Shunt Rate Research Articles

Microtransesophageal Echocardiographic Guidance during Percutaneous Interatrial Septal Closure without General Anaesthesia.

Objective To study the safety and efficacy of microtransesophageal echocardiography (micro-TEE) and TEE during percutaneous atrial septal defect (ASD) and patent foramen ovale (PFO) closure. Background TEE has proven to be safe during ASD and PFO closure under general anaesthesia. Micro-TEE makes it possible to perform these procedures under local anaesthesia. We are the first to describe the safety and efficacy of micro-TEE for percutaneous closure. Methods All consecutive patients who underwent ASD and PFO closure between 2013 and 2018 were included. The periprocedural complications were registered. Residual shunts were diagnosed using transthoracic contrast echocardiography (TTCE). All data were compared between the use of TEE or micro-TEE within the ASD and PFO groups separately. Results In total, 82 patients underwent ASD closure, 46 patients (49.1 ± 15.0 years) with TEE and 36 patients (47.8 ± 12.1 years) using micro-TEE guidance. Median device diameter was, respectively, 26 mm (range 10–40 mm) and 27 mm (range 10–35 mm). PFO closure was performed in 120 patients, 55 patients (48.6 ± 9.2 years, median device diameter 25 mm, range 23–35 mm) with TEE and 65 patients (mean age 51.0 ± 11.8 years, median device diameter 27 mm, range 23–35 mm) using micro-TEE. There were no major periprocedural complications, especially no device embolizations within all groups. Six months after closure, there was no significant difference in left-to-right shunt after ASD closure and no significant difference in right-to-left shunt after PFO closure using TEE or micro-TEE. Conclusion Micro-TEE guidance without general anaesthesia during percutaneous ASD and PFO closure is as safe as TEE, without a significant difference in the residual shunt rate after closure.

Risk factors of chronic shunt dependent hydrocephalus following aneurysmal subarachnoid haemorrhage

BackgroundAcute and delayed hydrocephalus are common sequelae following aneurysmal subarachnoid haemorrhage. AimsTo identify factors that may influence cerebrospinal fluid diversion either temporarily or permanently in order to guide clinical judgement. MethodsPatients treated in our unit between 01/2014 until 12/2017 with aneurysmal SAH were retrospectively analysed to identify significant factors predisposing to CSF diversion. Results242 patients were analysed (180F, 62M) with mean age 56 years over 36 months. 31 % patients had EVD inserted and 12 % received shunts. 19 patients had EVDs prior to their shunt. 11.8 % patients received serial lumbar puncture.Higher WFNS (P<0.05) and Fisher grade (P<0.05) were associated with increased rates of EVD insertion and shunting. Higher WFNS and Fisher scores were observed within posterior circulation aneurysms. Lower GCS and higher WFNS had significant correlation towards early shunting (P<0.05). EVD infection predisposes to higher rates of shunt conversion (P<0.05).Factors predisposing to post aneurysmal subarachnoid haemorrhage hydrocephalus and CSF drainage included aneurysm location in posterior circulation (P<0.05), increasing relative need of EVD insertion by 185 % and shunting by 240 %. Basilar tip aneurysms had even higher incidence of shunting (42 % of all posterior circulation aneurysms). Posterior circulation aneurysms had significantly higher risk of requiring EVD insertion, with 48 % of aneurysms in the posterior circulation compared to 25 % in the anterior circulation requiring EVDs (P<0.05). Incidence of posterior circulation aneurysms increases with age (>50(P<0.05)). ConclusionOur study demonstrated factors that may predict chronic post aneurysmal subarachnoid haemorrhage hydrocephalus (PASHH) in patients that will ultimately need timely intervention.

Analysis of the Rate and Pattern of Ventriculoperitoneal Shunt Infection and Ventricular Catheter Culture Yield: A 10-Year Single-Institute Experience

Aim: We aimed to study the rate and pattern of ventriculoperitoneal shunt (VPS) infections at the Jordan University Hospital (JUH) over 10 years and investigate the yield of ventricular catheter tip culture in the evaluation of shunt infection. Patients and Methods: All patients operated on at our institution for ventriculoperitoneal shunt (VPS) insertion, reinsertion, and revision between 2009 and 2018 were included. Data (age, gender, pathology, and history of shunt infection) were collected from patients’ files. Rates of infection and results of culture (cerebrospinal fluid and ventricular catheter tip) were obtained from laboratory records. Results: According to our hospital database, 310 patients were eligible for this study. The rate of infection was 11.1% per ventriculoperitoneal procedure, and the most common ­organism was coagulase-negative Staphylococcus (CoNS) which was the cause of infection in 51.4% of the cases. Twenty-one percent of proved shunt infection cases showed a positive ventricular catheter tip culture. Conclusion: The rate and pattern of shunt infections at our institution are comparable with the international figures and data. Methods of catheter tip culturing should be improved to increase the yield of this practice.

