Shunt Revision Research Articles

Shuntogram utility in predicting future shunt failures.

Shunt failure remains a challenging diagnosis for neurosurgeons, particularly when patient symptoms suggest shunt malfunction but radiographic evidence is lacking. In such situations, shuntograms are sometimes employed to guide medical decision-making. In this study, the authors aimed to investigate the utility of shuntograms in aiding patient management, particularly in terms of a negative result. This retrospective single-institution series comprises patients who underwent a shuntogram procedure to evaluate shunt patency over a roughly 6-year period. The medical records of patients were reviewed to determine the findings of the shuntogram procedure, the type of obstruction, and whether a subsequent operation for a shunt revision took place either within 30 days or up to 1 year after the procedure. Statistical analysis was completed by calculating the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of the shuntogram as compared with the revision surgery. Of the 98 patients who underwent a shuntogram, 95 patients were included in the statistical analysis. A ventriculoperitoneal shunt was assessed in 81% of patients (77/95). The PPV of the procedure was 100%. The NPV for predicting a subsequent shunt revision within 30 days was 68.3% (false-negative rate of 31.7%) or within 365 days was 61.2% (false-negative rate of 38.8%). The sensitivity and specificity of the shuntogram were 55.8% and 100% within 30 days and 51.9% and 100% within 365 days, respectively. The most common intervention at the time of surgery following a negative shuntogram was a valve replacement in 38.5% of patients (10/26). With an NPV of 68.3% for predicting revision within 30 days in our series of 95 patients, shuntograms remained a useful tool in the clinical decision-making process when evaluating potential shunt failure.

Pediatric shunt revision analysis within the first year of shunt placement: A single center experience.

Background: Hydrocephalus is a common problem in neurosurgery with shunt placement remains the mainstay of the management. However, shunt placement generally requires following surgical procedures, including shunt revision. Despite the recent developments, the incidence of shunt failure remains high, approximately 30–51% in the 1st year following the shunt placement.Methods: An observational retrospective study of pediatric neurosurgery patients whom underwent CSF shunting procedure, both primary and repeated VPS, VAS, CPS, and subdural-peritoneal shunt procedures between January 2018 and May 2019. The patients were observed for 12 months for potential complication requiring shunt revision following the shunt placement.Results: A total of 142 patients underwent shunt placement. The shunt revision within 12 months was found in 26 patients (18.3%), 25 cases were VPS (96.2%) and one case was CPS (3.8%). The mean period of time between shunt placement to shunt revision was 3.96 months. Age of under 6 months old during the shunt placement showed significantly higher risk for shunt revision (RR 2.32 CI 1.13–4.74, P = 0.018). The most common diagnosis requiring shunt revision was congenital anomaly (16 cases, 61.5%). The most common cause of revision was shunt malfunction, with 21 cases (80.8%) followed by infected shunt with 5 cases (19.2%).Conclusion: The 1st year observation showed relatively high rate for shunt revision. The patient underwent shunt procedure should be regularly followed up in long period for better evaluation of the outcome. The application of shunt registry in some countries appears to be efficient and beneficial for sustainable follow-up in patients underwent shunt placement.

Treatment Options for Scrotal Migration of Ventriculoperitoneal Shunts: Case Illustration and Systematic Review of 48 Cases.

Scrotal migration of intact or disconnected tubing is a rare complication of ventriculoperitoneal shunts. While some illustrative case reports can be found in the literature, a systematic review on treatment options is lacking. To propose the first literature-based treatment algorithm on scrotal shunt migration. We conducted a literature search using the keywords: "VP," "ventriculoperitoneal," "shunt," and "scrotum." We identified 36 publications with 48 cases reported including our index case. Median age at presentation was 13.5 mo (3 d to 65 yr) which was 4 mo (3 d to 72 mo) after last shunt-related surgery. All patients had scrotal swelling, 39 (81%) patients presented without other symptoms, 4 (8%) had additionally local pain, and 4 (8%) patients presented with symptoms of shunt dysfunction. Treatment was surgically in all but one case where spontaneous resolution without repeat migration occurred. In 3 of 4 patients who had either subcutaneous shortening or abdominal repositioning of the shunt without hernia repair, scrotal shunt migration recurred within the following month. Whereas the surgical treatment with reposition of the migrated catheter back into the peritoneal cavity via a groin incision plus hernia repair yielded a definite treatment in all 26 performed cases, the revision rate was significantly higher in the shunt revision without hernia repair cohort (P=.0009). Scrotal shunt migration is a rare shunt complication with good recovery when treated surgically. We recommend hernia repair in addition to either manual or surgical repositioning of migrated tubing.

