Shunt Surgery Research Articles

Failed Ahmed glaucoma valves: trabeculectomy versus repeat shunt surgery

IntroductionTo investigate the outcomes of trabeculectomy (TRAB) versus repeat Ahmed glaucoma valve (re-AGV) implantation in eyes with Ahmed glaucoma valve (AGV) failure.MethodsThis quasi-experimental study includes patients with failed AGV implants requiring additional surgical intervention between 2018 and 2022. Patients in the TRAB group underwent a fornix-based procedure with mitomycin C 0.01% injection (0.1 mL). Eyes in the re-AGV group underwent repeat shunt surgery. The choice of the procedure was based on conjunctival condition. The primary outcome measure was surgical success rate based on various intraocular pressure (IOP) targets and percentages of IOP reduction from baseline: IOP ≤ 21 mmHg and 20% reduction (conventional criteria), IOP ≤ 18 and > 20% reduction (criterion A), IOP ≤ 15 and > 25% reduction (criterion B), and IOP ≤ 12 and > 30% reduction (criterion C).ResultsForty-eight eyes of 48 patients were operated and reported herein, consisting of 22 eyes of 22 patients undergoing TRAB and 26 eyes of 26 subjects undergoing re-AGV. No significant difference was observed between the study groups in terms of initial diagnoses, baseline IOP or the number of prior surgeries. The cumulative probability of survival at one year was significantly higher in the trabeculectomy group using the three stricter success definitions. In both study groups, IOP was significantly reduced from baseline at all postoperative visits, and was significantly lower in the TRAB group at all time points beyond one month. At 12 months, 5% of TRAB versus 48% of re-AGV eyes required glaucoma medications (P < 0.001). The rate of complications was comparable between the study groups (P = 0.76) but there was a trend toward a greater need for repeat surgery in the re-AGV group (4 eyes versus nil, P = 0.07).ConclusionsTrabeculectomy can be considered a safe and effective surgical option in eyes with failed AGV leading to significantly lower IOP levels and more favorable success rates than re-AGV in selected patients.

Blood-brain barrier-associated biomarker correlated with cerebral small vessel disease and shunt outcome in normal pressure hydrocephalus: a prospective cohort study.

Blood-brain barrier (BBB) breakdown is associated with neurodegeneration and cognitive impairment. Cerebral small vessel disease (CSVD) is also common in idiopathic normal pressure hydrocephalus (iNPH). Biomarkers in the cerebrospinal fluid (CSF) may reflect the severity of neuropathological damage and indicate a relationship between BBB integrity and iNPH and its surgical outcome. We investigated the association of CSVD and comorbidity-related CSF biomarkers with shunt outcomes in iNPH. This prospective cohort study recruited 53 patients with iNPH, who were subgrouped by CSVD severity. CSF proteins were analyzed, including soluble platelet-derived growth factor receptor-β (sPDGFR-β), Alzheimer's disease biomarkers, neurofilament light chain (NfL), and triggering receptor expressed on myeloid cells 2 (Trem2). We assessed symptom improvement, investigated its association with biomarkes levels, calculated protein cutoffs for surgical outcomes using receiver operating characteristic (ROC) curves, and compared model predictions using different proteins using hierarchical regression analysis. Among patients with iNPH, 74% had comorbid CSVD. Patients with severe CSVD exhibited significantly higher sPDGFR-β levels (P=0.019) and better postoperative performance (β=0.332, t=2.174, P=0.039; r=0.573, P=0.001). Analysis of the predictive potential of the biomarkers showed that sPDGFR-β was predictive of surgical outcomes (area under curve=0.82, sensitivity=66.8%, specificity=94.7%). A Comparison of the models revealed a greater effect of sPDGFR-β (Adjusted R2=0.247, ∆R2=0.160, ∆F(1, 37)=8.238, P=0.007) on cognitive improvement. This study highlighted the relevance of CSF biomarkers in assessing CSVD severity and predicting iNPH surgical outcome. CSF shunt surgery may provide an alternative treatment for neurodegenerative diseases with BBB breakdown and dysfunctional CSF clearance.

Contemporary management of ischemic priapism: A 12-year population-based analysis from a large US database.