Transjugular intrahepatic portosystemic shunt placement: portal vein puncture guided by 3D/2D image registration of contrast-enhanced multi-detector computed tomography and fluoroscopy

BackgroundTo assess the technical feasibility, success rate, puncture complications and procedural characteristics of transjugular intrahepatic portosystemic shunt (TIPS) placement using a three-dimensional vascular map (3D-VM) overlay based on image registration of pre-procedural contrast-enhanced (CE) multi-detector computed tomography (MDCT) for portal vein puncture guidance.Materials and methodsOverall, 27 consecutive patients (59 ± 9 years, 18male) with portal hypertension undergoing elective TIPS procedure were included. TIPS was guided by CE-MDCT overlay after image registration based on fluoroscopic images. A 3D-VM of the hepatic veins and the portal vein was created based on the pre-procedural CE-MDCT and superimposed on fluoroscopy in real-time. Procedural characteristics as well as hepatic vein catheterization time (HVCT), puncture time (PT), overall procedural time (OPT), fluoroscopy time (FT) and the dose area product (DAP) were evaluated. Thereafter, HVCT, PT, OPT and FT using 3D-VM (61 ± 9 years, 14male) were compared to a previous using classical fluoroscopic guidance (53 ± 9 years, 21male) for two interventional radiologist with less than 3 years of experience in TIPS placement.ResultsAll TIPS procedure using of 3D/2D image registered 3D-VM were successful with a significant reduction of the PSG (p < 0.0001). No clinical significant complication occurred. HVCT was 14 ± 11 min, PT was 14 ± 6 min, OPT was 64 ± 29 min, FT was 21 ± 12 min and DAP was 107.48 ± 93.84 Gy cm2. HVCT, OPT and FT of the interventionalist with less TIPS experience using 3D/2D image registered 3D-VM were statistically different to an interventionalist with similar experience using fluoroscopic guidance (pHVCT = 0.0022; pOPT = 0.0097; pFT = 0.0009). PT between these interventionalists was not significantly different (pPT = 0.2905).ConclusionTIPS placement applying registration-based CE-MDCT vessel information for puncture guidance is feasible and safe. It has the potential to improve hepatic vein catherization, portal vein puncture and radiation exposure.

Neuroendoscopic lavage for the management of posthemorrhagic hydrocephalus in preterm infants: safety, effectivity, and lessons learned.

Treatment of posthemorrhagic hydrocephalus in preterm infants is a matter of debate among pediatric neurosurgeons. Neuroendoscopic lavage (NEL) has been proposed as a suitable technique for the management of this pathology. The authors present their experience with 46 patients treated with NEL after germinal matrix hemorrhage, describe their technique, and analyze the outcomes. A retrospective analysis of patients affected by grade III or IV intraventricular hemorrhage (IVH) treated with NEL was performed. Nonmodifiable risk factors such as gestational age, weight at birth, modified Papile grade, and intercurrent diseases were reviewed. Safety analysis was performed, evaluating the incidence of postoperative complications. Effectivity was measured using radiological (frontal horn index and white matter injury), CSF biochemical (proteins, blood, and cellularity), and clinical variables. Permanent shunt rate and shunt survival were analyzed. The motor outcome was measured using the Gross Motor Function Classification System (GMFCS) at 18-24 months, and the neurocognitive outcome was evaluated according to the grade of adaptation to schooling. Forty-six patients met the inclusion criteria. Patients were treated with a single NEL in 21 cases, 2 lavages in 13 cases, and 3 lavages in 12 cases. The mean gestational age at birth was 30.04 weeks, and the mean weight at birth was 1671.86 g. Hyaline membrane disease was described in 4.8% of the cases, hematological sepsis in 43.47%, persistent ductus arteriosus in 23.9%, and necrotizing enterocolitis in 10.9% of the cases. Modified Papile grade III and IV IVHs were observed in 60.9% and 39.1% of the cases, respectively. Postoperative infection was diagnosed in 10 of the 46 cases, CSF leak in 6, and rebleeding in 3. The mean frontal horn index decreased from 49.54 mm to 45.50 mm after NEL. No white matter injury was observed in 18 of 46 patients, focal injury was described in 13 patients, and diffuse bilateral white matter injury was observed in 15 patients. All CSF biochemical levels improved after lavage. The shunt rate was 58.7%, and shunt survival at 1 year was 50%. GMFCS grades I, II, III, IV, and V were observed in 44.74%, 21.05%, 2.63%, 15.79%, and 15.79% of patients, respectively. Good neurocognitive results were observed in 53.3% of the cases. Neuroendoscopic lavage was a suitable alternative for the management of IVH in preterm infants in our series. Good motor and neurocognitive results were achieved by this technique, and the permanent shunt rate was reduced compared with historical controls.