Challenges in the Management of Gram-Negative Bacterial Infections in Patients With Ventriculoperitoneal Shunt.

Gram-negative bacterial infections of the central nervous system (CNS) have worse clinical outcomes. The most common bacteria include Escherichia Coli, Citrobacter species, Enterobacter species, Serratia species, and Pseudomonas aeruginosa. There are multiple risk factors for CNS infection after shunt insertion, including younger age, obstructive hydrocephalus, shunt revision surgery, and trauma. The clinical presentation of a ventriculoperitoneal (VP) shunt infection includes the signs and symptoms of meningitis to fever with abdominal pain and peritonitis. Apart from cerebrospinal fluid (CSF) analysis, microbiological cultures and radiological studies are key diagnostic tools. Initial empirical intravenous antimicrobial therapy is preferably broad spectrum with appropriate coverage for resistant Gram-negative pathogens and the duration of treatment depends upon pathogenesis, host factors, and clinical response to the therapy.Considering the importance of this disease and associated clinical outcomes, in this review article, we have summarized the epidemiology, clinical features, management, and prevention of Gram-negative VP shunt infections in adults.

Percutaneous mechanical thrombectomy device assisted TIPS recanalization: a feasibility study.

Despite improved shunt patency, transjugular intrahepatic portosystemic shunt (TIPS) occlusion remains a serious complication, and effective debulking of the existing tract is needed to restore sufficient blood flow. To evaluate the technical and clinical success of percutaneous mechanical thrombectomy in restoring patency of acutely and chronically thrombosed covered TIPS using the Aspirex®S and Rotarex®S system. We evaluated mechanical thrombectomy-assisted revisions in five patients between January 2012 and April 2021. Two patients had to be revised twice due to recurrent occlusion. We designated thrombosis within 10 days after shunt creation or revision as acute. Insidious deterioration of portal hypertension related symptoms for at least 6-8 weeks was recorded in chronic cases. We treated four acute and three chronic occlusions. After transjugular lesion crossing, we performed two mechanical thrombectomy device passages. If indicated, balloon dilatation, covered stent placement, or variceal embolization were added. The technical success rate was 100%. No procedure-related complications occurred. In one patient with acute decompensation of Budd-Chiari syndrome and acute-on-chronic liver failure, early re-thrombosis occurred twice with patency intervals of up to eight days. In contrast, stable patency was achieved in the other four patients with documented patency intervals of at least five months and improvement of portal hypertension-related symptoms, resulting in a patient based clinical success rate of 80%. In five patients, percutaneous mechanical thrombectomy assisted TIPS recanalization of four acute and three chronic occlusions proved to be technically feasible and safe with a high clinical success rate.

Experience With Ventriculoperitoneal and Lumboperitoneal Shunting for the Treatment of Idiopathic Intracranial Hypertension: A Single Institution Series.