Priapism is a urological condition characterized by a persistent erection. The management varies based on its subclassifications. Despite established clinical guidelines for ischemic priapism, there is a lack of large-scale research focused on patient characteristics and management strategies. To analyze the contemporary management of ischemic priapism in the US, exploring patient demographics and clinical characteristics, as well as predictors of erectile dysfunction (ED) and penile prosthesis implantation (PPI). We performed a retrospective analysis of the PearlDiver Mariner database, reviewing records from 2010-2021. Adult males diagnosed with ischemic priapism were included. Data analysis covered demographic, clinical variables, and management strategies. Predictors of de novo ED and PPI were evaluated using multivariable logistic regression analysis. Of 36,120 patients, most (93%) received only medical management, and a minority underwent surgical interventions (penile shunt surgery [PSS], PPI or both). Medical management was typically effective, as 67.08% of the patients in this group experienced only one episode of priapism. However, de novo ED occurred in 16.57% of these patients. The majority of patients undergoing PPI had an inflatable prosthesis (81%). Older age (odds ratio, OR 1.02), the presence of metabolic diseases (OR 1.39), neurogenic disorders (OR 1.72), solid pelvic malignancies (OR 1.09), and multiple episodes of priapism were identified as significant predictors of de novo ED (all p<0.05). Similarly, age (OR 1.03), the presence of metabolic diseases (OR 1.23), solid pelvic malignancies (OR 1.99), and multiple episodes of priapism were associated with higher likelihood of PPI (all p<0.05). Most cases of ischemic priapism are managed with the medical therapy. Less than 3% of patients with ischemic priapism receive PPI, and when this occurs an inflatable prosthesis is favored. Age, specific comorbidities, and multiple episodes of priapism appear to be significant predictors of ED and PPI.

Repeated complete atrioventricular block during remifentanil administration in a pediatric patient with brain tumor and acute hydrocephalus: a case report

BackgroundRemifentanil, an ultra-short-acting µ-opioid receptor agonist, is commonly used for anesthetic management due to excellent adjustability. Remifentanil is known to cause sinus bradycardia, however, because it has a direct negative chronotropic effect on the cardiac conduction system and there is an indirect negative chronotropic effect via the parasympathetic nervous system.Case presentationAn 8-year-old Japanese boy was diagnosed with acute hydrocephalus due to a brain tumor in the fourth ventricle and underwent emergency surgery. Imaging examination showed brainstem compression. Endoscopic third ventriculostomy and ventriculoperitoneal shunt surgery were scheduled. Remifentanil was started during induction of general anesthesia, but electrocardiogram showed sinus bradycardia, then Wenckebach-type atrioventricular block, and then complete atrioventricular block. Remifentanil was immediately discontinued, and we administered atropine sulfate. Complete atrioventricular block was restored to sinus rhythm. When remifentanil was restarted, however, the electrocardiogram again showed sinus bradycardia, Wenckebach-type atrioventricular block, and then complete atrioventricular block. Remifentanil was again immediately discontinued, we administered adrenaline, and then complete atrioventricular block was restored to sinus rhythm. Fentanyl was used instead of remifentanil with continuous infusion of dopamine. There has since been no further occurrence of complete atrioventricular block.ConclusionsThis is the first known case of complete atrioventricular block in a pediatric patient with increased intracranial pressure seemingly caused by administration of remifentanil.

Changes in Callosal Angle and Evans Index After Shunt Surgery in Patients with Idiopathic Normal Pressure Hydrocephalus

BackgroundIdiopathic normal pressure hydrocephalus (iNPH) is a disease characterized by gait disturbance, cognitive impairment and urinary incontinence. For those patients who do not respond to shunt surgery, it lacks objective radiological findings for the diagnosis of shunt malfunction. Here we aimed to evaluate whether Evans index and callosal angle change during a prospective long-term follow-up of patients with iNPH submitted to shunt surgery. MethodsClinical (NPH Japanese Scale) and radiological (Evans index, callosal angle) data were collected pre- and postoperatively (3, 6, 12 months) in 19 patients with iNPH. Imaging tests were evaluated by the same neuroradiologist during the follow-up. ResultsPatients had lower scores on NPH Japanese Scale over time (p< 0.001). There was no significant difference among Evans index values during the follow-up (p= 0.24). Preoperative average callosal angle was 72 ± 15, which increased to 91 ± 18 in 6 months (p= 0.003). ConclusionsIn this sample, patients with iNPH submitted to a programmable valve shunt had an increase in callosal angle concomitant to neurological improvement. Evans index did not change during follow-up.