MP78-16 PROBABILITY OF SHUNTING FOR ISCHEMIC PRIAPISM BASED ON ETIOLOGY: ROLE FOR PATIENT EDUCATION

You have accessJournal of UrologySexual Function/Dysfunction: Evaluation II (MP78)1 Apr 2020MP78-16 PROBABILITY OF SHUNTING FOR ISCHEMIC PRIAPISM BASED ON ETIOLOGY: ROLE FOR PATIENT EDUCATION Ethan Matz*, Rahul Dutta, William Anderson, Kyle Scarberry, and Ryan Terlecki Ethan Matz*Ethan Matz* More articles by this author , Rahul DuttaRahul Dutta More articles by this author , William AndersonWilliam Anderson More articles by this author , Kyle ScarberryKyle Scarberry More articles by this author , and Ryan TerleckiRyan Terlecki More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000964.016AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Refractory ischemic priapism (IP) often requires shunting. We hypothesize cases due to sickle cell (SC) disease or prescribed intracavernosal injection (ICI) may present earlier. We sought to characterize etiology and management for IP to determine likelihood of shunting based on patient parameters. METHODS: An IRB approved database of men seen for IP at our emergency department (ED) since January of 2011 was reviewed. Case data through December 2018 was evaluated for demographics and event details. For patients with recurrent IP, the most recent event was considered. Statistical associations were assessed with chi square and 2-sided t-test, and ROC analysis performed. RESULTS: In total, 110 men were included. Median overall time to presentation (TTP) to ED for IPP was 10 hours (1.5-196). Etiologies included: ICI (24%), idiopathic (16%), trazodone use (16%), SC trait or disease (15%), use of other psychotropic medications (15%). Other etiologies comprised an insignificant number of cases. Median TTP for SC and ICI were not significantly different with median of 6.5 (1.5-22) and 6 (3-120) hours, respectively (p = 0.42).Likelihood of undergoing shunt surgery was highest among cases due to psychotropic medication (59%), followed by trazodone (44%), idiopathic (38%), and ICI (8%). No SC patients required shunting.When compared directly to ICI, the odds of shunting were significantly higher for idiopathic (OR 7.6 CI 1.35, 42.89 p=0.02) or trazodone-related cases (OR 9.6 CI 1.72, 53.4 p=0.0098). ROC analysis yielded a sensitivity of 1 and specificity of 0.9231 for requiring distal shunt using 20 hours to presentation as a cutoff (AUC=0.9904, p<0.0001). No men presenting sooner had distal shunting, while 84% of those seen after were shunted.Grouping SC and ICI cases together (42 men, 38% of cohort), rate of shunting was 4.8% vs 44.1% in others combined (p < 0.001). Median TTP for SC and ICI combined was 6 (1.5-120) hours vs 17 (2-196) hours for others combined (p = 0.001) CONCLUSIONS: Cases of IP presenting to the ED are most commonly due to ICI, and these cases typically present earlier and have a lower incidence of shunting. IP secondary to trazodone or other oral medications presents later with a significantly higher chance of surgery. TTP beyond 20 hours is unlikely to avoid shunting. Analysis for SC and ICI cases suggest lower likelihood of surgery is due to earlier TTP, possibly secondary to better education regarding risk of IP. Prescribers offering trazodone or psychotropic medications associated with IP may need to better educate patients on risk. Source of Funding: N/A © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1179-e1179 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ethan Matz* More articles by this author Rahul Dutta More articles by this author William Anderson More articles by this author Kyle Scarberry More articles by this author Ryan Terlecki More articles by this author Expand All Advertisement PDF downloadLoading ...

Fetal open spinal dysraphism repair through a mini-hysterotomy: Influence of gestational age at surgery on the perinatal outcomes and postnatal shunt rates.

To analyze the impact of gestational age (GA) at the time of fetal open spinal dysraphism (OSD) repair through a mini-hysterotomy on the perinatal outcomes and the infants' ventriculoperitoneal shunt rates. Retrospective study of cases of fetal OSD correction performed from 2014 and 2019. One hundred and ninety women underwent fetal surgery for OSD through a mini-hysterotomy, and 176 (176/190:92.6%) have since delivered. Fetal OSD correction performed earlier in the gestational period, ranging from 19.7 to 26.9 weeks, was associated with lower rates of postnatal ventriculoperitoneal shunting (P: .049). Earlier fetal surgeries were associated with shorter surgical times (P: .01), smaller hysterotomy lengths (P < .001), higher frequencies of hindbrain herniation reversal (P: .003), and longer latencies from surgery to delivery (P < .001). Median GA at delivery was 35.3 weeks. Multivariate binary logistic regression showed that both fetal lateral ventricle-to-hemisphere ratio (%; P < .001; OR: 1.14 [95% CI: 1.09-1.21]) and GA at the time of fetal surgery (P: .016; OR: 1.37 [95% CI: 1.07-1.77]) were independent predictors of postnatal ventriculoperitoneal shunting. Fetuses with OSD who were operated on earlier in the gestational interval, which ranged from 19.7 to 26.9 weeks, were less prone to receiving postnatal ventriculoperitoneal shunts.