CSF shunting is among the most widely utilized interventions in patients with idiopathic intracranial hypertension (IIH). Ventriculoperitoneal shunting (VPS) and lumboperitoneal shunting (LPS) are 2 possible treatment modalities. To evaluate and compare complications, malfunction, infection, and revision rates associated with VPS compared to LPS. Electronic medical records were reviewed to identify baseline and treatment characteristics for patients diagnosed with IIH treated with VPS or LPS. A total of 163 patients treated with either VPS (74.2%) or LPS (25.8%) were identified. The mean follow-up was 35 mo. Shunt revision was required in 40.9% of patients. There was a nonsignificant higher rate of revision with LPS (52.4%) than VPS (36.4%, P=.07). In multivariate analysis, increasing patient age was associated with higher odds of shunt revision (P=.04). LPS had higher odds of shunt revision, yet this association was not significant (P=.06). Shunt malfunction was the main indication for revision occurring in 32.7%, with a significantly higher rate with LPS than VPS (P=.03). In total, 15 patients had shunt infection (9.4% VPS vs 12.2% LPS P=.50). The only significant predictor of procedural infection was the increasing number of revisions (P=.02). The incidence of shunt revision was 40.9%, with increasing patient age as the sole predictor of shunt revision. The incidence of shunt malfunction was significantly higher in patients undergoing LPS, while there was no significant difference in the incidence of shunt infection between the 2 modalities.

Case Series of Rapid Surgical Interventions in Fulminant Intracranial Hypertension.

Examine ophthalmologic outcomes and complications of lumbar drain and cerebrospinal fluid shunts in pediatric fulminant intracranial hypertension. Patients under 21 years of age with a diagnosis of fulminant intracranial hypertension with temporary lumbar drain only, shunt after lumbar drain, and shunt only were included. Parameters investigated include lumbar drain data, medication freedom, time to resolution of papilledema, improvement in cranial nerve palsy, afferent pupillary defects, visual fields, visual acuity, and complications of each intervention. Four patients had temporary lumbar drain, 2 temporary lumbar drain and cerebrospinal fluid shunt, and 3 shunt only. All achieved medication freedom and resolution of papilledema and cranial nerve palsies (if present). Most had resolution of preprocedure afferent pupillary defects. Minor residual visual field deficits occurred in 67%, and all had visual acuity improvement. One patient's lumbar drain dislodged, and one patient had 2 cerebrospinal fluid shunt revisions. Temporary lumbar drain with medical therapy may be a viable first approach to fulminant intracranial hypertension.

VP Shunt With Recurrent Malfunction in Two Pediatric Patients: Is the Hydrocephalus Truly Idiopathic?

VP Shunt With Recurrent Malfunction in Two Pediatric Patients: Is the Hydrocephalus Truly Idiopathic?

The Expanding Role of Posterior Vault Distraction Osteogenesis in Idiopathic Intracranial Hypertension and Slit Ventricle Syndrome.

The purpose of this study was to compare perioperative safety and efficacy of posterior vault distraction osteogenesis (PVDO) in patients with primary nonsynostotic cephalo-cranial disproportion, namely slit ventricle syndrome and idiopathic intracranial hypertension (IIH), to a cohort of patients with craniosynostosis (CS). A retrospective review of patients undergoing PVDO from 2009 to 2019 at our institution was performed. Craniosynostosis patients were matched by sex and age at PVDO to the nonsynostotic cohort. Operative details, perioperative outcomes, and distraction patterns were analyzed with appropriate statistics. Nine patients met inclusion criteria for the non-CS cohort. Six patients (67%) underwent PVDO for slit ventricle and the remaining 3 patients (33%) underwent PVDO for IIH. The majority of CS patients were syndromic (n = 6, 67%) and had multisuture synostosis (n = 7, 78%). The non-CS cohort underwent PVDO at a median 56.1 months old [Q1 41.1, Q3 86.6] versus the CS cohort at 55.7 months [Q1 39.6, Q3 76.0] (P = 0.931). Total hospital length of stay was longer in the non-CS patients (median days 5 [Q1 4, Q3 6] versus 3 [Q1 3, Q3 4], P = 0.021). Non-CS patients with ventriculoperitoneal shunts had significantly less shunt operations for ICP concerns post-PVDO (median rate: 1.74/year [Q1 1.30, Q3 3.00] versus median: 0.18/year [Q1 0.0, Q3 0.7]; P = 0.046). In this pilot study using PVDO to treat slit ventricle syndrome and IIH, safety appears similar to PVDO in the synostotic setting. The cohort lacks adequate follow-up to assess long term efficacy, although short-midterm follow-up demonstrates promising results with less need for shunt revision and symptomatic relief. Future studies are warranted to identify the preferred surgical approach in these complex patients.