Transsylvian transopercular peri-central core hemispherotomy for treating epilepsy: anatomy, surgical technique, and clinical outcome.

The objective of this study was to display the anatomical landmarks, surgical technique, and clinical outcome of transsylvian transopercular peri-central core hemispherotomy (TTPH) for treating refractory epilepsy. From 2011 to 2023, 26 patients (12 with Rasmussen syndrome, 8 with hemimegalencephaly/cortical malformations, and 6 with hypoxic-ischemic encephalopathy; mean [range] age 11.3 years [16 months to 35 years]; 13 females; and 13 with right-side pathology) underwent TTPH. The mean (range) follow-up was 88 (14-156) months. The intradural surgical time, use and amount of blood transfusion, postoperative fever, hospital stay, weight at surgery, and seizure onset to surgery interval are reported. TTPH consists of 1) sylvian fissure opening, 2) coagulation of the M2 and M3 branches, 3) frontoparietal opercula removal, 4) suprainsular resection, 5) insula removal, 6) selective amygdalohippocampectomy, 7) disconnection of the posterior temporal and occipital lobes using the tentorium and falx as landmarks, 8) intraventricular callosotomy, and 9) disconnection of the basal frontal lobe. In cortical malformation, the gray-white matter interface serves as a landmark. The average intradural operating time was 7 hours 18 minutes (3 hours 33 minutes to 13 hours 45 minutes); all patients were Engel class I; and 2 patients presented with procedure-related complications (meningitis and transient abducens nerve palsy). No patient required shunt surgery or reoperation. TTPH offers anatomical landmarks as intraoperative guides and has achieved good seizure control and low complication rates.

Depressive symptoms, functional impairment, and health-related quality of life in idiopathic normal pressure hydrocephalus: A population-based study.

Maximising quality of life is a central goal for all healthcare, especially when dealing with dementing disorders. In this study we aimed to compare health-related quality of life (HRQoL), depressive symptoms and functional impairment between individuals with and without idiopathic normal pressure hydrocephalus (iNPH) from the general population. A total of 122 individuals, 30 with iNPH (median age 75 years, 67 females) underwent neurological examinations and computed tomography of the brain with standardised rating of imaging findings and clinical symptoms. The participants completed the Geriatric Depression Scale (GDS-15) and the HRQoL instrument EQ5D-5L. In addition, the modified Rankin Scale (mRS) was used to evaluate functional impairment. Compared with participants without iNPH, those with iNPH reported a higher score on GDS-15 (median 3 vs 1) and mRS (median 2 vs 1) (p < 0.05). Further, those with iNPH rated lower on EQ5D-5L (index 0.79, VAS 70) than those without iNPH (index 0.86, VAS 80) (p < 0.05). In logistic regression models, low HRQoL was associated with more depressive symptoms, a higher degree of iNPH symptoms, and lower functional status. In this population-based sample, those with iNPH had more depressive symptoms, lower functional status, and worse quality of life compared to those without iNPH. The strongest association with low HRQoL was found for depressive symptoms, functional level, and degree of iNPH symptoms. These results underline the value of shunt surgery because of its potential to reduce symptoms and disability in iNPH and therefore improve HRQoL.

Shunt options for normal pressure hydrocephalus: a comparison of complications, overdrainage rates and neurological outcomes between integra low flow regulated and Codman Hakim programmable shunts