Effects of apneic oxygen insufflation on oxygenation and intra-alveolar pressure during one lung ventilation

Objective To observe the effects of apneic oxygen insufflation (AOI) on the oxygenation and intra-alveolar pressure of patients with one lung ventilation (OLV). Methods Ninety patients undergoing open thoracotomy were enrolled, where 45 patients were divided into three groups according to a random number table: a control group (group A), a test 1 group (group B) and a test 2 group (group C), with 15 patients in each group; and another 45 patients were divided into three groups according to the pattern of double-lumen tubes: a 35 Fr group (group D), a 37 Fr group (group E), and a 39 Fr group (group F), with 15 patients in each group. During OLV, the non-ventilated lungs in groups A, B, and C were delivered with oxygen at a rate of 0, 3 and 5 L/min, respectively, and arterial blood samples were taken 1 min before OLV (T1), 30 min after the beginning of OLV (T2), and 60 min after the beginning of OLV (T3) for blood gas analysis, so as to calculate oxygenation index (OI), intrapulmonary shunt rate (Qs/Qt) and the satisfaction of surgeons towards collapsed lung. The intra-alveolar pressure at different oxygen flow rates (2-9 L/min) was measured in groups D, E and F after the beginning of OLV. Results OI decreased and Qs/Qt increased in groups A, B and C at T2 and T3 compared with those at T1 (P< 0.05). OI was remarkably higher in group B at T2 and higher in group C at T2 and T3 than those in group A, and Qs/Qt was significantly lower in group B at T2 and lower in group C at T2 and T3than those in group A (P<0.05). Compared with group B, group C presented remarkable increases in OI and significant decreases in Qs/Qt at T2 and T3 (P<0.05). The intra-alveolar pressure was lower in groups E and group F at different oxygen flow rates than that in group D (P<0.05); the intra-alveolar pressure was lower in group F at different oxygen flow rates than that in group E (P<0.05). Conclusions AOI at 5 L/min during OLV can maintain gas exchange to some extent in the alveoli, improve oxygenation and reduce Qs/Qt, which may be related to the intra-alveolar pressure produced by AOI in the operated lung. Key words: One lung ventilation; Apneic oxygen insufflation; Oxygenation index; Intra-alveolar pressure

Immediate angiographic residual shunt using the Nit-Occlud device for patent ductus arteriosus closure.

IntroductionThe Nit-Occlud PDA device is a newer coil-type device with a high degree of efficacy and safety. There are concerns about the high incidence of immediate angiographic residual shunt with this device.AimTo compare immediate angiographic residual shunts and their outcomes following PDA device closure with the Nit-Occlud device.Material and methodsA single-institution, retrospective chart review of PDA closures was performed. Thirty patients who underwent Nit-Occlud PDA closure were compared with 34 patients who underwent PDA closure with an Amplatzer Duct Occluder-1 (ADO-1) and 25 patients who underwent PDA closure with coils.ResultsThe three groups were similar in age, weight, and procedural characteristics. The PDA dimensions were smaller in the coils group. Technical success in the ADO-1 and Nit-Occlud groups was 100%. A small angiographic residual shunt was seen more often in the Nit-Occlud group (70%) than in the ADO-1 (59%) and coils (26%) groups (p = 0.005). Most residual shunts in the Nit-Occlud group disappeared in the echocardiogram performed 4 h later (90% echocardiographic closure). Echocardiographic closure (100%) was seen at 2 months and 6 months in the Nit-Occlud group. No correlation was noted between the angiographic residual shunt and Nit-Occlud device orientation with respect to the ductus, the device-ductal angle or the number of loops at the pulmonary artery end.ConclusionsDespite the higher immediate angiographic residual shunt rate in the Nit-Occlud group than the other groups, high echocardiographic closure rates were seen within hours after device closure, which persisted at follow-up. The angiographic residual shunt is not related to the device orientation and should not be a deterrent in using this device.

Self assessment questions

Please match one of the following outcomes to each of the four questions below:A.Ventriculoperitoneal shunt rates at 12 monthsB.The need for classical caesarean section in all future pregnanciesC.Preterm birthD.Hindbrain herniation at 18 monthsE.Postnatal neurological infectionF.Uterine dehiscence or ruptureG.Postnatal neurosurgical interventionH.Chorioamnionitis1.In babies with open spina bifida, open fetal surgical repair prior to 26 weeks' gestation has been shown to improve which outcome?2.Both open repair and fetoscopic repair of spina bifida are associated with what?3.Open repair of spina bifida carries a significant maternal risk of what?4.When compared to open repair, fetoscopic repair of spina bifida has the potential to reduce maternal risks, although it currently carries a higher risk of which postnatal outcome?