Emergency Intraoperative Ultrasound for the Neurosurgical Trainee

The use of intraoperative ultrasound in emergency cranial neurosurgical procedures is not well described. It may improve surgical outcomes and is useful when other neuro-navigation systems are not readily available. We provide a practical guide for neurosurgical trainees to utilize ultrasound for various emergency cranial neurosurgical procedures, including lesion localization, insertion of an external ventricular drain, and shunt revision surgery. Intraoperative ultrasound is a useful modality for urgent neurosurgical procedures.

Clinical and Radiological Predictors of Ventriculoperitoneal Shunt Insertion in Myelomeningocele Patients

BACKGROUND: Myelomeningocele (MMC) is one of the most common developmental anomalies of the CNS. Many of these patients develop hydrocephalus (HCP). The rate of cerebrospinal fluid diversion in these patients varies significantly in literature, from 52% to 92%. MMC repair conventionally occurs in the post-natal period. With the technological advances in surgical practice and fetal surgeries, intra uterine MMC repair IUMR is adopted in some centers. Cerebrospinal fluid shunting has numerous complications, most notably shunt failure and shunt infection. Studies have suggested that patients with greater numbers of shunt revisions have poorer performance on neuropsychological testing. There is also good evidence to suggest that the IQs of patients with MMC who do not undergo shunt placement are higher than that of their shunt treated counterparts. AIM: In this study, we are trying to identify strong clinical and radiological predictors for the need of ventriculoperitoneal (VP) shunt insertion in patients with MMC who underwent surgical repair and closure of the defect initially. This will decrease the overall rate of shunt placement in this group of patients through applying a strict policy adopting only shunt insertion for the desperately needing patient. METHODS: Prospective clinical study conducted on 96 patients with MMC presented to Aboul Reish Pediatric Specialized Hospital, Cairo University. After confirming the diagnosis through clinical and radiological aids, patients are carefully examined, if HCP is evident clinically and radiologically a shunt is inserted together with MMC repair at the same session after excluding sepsis or cerebrospinal fluid (CSF) infection, (GROUP A). If there are no signs of increased ICP, MMC repair shall be done alone (GROUP B). Those patients shall be monitored carefully postoperatively and after discharge and shall be followed up regularly to early detect and promptly manage latent HCP. Multiple clinical and radiological indices were used throughout the follow-up period and statistical significance of each was measured. RESULTS: Shunt placement was required in 45 (46.88%) of the 96 patients. Eighteen patients (18.75%) needed the shunt as soon as they presented to us (GROUP A), because they were having clinically active HCP. Twenty-seven (28.13%) patients were operated on by MMC repair initially without shunt placement because they did not have signs of increased ICP at the time of presentation. Yet, they developed latent HCP requiring shunt placement during the follow-up period (GROUP B2). Fifty-one patients of the study population (53.13%) underwent surgical repair of the MMC without the need of further VP insertion and they were followed up for 6 months period after the repair without developing latent HCP (GROUP B1). Patients of GROUP B were the study population susceptible for the development of latent HCP. Out of 78 patients in GROUP B, only 27 patients (34.62%) needed a VP shunt. CONCLUSION: In our study, we found that the rate of shunt insertion in patients with MMC is lower than the previously reported rate in the literature. A more thorough evaluation of the patient’s post-operative need for a shunt is mandatory. We suggest that we could accept postoperative (after MMC repair) ventriculomegaly provided it does not mean any deterioration in the patient’s clinical or developmental state. We assume that reduction of shunt insertion rate will eventually reduce what has previously been an enormous burden for a significant proportion of children with MMC.

Transition to Ductal Stenting for Single Ventricle Patients Led to Improved Survival: An Institutional Case Series.