Aims: Shunt surgery is the most commonly performed treatment for idiopathic normal pressure hydrocephalus, and shunt systems with different operating principles are employed. This study aimed to retrospectively compare programmable ventriculoperitoneal shunts and flow-regulated shunts in terms of complications, overdrainage rates, and neurological outcomes. Methods: Between January 2020 and May 2022, 44 patients who underwent shunt operation with a diagnosis of idiopathic normal pressure hydrocephalus at our clinic were retrospectively analyzed. Patients were categorized into two groups: the programmable ventriculoperitoneal shunt and the flow-regulated shunt group. Demographic characteristics, complications, rates of insufficient drainage/overdrainage, and surgical outcomes were compared. Results: There were 26 patients in the programmable ventriculoperitoneal shunt group and 18 patients in the flow-regulated shunt group. In the programmable ventriculoperitoneal shunt group, 14 patients (53.8%) required 27 shunt setting adjustments owing to excessive or inadequate drainage. Subdural effusion was observed in five patients (19.2%), and shunt revision was performed in one patient (3.8%). Subdural effusion was observed in two (11.1%) patients in the flow-regulated shunt group. One of these patients (5.5%) underwent shunt revision. There was no significant difference between the groups in terms of the development of subdural effusion and need for shunt revision (p&gt;0.05). The rate of improvement in at least one of the symptoms was 53.8% in the programmable ventriculoperitoneal shunt group at the 1st-month postoperative outpatient follow-up. In the flow-regulated shunt group, this rate was 72.2% and there was no statistically significant difference. Both groups showed similar clinical improvement at the 1-year follow-up. Conclusion: There was no difference between the groups in terms of neurological outcomes and the need for shunt revision. However, the use of flow-regulated shunts has demonstrated earlier rates of clinical improvement without the need for reprogramming.

Surgical treatment of liver cancer and pancreatic cancer under the China Healthcare Security Diagnosis Related Groups payment system.

Data from the World Health Organization's International Agency for Research on Cancer reported that China had the highest prevalence of cancer and cancer deaths in 2022. Liver and pancreatic cancers accounted for the highest number of new cases. Real-world data (RWD) is now widely preferred to traditional clinical trials in various fields of medicine and healthcare, as the traditional research approach often involves highly selected populations and interventions and controls that are strictly regulated. Additionally, research results from the RWD match global reality better than those from traditional clinical trials. To analyze the cost disparity between surgical treatments for liver and pancreatic cancer under various factors. This study analyzed RWD 1137 cases within the HB1 group (patients who underwent pancreatectomy, hepatectomy, and/or shunt surgery) in 2023. It distinguished different expenditure categories, including medical, nursing, technical, management, drug, and consumable costs. Additionally, it assessed the contribution of each expenditure category to total hospital costs and performed cross-group comparisons using the non-parametric Kruskal-Wallis test. This study used the Steel-Dwass test for post-hoc multiple comparisons and the Spearman correlation coefficient to examine the relationships between variables. The study found that in HB11 and HB13, the total hospitalization costs were significantly higher for pancreaticoduodenectomy than for pancreatectomy and hepatectomy. Although no significant difference was observed in the length of hospital stay between patients who underwent pancreaticoduodenectomy and pancreatectomy, both were significantly longer than those who underwent liver resection. In HB15, no significant difference was observed in the total cost of hospitalization between pancreaticoduodenectomy and pancreatectomy; however, both were significantly higher than those in hepatectomy. Additionally, the length of hospital stay was significantly longer for patients who underwent pancreaticoduodenectomy than for those who underwent pancreatectomy or liver resection. China Healthcare Security Diagnosis Related Groups payment system positively impacts liver and pancreatic cancer surgeries by improving medical quality and controlling costs. Further research could refine this grouping system and ensure continuous effectiveness and sustainability.

Comparison of Blalock-Taussig-Thomas Shunts With Patent Ductus Arteriosus Ligated Versus Left Open.

The optimal approach to patent ductus arteriosus management during systemic-to-pulmonary artery shunt placement is currently unknown. The purpose of this study is to examine the outcomes of variable strategies for patent ductus arteriosus management during Blalock-Taussig-Thomas shunt surgery. A retrospective cohort study of infants who underwent shunt placement was performed, comparing those who had the ductus ligated with those who had the ductus left open. Indicators of low cardiac output syndrome, development of necrotizing enterocolitis, and secondary outcomes such as resuscitation events were examined. Thirty-six infants were included all of whom had their shunt placed via median sternotomy. Twenty infants had their ductus ligated at the time of the shunt, and they were compared with 16 infants whose ductus was left open. There was no statistical difference in preoperative baseline characteristics, including corrected gestational age, age in days, weight, mechanical ventilation, vasoactive use, heterotaxy, and gastrointestinal anomalies. There was also no statistical difference in postoperative indicators of low cardiac output, including urine production, total fluids given, renal injury, maximum lactate, and vasoactive-inotropic score. Three patients had postoperative renal injury, and all were in the ligated duct group. There was also no statistical difference in any secondary outcomes, including the development of necrotizing eneterocolitis, resuscitation events, reinterventions, length of intubation, total length of stay, and mortality. This study provides evidence that variable management of the ductus during shunt placement does not significantly impact outcomes. Leaving the ductus open allows for a potential rescue source of pulmonary blood flow and does not appear to increase the risk of postoperative low cardiac output.