Endoscopic Surgery for Thalamic Hemorrhage with Intraventricular Hemorrhage: Effects of Combining Evacuation of a Thalamic Hematoma to External Ventricular Drainage.

Objectives:Intraventricular hemorrhage (IVH) caused by thalamic hemorrhage leads to hydrocephalus, increased intracranial pressure, and reduced levels of consciousness. The aim of this study was to investigate the efficacy and compare the results of endoscopic surgery for the evacuation of a thalamic and intraventricular hematoma against those of external ventricular drainage (EVD) surgery.Materials and Methods:From January 2010 to December 2018, 68 patients with IVH caused by thalamic hemorrhage were treated in our department. Our study was approved by the Institutional Ethics Committee. The included patients were randomly divided into an EVD group and an endoscopic surgery group. The outcome was measured after 3 months using a 30-day mortality rate, pneumonia onset rate, ventriculoperitoneal (VP) shunt dependency rate, and Glasgow Outcome Scale (GOS) score.Results:Thirty-eight of the 68 patients were randomly assigned to the endoscopic surgery group and 30 were assigned to the EVD group. Patients treated with endoscopic surgery had significantly less drainage dependency on day 30 (P = 0.00014 < 0.00005) in comparison to those treated with EVD. The difference in the functional outcomes between the two groups of patients was mainly dependent on the onset of pneumonia and the consciousness level at the time of admission. The onset rate of aspiration-related pneumonia until day 30 was 11% in the endoscopic surgery group and 45% in the EVD group. The VP shunt rates were 27.8% in the endoscopic surgery group and 60% in the EVD group. The endoscopic surgery group had a significantly lower VP shunt rate compared with the EVD group. Intracerebral hemorrhage evacuation late was found to be associated with shunt-dependent rate and hospitalization.Conclusions:Endoscopic surgery was found to be associated with a lower GOS score and lower onset rates for shunt-dependent hydrocephalus and aspiration-related pneumonia in comparison to EVD. High evacuation rate was associated with lower shunt-dependent rate and short hospitalization.

P3721Clinical and echocardiographic outcomes after treatment of patent foramen ovale with two transcatheter occlusion devices: mononcenter observational study

Abstract Background Percutaneous closure of patent foramen ovale (PFO) after cryptogenic stroke (CS) is strongly recommended in the current guidelines. Most available evidence has been obtained from randomized studies in which Amplatzer PFO occluder device or Groe occluder device were implanted. Several occluder devices are used off-label for percutaneous treatment of PFO. Rate of recurrent CS and rate of residual shunting after percutaneously occlusion of PFO varies between different occlusion devices. To date, there are no randomized clinical studies that compare the effectivity and safety of several devices in patients with CS. Aim The aim of this study was to compare rate of residual shunting and recurrent CS after percutaneus treatment of PFO with the most common used PFO occluder devises. Methods This was a retrospective, non-randomized, monocenter study. Between 2008 and 2014, all patients with CS or transient ischemic attack (TIA) treated with transcatheter occlusion of PFO with Amplatzer PFO occlusion device or Occlutech occlusion device were included. Patients were followed up at 1 and 6 months with contrast-enhanced transesophageal echocardiography (TEE), and at 3 months with contrast-enhanced transthoracic echocardiography. Primary endpoint was residual shunting at 6 months. Secondary endpoint was recurrent CS or TIA at 6 months after the procedure. Results 220 consecutive patients (57±12 year, 131 men) were treated with Amplanz PFO occlusion device (140 patients) or Occlutech PFO occlusion device (80 patients) after CS or TIA. Procedural success was 100% in both groups. Residual shunting was observed directly after the procedure in 26 patients in the Amplatzer group and 22 patients in the Occlutech group (19% and 27%, respectively; p=0.003), at 1 months follow (15% and 25%, respectively; p=0.064) and at 6 months (9% and 16%, respectively; p=0.024). There was no significant difference between both groups according recurrent CS (0.7% and 0%, respectively; p=0.449). At 6 months follow up atrial fibrillation was detected in 2 patients from Amplatzer group and 5 patients from Occlutech group (1.4% and 6.0%, respectively; p=0.050). Death, aortic erosion and pericardial effusion was not observed in both groups. Clinical and echocardiographic outcome Variable Amplatzer occluder device (N=140) Occlutech occluder device (N=80) p-value Clinical outcome at 6 months follow up Death, n (%) 0 (0%) 0 (0%) 1.000 Stroke, n (%) 1 (1%) 0 (0%) 0.449 Transient ischemic attack, n (%) 0 (0%) 0 (0%) 1.000 Atrial fibrillation, n (%) 2 (1.4%) 5 (6%) 0.050 Aortic erosion, n (%) 0 (0%) 0 (0%) 1.000 Pericardial effusion, n (%) 0 (0%) 0 (0%) 1.000 Echocardiographic Outcome at 6 months follow up Residual shunting after Implantation directly, n (%) 26 (19%) 22 (27%) 0.003 Residual shunting at one month, n (%) 21 (15%) 20 (25%) 0.064 Residual shunting at 6 months, n (%) 13 (9%) 16 (20%) 0.024 Conclusion Percutaneous treatment of PFO after CS or TIA with Amplatzer PFO occluder device was associated with lower rate of residual shunting and lower rate of atrial fibrillation at 6 months follow up, whereas rate of recurrent CS and TIA was comparable between both groups.

