patients improved clinically, only 12 % (N=3) deteriorated. Complications comprised infection in 12 % (N=3) of patients and valve dysfunction in 1 patient. ConclusionsOur study shows that SDPS in adults is an effective treatment to eliminate or reduce subdural collections, that improves clinical outcomes in the majority of patients. Hence, it should be utilised more widely in this patient population. However, further studies are necessary to validate the treatment and identify eligible patients.

The economic burden of ventriculoperitoneal shunt insertion and its complications: findings from a cohort in the Philippines.

Ventriculoperitoneal shunt (VPS) insertion is the gold standard treatment for congenital hydrocephalus, but there is little data about the cost of this procedure in developing countries. We aimed to determine the in-hospitalization cost of initial VPS insertion and its complications (malfunction and infection) and identify predictors of increased cost. We performed a retrospective cohort study by reviewing the medical and financial records of pediatric patients with congenital hydrocephalus and underwent shunt surgery at our institution between 2015 and 2019. We also performed multivariable linear regression analysis to determine clinical characteristics that were predictive of cost. A total of 230 cerebrospinal fluid diversion procedures were performed on 125 patients. The mean age during index VPS insertion was 9.8months (range: 7days-8years). Over a median follow-up of 222days, 15 patients (12%) developed shunt malfunction while 25 (20%) had a shunt infection. The mean in-hospitalization cost for all patients was PHP 94,573.50 (USD 1815). The predictors of higher cost included shunt infection (p < 0.001), shunt malfunction (p < 0.001), pneumonia (p = 0.006), sepsis (p = 0.004), and length of hospital stay (p = 0.005). Patients complicated by shunt infection had a higher mean cost (PHP 282,631.60; USD 5425) than uncomplicated patients (PHP 40,587.20 or USD 779; p < 0.001) and patients who had shunt malfunction (PHP 87,065.70 or USD 1671; p < 0.001). The study provided current data on the in-hospitalization cost of VPS insertion in a public tertiary hospital in a developing country. Shunt infection, malfunction, pneumonia, sepsis, and length of hospital stay were significant predictors of cost.

A lumped parameter modelling study of cerebral autoregulation in normal pressure hydrocephalus suggests the brain chooses to be ischemic

Normal pressure hydrocephalus (NPH) is associated with a reduction in cerebral blood flow and an ischemic metabolic state. Ischemia should exhaust the available autoregulation in an attempt to correct the metabolic imbalance. There is evidence of some retained autoregulation reserve in NPH. The aim of this study is to model the cerebral autoregulation in NPH to discover a solution to this apparent paradox. A lumped parameter model was developed utilizing the known limits of autoregulation in man. The model was tested by predicting the cerebral blood volume changes which would be brought about by changes in resistance. NPH and the post shunt state were then modeled using the known constraints provided from the literature. The model successfully predicted the cerebral blood volume changes brought about by altering the cerebral perfusion pressure to the limit of autoregulation. The model suggests that NPH is associated with a balanced increase in resistance within the arterial and venous outflow segments. The arterial resistance decreased after modelling shunt insertion. The model suggests that the cerebral blood flow is actively limited in NPH by arteriolar constriction. This may occur to minimize the rise in ICP by reducing the apparent CSF formation rate.

Utility of routine postoperative imaging in adults undergoing primary ventriculoperitoneal shunts.

There is currently no consensus on the usefulness of postoperative imaging after ventriculoperitoneal (VP) shunt insertion in adults. The aim of this study was to investigate the utility of routine postoperative imaging (CT head scans and radiographs) following primary VP shunt insertion in a general adult population treated at a tertiary neurosurgical centre. Patients undergoing primary VP shunt insertion between 2017-2021 were included. Actions taken based on routine postoperative imaging and need for subsequent shunt revision were recorded. 236 patients were included. The median age was 63years (range 17-90). There was a slight female preponderance (121/236, 51.3%). The median follow-up was 38.5months (3.1 - 60.5months). Acute intervention was employed in 9 patients (3.9%) on the basis of routine postoperative CT head scan. Routine postoperative radiographs did not result in reoperation. Around a quarter (28.8%) of patients had a shunt revision, most of whom underwent urgent primary shunt insertions. Postoperative ventricular catheter characteristics (position of shunt tip, tip relation to septum pellucidum, and intraventricular catheter distance) were not predictive of shunt revision. Surgical urgency (emergency vs. elective procedures) was associated with long-term shunt revision (OR = 2.80, 95% CI 1.42 - 5.53, p = 0.003). Routine postoperative imaging rarely led to reoperation in adult patients undergoing primary VP shunt insertion. Patients undergoing emergency shunt insertions were at the highest risk for requiring revision.

Evaluation of ventriculoperitoneal shunt infections and risk factors in children.

To evaluate the demographic, clinical, diagnostic, and treatment data of pediatric patients with ventriculoperitoneal shunt infection and risk factors for ventriculoperitoneal shunt infection and recurrence of ventriculoperitoneal shunt infection. Patients aged 0-18 years who were diagnosed with ventriculoperitoneal shunt infection at CukurovaUniversity Faculty of Medicine Hospital between 2016 and 2021 were included in the study. Demographic, clinical, laboratory, and treatment data of the patients were evaluated retrospectively. Risk factors for the development and recurrence of ventriculoperitoneal shunt infection were evaluated. Patients who underwent ventriculoperitoneal shunt but did not develop any shunt infection were selected as the control group. Eighty-five patients with a diagnosis of ventriculoperitoneal shunt infection were included in the study. Fever (58.8%), anorexia (58.8%), vomiting (56.5%), and altered consciousness (54.1%) were the most common complaints at admission. The control group consisted of 48 patients. The number of shunt revisions was statistically significantly higher in the group that developed ventriculoperitoneal shunt infection compared to the control group (p < 0.001). In patients with ventriculoperitoneal shunt infection, C-reactive protein and cerebrospinal fluid protein values before shunt insertion were found to be statistically significantly higher than the control group (p < 0.001). Ventriculoperitoneal shunt infection occurs most frequently in the first months after shunt application. Therefore, it is extremely important to prevent colonization and contamination during surgery in preventing the development of ventriculoperitoneal shunt infection. In the present study, cerebrospinal fluid protein elevation and C-reactive protein elevation before shunt application were found to be significant in terms of the development and recurrence of ventriculoperitoneal shunt infection.