Ứng dụng của test chọc tháo dịch não tủy trong chẩn đoán và điều trị giãn não thất áp lực bình thường nguyên phát: ca lâm sàng

Normal Pressure Hydrocephalus (NPH) is a clinical syndrome characterized by gait disturbance, cognitive decline, and urinary incontinence accompanied by ventricular enlargement without increased intracranial pressure. NPH is a diagnosis of particular note as it differs from other neurodegenerative disorders such as Alzheimer’s and Lewy body disease. Symptoms may improve if diagnosed and treated promptly. Clinical symptoms of the disease were first described by Salomon Hakim and R.D. Adam in 1965, though they are common but not specific enough. Additionally, age-related ventricular enlargement and periventricular white matter damage are found in various conditions, both in normal individuals and in other cognitive decline disorders (vascular cognitive impairment, Alzheimer’s), making early diagnosis challenging. Treatment of NPH mainly relies on surgical intervention with ventriculoperitoneal shunting, with accurate preoperative diagnosis being crucial for success.Lumbar puncture (LP) can be considered the most important procedure to demonstrate the underlying pathophysiology of NPH, which is normal pressure hydrocephalus. High-volume lumbar tap test (LTT) is a relatively simple and effective method when clinical-radiological suspicion is present: it helps to distinguish NPH from other conditions with ventricular enlargement and aids in predicting the success of ventriculoperitoneal shunting surgery. The clinical case presented below illustrates the value of LTT in the definitive diagnosis of NPH at the Department of Neurology and Alzheimer’s Disease - National Geriatric Hospital.

Infection rates during eras of intrathecal antibiotic use followed by antibiotic-impregnated catheter use in prevention of cerebrospinal fluid shunt infection.

The Hydrocephalus Clinical Research Network (HCRN) implemented a perioperative infection prevention bundle for all CSF shunt surgeries in 2007 that included the relatively unproven technique of intrathecal instillation of the broad-spectrum antibiotics vancomycin and gentamicin into the shunt. In the meantime, the field debated the use of antibiotic-impregnated catheter (AIC) shunt tubing using clindamycin and rifampin, an increasingly widespread, but expensive and controversial, technique. It is unknown whether there were changes in infecting organisms associated with the use of these techniques during CSF shunt surgery at the hospital level. Key comparison periods include during the use of intrathecal antibiotics (period 1 from June 1, 2007, to December 31, 2011, at HCRN hospitals) and AIC (period 2 from January 1, 2012, to December 31, 2015, at HCRN as well as increasing over time at non-HCRN hospitals) and only standard use of routine prophylactic antibiotics (period 1 at non-HCRN hospitals). The aim of this study was to examine rates of CSF shunt surgery-related infections from 2007 to 2012 at the hospital level, including HCRN and non-HCRN hospitals, with a focus on infections with gram-negative organisms. The authors conducted a retrospective observational cohort study at 6 children's hospitals with enrollment from 2007 to 2012 and surveillance through 2015. Bimonthly rates of shunt surgery-related infections were summarized to produce an overall hospital-specific time series, as well as by HCRN/non-HCRN status. An interrupted time series analysis was performed to assess the impact of change in HCRN perioperative infection prevention bundle on overall bimonthly infection rates. Quarterly rates of gram-negative shunt surgery-related infections were summarized to produce an overall hospital-specific time series. The overall bimonthly CSF shunt infection rate over time did not change significantly from 2007 to 2012. There was no difference in the trajectory of infection rates between HCRN and non-HCRN hospitals during the entire study period. No change in distributions of gram-negative organism infections was observed in hospitals from 2007 to 2015. There were no differences observed in hospital-level infection rates for low-risk patients undergoing CSF shunt surgery. This included analyses based on participation in the HCRN network, given their regular use of intrathecal antibiotics in period 1 and a focus on gram-negative infections with increasing adoption of AICs in period 2.