Endoscopic Versus Microscopic Transcallosal Excision of Colloid Cysts: A Systematic Review in the Era of Complete Endoscopic Excision

Transcallosal microscopic and endoscopic excisions are both well established approaches to colloid cyst resection; however, there has been no clear consensus regarding the favored approach. We performed a systematic review comparing the transcallosal microscopic and endoscopic transcortical approaches for colloid cyst excision. We performed a systematic review from 2000-2018 of patients undergoing colloid cyst excision via a microscopic transcallosal or endoscopic transcortical approach where the surgical intent was gross total resection. Studies that included multiple approaches were included if the reported results were stratified by approach. The microsurgical transcallosal approach had a higher rate of gross total resection when compared with endoscopic excision (96% for transcallosal vs. 78.5% endoscopic; P < 0.0001). There was also a lower recurrence rate with the transcallosal approach (0.98% vs. 2.16%; P= 0.0036); however, there was no difference in reoperation rates with similar length of follow-up (0.33% transcallosal, 0.61% endoscopic; P= 1.000). Endoscopy had lower overall morbidity when compared with transcallosal approaches (8.7% vs. 18.6%; P= 0.0001), including statistically significant lower rates of infection, infarct, and seizures in the endoscopic cohort. Rates of permanent memory deficit were similar (6.55% transcallosal vs. 4.5% endoscopic; P= 0.52). Shunt dependency was 9.8% after transcallosal excision versus 3.5% after endoscopic excision (P= 0.0002). Modern series of colloid cyst excision continue to favor transcallosal approaches in achieving gross total resection. Nevertheless, endoscopic techniques have significantly reduced morbidity compared to transcallosal approaches, including lower rates of infection, infarct, and seizure. Endoscopic approaches also have a statistically significant decreased rate of shunt dependency-arguably the most important primary endpoint of surgery. With improving endoscopic technology and mastery of the technique, endoscopic excision is maturing into a standard first-line approach for colloid cyst excision.

Bedside placement of ventricular access devices under local anaesthesia in neonates with posthaemorrhagic hydrocephalus: preliminary experience

PurposePosthaemorrhagic ventricular dilatation in preterm infants is primarily treated using temporising measures, of which the placement of a ventricular access device (VAD) is one option. Permanent shunt dependency rates are high, though vary widely. In order to improve the treatment burden and lower shunt dependency rates, we implemented several changes over the years. One of these changes involves the setting of the surgery from general anaesthesia in the OR to local anaesthesia in bed at the neonatal intensive care unit (NICU), which may seem counterintuitive to many. In this article, we describe our surgical technique and present the results of this regimen and compare it to our previous techniques.MethodsRetrospective study of a consecutive series of 37 neonates with posthaemorrhagic ventricular dilatation (PHVD) treated using a VAD, with a cohort I (n = 13) treated from 2004 to 2008 under general anaesthesia in the OR, cohort II (n = 11) treated from 2009 to 2013 under general anaesthesia in the NICU and cohort III (n = 13) treated from December 2013 to December 2017 under local anaesthesia on the NICU.ResultsThe overall infection rate was 14%; the VAD revision rate was 22% and did not differ significantly between the cohorts. Procedures under local anaesthesia never required conversion to general anaesthesia and were well tolerated. After an average of 33 tapping days, 38% of the neonates received a permanent ventriculoperitoneal (VP) shunt. The permanent VP shunt rate was 9% with VAD placement under local anaesthesia and 52% when performed under general anaesthesia (p = 0.02).ConclusionBedside placement of VADs for PHVD under local anaesthesia in neonates is a low-risk, well-tolerated procedure that results in at least equal results to surgery performed under general anaesthesia and/or performed in an OR.

Smartphone-assisted endoscopic surgery via Kocher's point for intraventricular hemorrhage caused by thalamic hemorrhage: A comparison with external ventricular drainage.

The aim of the present study was to investigate the efficacy of endoscopic surgery via a Kocher point approach for intraventricular hemorrhage (IVH) caused by thalamic hemorrhage (TH), in comparison with external ventricular drainage (EVD). Between January 2016 and August 2017, a total of 40 patients with IVH caused by TH were enrolled. The patients were assigned to an EVD group and an endoscopic surgery group in a non-randomized manner. The pre-operative characteristics recorded included age, pre-operative Glasgow Coma Scale (GCS) score, hemorrhage volume, length of neuro-intensive care unit stay and Graeb score of IVH. Outcomes included the GCS score at 2 weeks after surgery, 30-day and 90-day mortality rates, modified Rankin scale at 6 months after ictus and ventriculo-peritoneal (VP) shunt rate. The baseline characteristics were not significantly different between the two groups. The VP shunt rate in the EVD group was significantly higher compared with that in the endoscopic surgery group (50.0 vs. 15.0%; P=0.02; odds ratio, 5.7). In conclusion, smartphone-assisted endoscopic surgery via Kocher's point is feasible and safe, and significantly reduces permanent shunt dependency for IVH caused by TH.

Onset and Resolution of Chiari Malformations and Hydrocephalus in Syndromic Craniosynostosis following Posterior Vault Distraction.

Patients with syndromic craniosynostosis have an increased incidence of progressive hydrocephalus and Chiari malformations, with few data on the relative benefit of various surgical interventions. The authors compare the incidence and resolution of Chiari malformations and hydrocephalus between patients undergoing posterior vault distraction osteogenesis (PVDO) and patients undergoing conventional cranial vault remodeling. Patients with syndromic craniosynostosis who underwent cranial vault surgery from 2004 to 2016 at a single academic hospital, with adequate radiographic assessments, were reviewed. Demographics, interventions, the presence of a Chiari malformation on radiographic studies and hydrocephalus requiring shunt placement were recorded. Mann-Whitney U and Fisher's exact tests were used as appropriate. Forty-nine patients underwent PVDO, and 23 patients underwent cranial vault remodeling during the study period. Median age at surgery (p = 0.880), sex (p = 0.123), and types of syndrome (p = 0.583) were well matched. Patients who underwent PVDO had a decreased incidence of developing Chiari malformations postoperatively compared with the cranial vault remodeling cohort (2.0 percent versus 17.4 percent; p = 0.033). Not surprisingly, no significant difference was found between the groups with regard to the incidence of postoperative hydrocephalus requiring shunt placement (PVDO, 4.1 percent; cranial vault remodeling, 4.3 percent; p = 0.999). As expected, PVDO did not significantly affect intracranial hydrodynamics to the extent that hydrocephalus shunting rates were different for patients with syndromic craniosynostosis. However, PVDO was associated with a reduced risk of developing a Chiari malformation; however, prospective evaluation is needed to determine causality. Therapeutic, III.

A meta-analysis of perventricular device closure of perimembranous ventricular septal defect

BackgroundTo investigate the safety and efficacy of perventricular device closure of perimembranous VSD (pmVSD).MethodsPubMed and Scopus were searched for studies in English focusing on perventricular device closure of pmVSD published up to the end of March 2019. We used a random-effects model to obtain pooled estimates of the success and complication rates.ResultsA total of 15 publications comprising 1368 patients with pmVSD were included. The median follow-up duration was 2 months to 5 years, with a mean patient age ranging from 2 months to 56 years. The pooled success rate was 0.95 (I2 = 86.2%, P = 0.000). The pooled rate of postoperative residual shunting was 0.02 (95% CI: 0.01–0.03, I2 = 87.3%, P < 0.001). The pooled rate of residual shunting in the follow-up period was 0.001 (95% CI:-0.001–0.002, I2 = 30.5%, P = 0.126). The pooled estimated rate of severe complications was 0.074 (95% CI: 0.046–0.102, I2 = 30.5%, P = 0.126). The pooled incidence of complete atrioventricular block (cAVB) was 0.002 (95% CI: 0.000–0.005, I2 = 0.0%, P = 0.577).ConclusionsPerventricular device closure may be an alternative to conventional surgical repair in selected patients with pmVSD. The success rate was stable regarding the publication year and sample size and suggested both the short learning curve of this technology and its potential for wide application. The incidence of severe arrhythmia, especially cAVB, was low. These good results may be limited by the number of enrolled patients, and a more detailed and larger sample is required for further analysis.