Predictive factors and outcomes in treating shunt malfunctions: a case study of multiloculated hydrocephalus

Background. Endoscopic septostomy is a secure and reliable endoscopic for treating multiloculated hydrocephalus. The ventriculoperitoneal (VP) shunt procedure is known as the gold standard. However, shunt malfunction often occurs. The combination of these has been reported to reduce the incidence of recurrent malfunction and reestablish communication between isolated intraventricular compartments making a special ventricular cavity. Case presentation. A one-year-old child who had previously communicated hydrocephalus complained of vomiting, appeared agitated, and had difficulty falling asleep. The patient had a history of congenital diseases. The patient had VP shunt Keen dextra and sinistra fitted to manage the hydrocephalus before, but one side of the VP shunt was found to be malfunctioning. Physical examination revealed a sunset eye phenomenon with a head circumference of 48 cm dry and clean ventricular parietal shunt surgery scars. The findings of the multiloculated cystic lesions on the endoscopic, agenesis of the septum pellucidum, and dysgenesis of the corpus callosum. Discussion. The patient was scheduled for endoscopic cyst fenestrations surgery, endoscopic third ventriculostomy (ETV), VP shunt Kocher dextra low pressure, and aff VP shunt Keen dextra that was evaluated with preoperative and postoperative CT scans which showed the sulcus and gyrus prominent had improved, slightly open in fissure Sylvie, reduced size in ventricular (the average decrease was 5 cm3) that decreased intracranial pressure which improved the patient’s quality of life. Conclusion. Endoscopy septostomy and VP shunt are a great combination to treat multiloculated hydrocephalus and VP shunt malfunction.

Visual disorders in children with shunted hydrocephalus.

The introduction of shunt operations in neurosurgical practice gave a chance for life to these patients and significantly improved its quality. Along with its positive effect, surgical treatment is associated with a number of complications that, together with hydrocephalus itself, affect the subsequent development of shunted patients in the short and long term. In the long term, problems observed in shunted patients are mental retardation, cerebral palsy (CP), epilepsy, hearing and vision disorders. Visual disturbances are common in children with shunted hydrocephalus. These include reduced visual acuity, eye movement disorders, refractive anomalies, visual field defects, reduced color vision and strabismus, optic atrophy. The mechanism of visual disturbances is associated with damage to the oculomotor pathways, optic nerves and optic radiation, dilatation of the lateral ventricles, and damage to the periventricular white matter. Age at onset of hydrocephalus and ventricular dimension are important in the development of visual disturbances and placement of a shunting system can improve visual function. At the same time ophthalmic disturbances may be the first and only sign of shunt dysfunction and rapid normalization of elevated ICP preserves vision. Visual disturbances in patients with shunted hydrocephalus correlate with higher incidence of CP and epilepsy. They determine the children’s social integration and quality of life.

The impact of real-time ultrasound guidance for ventricular catheter placement in cerebrospinal fluid shunts - a single center study.

Purpose Misplacement of ventricular catheters in shunt surgery occurs in 40% with freehand technique and represents therefore a risk for early shunt failure. The goal of this retrospective, single center study is to analyze the impact of real-time ultrasound guidance on ventricular catheter positioning and early outcome of shunt survival. Materials and Methods We analyzed the charts and images of all patients who underwent shunt surgery from 09/2017 to 12/2022 and compared the position of ventricular catheter by using the freehand technique and real-time ultrasound guidance. Central catheter position was graded as grade I (optimal), II (contact with ventricle structures or contralateral) and III (misplacement). Results Ventricular catheter was placed in 244 patients using real-time US-guidance and in 506 patients using freehand technique. The mean age (53.4 and 53.6 years respectively) and the preoperative frontal occipital horn ratio (FOHR; 0.47 versus 0.44) were almost equal in both groups. In the study group, grade I catheter position was achieved in 64%, grade II in 34% and grade III in 2%. The control group showed grade I position in 45%, grade II in 32% and grade III in 23% of cases (p<0.05). Early central catheter failure rate was the highest in grade III (40.5%) compared to 4% in grade I. Conclusion Our data demonstrate that real-time US-guidance lead to a significant improvement of ventricular catheter placement. In consequence early shunt revisions decrease significantly. Further prospective, randomized, and controlled studies comparing standard method to a real-time ultrasound catheter placement are required.