Analysis of the medium-term curative effect of transjugular intrahepatic portosystemic shunt through jugular vein with covered Viatorr stent

Objective: To investigate the medium-term curative effect of transjugular intrahepatic portosystemic shunt (TIPS) through jugular vein with covered Viatorr stent. Methods: Data of 105 consecutive patients with covered Viatorr stent of our hospital was retrospectively analyzed. Follow-up was performed after surgery, and color Doppler was reviewed to evaluate the efficacy of TIPS. Results: Transjugular intrahepatic shunt was successfully established in all patients. The pressure gradients of portal vein before and after operation were 22.33 ± 6.4 mmHg and 9.78 ± 4.9 mmHg, respectively,P< 0.01, and the difference was statistically significant. The follow-up period ranged from 12.7 to 15.6 months, with an average of 13.09 ± 1.4 month. Total bilirubin and coagulation time increased after operation, but there was no significant difference in total bilirubin and coagulation time at 1, 3, 6 and 12 months after operation. The patency rate of shunt was 100%, 99.05%, 99.05% and 99.05% at 1, 3, 6 and 12 months after operation. The incidence of hepatic encephalopathy was 34.2%, 29.5%, 19.1% and 14.3% respectively. The recurrence rate of symptoms was 0%. Conclusion: Patients with cirrhotic portal hypertension who underwent TIPS with covered Viatorr stent had a lower rate of restenosis, improved liver function, and a lower incidence of severe hepatic encephalopathy. However, the long-term efficacy needs further observation.

MOMS Plus: Single-Institution Review of Outcomes for Extended BMI Criteria for Open Fetal Repair of Myelomeningocele

Background: In utero repair has become an accepted therapy to decrease the rate of ventriculoperitoneal shunting and improve neurologic function in select cases of myelomeningocele. The Management of Myelomeningocele Study (MOMS) trial excluded patients with a BMI >35 due to concerns for increased maternal complications and preterm delivery, limiting the population that may benefit from this intervention. Objectives: The aim of this study was to evaluate outcomes associated with extending the maternal BMI criteria to 40 in open fetal repair of myelomeningocele. Method: Retrospective review of fetal closure of myelomeningocele at a quaternary referral center between 2013 and 2016 with maternal BMI ranging from 35 to 40. Results: Eleven patients with a BMI >35 were identified. The average BMI was 37. The average maternal age at the time of evaluation was 27 years. The average gestational age at fetal surgery was 24 weeks. Gestational age at birth was an average of 32 weeks. There was one perinatal death immediately following the fetal intervention. The shunt rate at 1 year was 45% (5/11 patients). Conclusions: In this single-institution review of expanded BMI criteria for fetal repair of myelomeningocele, we did not observe any adverse maternal outcomes associated with maternal obesity; however, the gestational age at delivery was 2 weeks earlier compared to the MOMS trial.

Intermittent CSF drainage and rapid EVD weaning approach after subarachnoid hemorrhage: association with fewer VP shunts and shorter length of stay.

There is variability and uncertainty about the optimal approach to the management and discontinuation of an external ventricular drain (EVD) after subarachnoid hemorrhage (SAH). Evidence from single-center randomized trials suggests that intermittent CSF drainage and rapid EVD weans are safe and associated with shorter ICU length of stay (LOS) and fewer EVD complications. However, a recent survey revealed that most neurocritical care units across the United States employ continuous CSF drainage with a gradual wean strategy. Therefore, the authors sought to determine the optimal EVD management approach at their institution. The authors reviewed records of 200 patients admitted to their institution from 2010 to 2016 with aneurysmal SAH requiring an EVD. In 2014, the neurocritical care unit of the authors' institution revised the internal EVD management guidelines from a continuous CSF drainage with gradual wean approach (continuous/gradual) to an intermittent CSF drainage with rapid EVD wean approach (intermittent/rapid). The authors performed a retrospective multivariable analysis to compare outcomes before and after the guideline change. The authors observed a significant reduction in ventriculoperitoneal (VP) shunt rates after changing to an intermittent CSF drainage with rapid EVD wean approach (13% intermittent/rapid vs 35% continuous/gradual, OR 0.21, p = 0.001). There was no increase in delayed VP shunt placement at 3 months (9.3% vs 8.6%, univariate p = 0.41). The intermittent/rapid EVD approach was also associated with a shorter mean EVD duration (10.2 vs 15.6 days, p < 0.001), shorter ICU LOS (14.2 vs 16.9 days, p = 0.001), shorter hospital LOS (18.2 vs 23.7 days, p < 0.0001), and lower incidence of a nonfunctioning EVD (15% vs 30%, OR 0.29, p = 0.006). The authors found no significant differences in the rates of symptomatic vasospasm (24.6% vs 20.2%, p = 0.52) or ventriculostomy-associated infections (1.3% vs 8.8%, OR 0.30, p = 0.315) between the 2 groups. An intermittent CSF drainage with rapid EVD wean approach is associated with fewer VP shunt placements, fewer complications, and shorter LOS compared to a continuous CSF drainage with gradual EVD wean approach. There is a critical need for prospective multicenter studies to determine if the authors' experience is generalizable to other centers.