Association of Glymphatic and White Matter Impairment With the Postoperative Outcome of Pediatric Hydrocephalus.

Assessment of postoperative outcomes on pediatric hydrocephalus is critical for adjusting treatment strategies. The aim of this work was to investigate the ability of MRI metrics to predict postoperative outcomes. A total of 55 children with hydrocephalus who underwent MRI and ventriculoperitoneal shunt surgery were prospectively enrolled. MRI was also performed at 6 months postoperatively in 33 of the 55 children. A total of 92 controls matched for age and sex were enrolled and divided into preoperative and postoperative control groups. We calculated the diffusion tensor imaging along the perivascular space (DTI-ALPS) index, Evans index, and diffusion tensor imaging metrics. The ability of various metrics to predict postoperative outcomes was assessed using receiver operating characteristic curve analysis. The DTI-ALPS index was significantly lower in patients with hydrocephalus than in controls. The abnormal DTI-ALPS index trended toward the normal range after surgery. Patients with lower preoperative DTI-ALPS index, lower fractional anisotropy (FA), and higher radial diffusivity in association fibers had less favorable short-term outcomes. Patients with worse long-term outcomes had lower postoperative DTI-ALPS index, higher postoperative Evans index, and lower FA and higher radial diffusivity in association fibers. Predictive performance was better when the DTI-ALPS index and FA in association fibers were used in combination than when either of these metrics was used alone. The DTI-ALPS index and FA in association fibers provided complementary information for prognostic assessment after the ventriculoperitoneal shunt surgery on pediatric hydrocephalus. A combination of DTI-ALPS index and FA would improve our ability to predict postoperative outcomes in these patients.

Assessment of childhood intracranial pressure: a comparative study of transcranial Doppler ultrasound indices and findings at ventriculoperitoneal shunt.

This study compares transcranial Doppler (TCD) Pulsatility Index (PI) and Resistivity Index (RI) with intra-operative CSF opening pressure measured by manometric technique during ventriculoperitoneal (V-P) shunt in children with hydrocephalus. It was a prospective, hospital-based study performed among patients diagnosed with hydrocephalus. Patients had TCD ultrasonography before V-P shunt. The TCD sonography was repeated within 1week post-op, and at 1month post-op. The PI and RI were retrieved after insonating the middle cerebral artery. Ventricular CSF opening pressure was measured. Associations between TCD indices and CSF pressure were determined using the t-test and the Wilcoxon rank /Mann-Whitney tests where the normality test failed. A p-value of < 0.05 was considered significant for associations. Fifty-two patients were enrolled with a mean age of 9.9 ± 11.5months. Of these, 41 (78.8%) were aged ≤ 12months. The mean CSF opening pressure was 21.4 ± 9.0. When raised, ICP was defined as opening pressure > 15cm of H2O, high PI (≥ 1.19), and high RI (> 0.8) diagnosed it with a sensitivity of 55% and 50%, respectively. The mean pre-operative PI (1.17 ± 0.56) reduced to 0.96 (Z = - 2.032, p = 0.042), while that of RI (0.66 ± 0.17) also decreased to 0.58 (t = 2.906, p = 0.044) after V-P shunt surgery. A strong positive correlation exists between a reduction in PI and RI after V-P shunt (r = 0.743, p = 0.014). Both PI and RI significantly decrease following V-P shunt, but a single reading has a poor sensitivity in predicting ICP.

Ventriculoperitoneal shunt infection and malfunction in adult patients: incidence, risk factors, and long-term follow-up of single institution experience.

Ventriculoperitoneal shunt surgery was developed to manage excessive cerebrospinal fluid (CSF) in the brain's ventricles and is considered a mainstream treatment. Despite the development of the shunt device system, various complications still occur. In this study, we reported 307 cases and a long-term follow-up of at least five years of adult patients who underwent VP shunt surgery and analyzed various factors that may affect revision surgery. A retrospective study was conducted at Asan Medical Center, Korea, a tertiary medical center. We reviewed 307 cases from January 2012 to December 2018. The patients' neurological status, predisposing medical conditions, laboratory findings, and other operation-related factors were reviewed using electrical medical records. The normal function group comprised 272 cases (88.6%), and the overall incidence of revision group comprised 35 cases (11.4%). Of the 35 revision surgery cases, 30 (85.71%) were due to shunt malfunctions, such as obstruction, overdrainage, and valve-related errors while 5 (14.29%) were due to shunt infection. Patient demographics, mental status, and operation time did not influence revision as risk factors. Serum laboratory findings showed no statistical difference between the two groups. The white blood cell (WBC) count in the CSF profile differed significantly between the two groups. The Hakim Programmable valve (Codman, USA) is mainly used in our center. In addition, various shunt systems were used, including Strata Regulatory valve (Medtronic, USA), proGAV (Aesculap, USA), and Accu-Flo (Codman, USA). This study analyzed the factors affecting long-term outcomes. Based on these findings, efforts are needed to achieve more favorable outcomes in the future.

Ventriculoperitoneal shunt complication in pediatric hydrocephalus: risk factor analysis from a single institution

Introduction: Ventriculoperitoneal (VP) shunt surgery is a commonly performed neurosurgical procedure. Complications due to shunt failure are associated with high morbidity and mortality. There is an absence of research in Indonesia that focuses on demographic factors related to complications from ventriculoperitoneal shunts. We report an analysis of risk factors for shunt failure in pediatric patients from a single institution Method: A retrospective analytical study with prospective data was designed. Pediatric patients with hydrocephalus were performed ventriculoperitoneal shunt in 5 years (January 2018 - December 2023). All of risk factors such as age, comorbidity, etiologies, types of shunts, CSF analysis were followed up. Result: 448 pediatric patients underwent VP shunts, and 175 of them had complications. The age group &lt;12 months, with 98 patients, noticed the highest number of complications of VP shunt. The logistic regression test showed that age, surgery duration, protein, CSF cells, and birth weight all had p-values &lt;0.05. The number of CSF cells has the largest OR value (OR = 136,800) (95% CI 27.185 – 688.391). The Kaplan Meier survival test showed that the age group (p 0.008, OR 0.580 and 95% CI 0.387 – 0.868). Conclusion: Patients under the age of six months had the highest incidence of VP shunt complications. Cell number, CSF protein, surgery duration, age, and birth weight all influence the risk of VP shunt complications in pediatric patients.

Artificial Intelligence for Automatic Analysis of Shunt Treatment in Presurgery and Postsurgery Computed Tomography Brain Scans of Patients With Idiopathic Normal Pressure Hydrocephalus.

Ventriculo-peritoneal shunt procedures can improve idiopathic normal pressure hydrocephalus (iNPH) symptoms. However, there are no automated methods that quantify the presurgery and postsurgery changes in the ventricular volume for computed tomography scans. Hence, the main goal of this research was to quantify longitudinal changes in the ventricular volume and its correlation with clinical improvement in iNPH symptoms. Furthermore, our objective was to develop an end-to-end graphical interface where surgeons can directly drag-drop a brain scan for quantified analysis. A total of 15 patients with 47 longitudinal computed tomography scans were taken before and after shunt surgery. Postoperative scans were collected between 1 and 45 months. We use a UNet-based model to develop a fully automated metric. Center slices of the scan that are most representative (80%) of the ventricular volume of the brain are used. Clinical symptoms of gait, balance, cognition, and bladder continence are studied with respect to the proposed metric. Fifteen patients with iNPH demonstrate a decrease in ventricular volume (as shown by our metric) postsurgery and a concurrent clinical improvement in their iNPH symptomatology. The decrease in postoperative central ventricular volume varied between 6 cc and 33 cc (mean: 20, SD: 9) among patients who experienced improvements in gait, bladder continence, and cognition. Two patients who showed improvement in only one or two of these symptoms had <4 cc of cerebrospinal fluid drained. Our artificial intelligence-based metric and the graphical user interface facilitate this quantified analysis. Proposed metric quantifies changes in ventricular volume before and after shunt surgery for patients with iNPH, serving as an automated and effective radiographic marker for a functioning shunt in a patient with iNPH.