The use of systemic-to-pulmonary shunts (SPS) in neonates with single ventricle heart defects and ductal-dependent pulmonary blood flow (ddPBF) was historically associated with high morbidity and mortality at our center. As a result, we transitioned to the preferential use of ductus arteriosus stents (DS) when feasible. This report describes our initial results with this strategy. A single-center study of single ventricle patients that received DS or SPS from 2015 to 2019 was performed to assess whether DS was associated with decreased in-hospital morbidity and increased survival to stage II palliation. A total of 34 patients were included (DS = 11; SPS = 23). Underlying cardiac anomalies were similar between groups and included pulmonary atresia, unbalanced atrioventricular septal defect, and tricuspid atresia. Procedure success was similar between groups (82% vs 83%). Two DS patients were converted to SPS, due to ductal vasospasm or pulmonary artery obstruction, and four SPS patients required surgical shunt revision. In DS patients, postprocedure mechanical ventilation duration was shorter (one vs three days, P = .009) and fewer required postprocedure extracorporeal membrane oxygenation (9% vs 39%, P = .11). A higher proportion of DS patients survived to stage II palliation (100% vs 64%, P = .035), and the probability of one-year survival was higher in DS patients (100% vs 61%, P = .02). At our center, patients with single ventricle heart defects and ddPBF that received DS experienced reduced in-hospital morbidity and increased survival to stage II palliation compared to SPS.

Machine Learning-Based Clinical Adjusted Selection of Predicting Risk Factors for Shunt Infection in Children

Background: Shunt Infection is a common complication of shunt insertion in children which can lead to bad neuro-developmental conditions and impose a considerable economic burden for the health care system. So, identifying predictive factors of shunt infection could help us in the proper improvement of this deteriorating condition. Methods: In this study, related risk factors of 68 patients with history of shunt infection and 80 matched controls without any history of shunt infection, who were all operated in a single referral hospital were assessed. Three machine learning (ML)-based measures including sparsity, correlation, and redundancy along with specialist’s score were applied to select the most important predictive risk factors for shunt infection. ML was determined by summation of sparsity, correlation and redundancy measures, and the final total score was considered as normalization (ML-based score + specialist score). Results: According to the total score, prematurity, first ventriculoperitoneal shunting (VPS) age, intraventricular hemorrhage (IVH), myelomeningocele (MMC) and low birth weight had higher weights as shunt infection risk factors. icterus, trauma, co-infection and tumor had the lowest weights and history of meningitis and number of shunt revisions were defined as intermediate risk factors. Conclusion: The "ML-based clinical adjusted" method may be used as a complementary tool to help neurosurgeons in better patient selection and more accurate follow-up of children with higher risk of shunt infection.

Post-haemorrhagic hydrocephalus is associated with poorer surgical and neurodevelopmental sequelae than other causes of infant hydrocephalus

PurposeThis retrospective cohort study aimed to investigate the surgical and neurodevelopmental outcomes (NDO) of infant hydrocephalus. We also sought to determine whether these outcomes are disproportionately poorer in post-haemorrhagic hydrocephalus (PHH) compared to other causes of infant hydrocephalus.MethodsA review of all infants with hydrocephalus who had ventriculoperitoneal (VP) shunts inserted at Great Ormond Street Hospital (GOSH) from 2008 to 2018 was performed. Demographic, surgical, neurodevelopmental, and other clinical data extracted from electronic patient notes were analysed by aetiology. Shunt survival, NDO, cerebral palsy (CP), epilepsy, speech delay, education, behavioural disorders, endocrine dysfunction, and mortality were evaluated.ResultsA total of 323 infants with median gestational age of 37.0 (23.29–42.14) weeks and birthweight of 2640 g (525–4684 g) were evaluated. PHH was the most common aetiology (31.9%) and was associated with significantly higher 5-year shunt revision rates, revisions beyond a year, and median number of revisions than congenital or “other” hydrocephalus (all p < 0.02). Cox regression demonstrated poorest shunt survival in PHH, related to gestational age at birth and corrected age at shunt insertion. PHH also had the highest rate of severe disabilities, increasing with age to 65.0% at 10 years, as well as the highest CP rate; only genetic hydrocephalus had significantly higher endocrine dysfunction (p = 0.01) and mortality rates (p = 0.04).ConclusionsInfants with PHH have poorer surgical and NDO compared to all other aetiologies, except genetic hydrocephalus. Research into measures of reducing neurodisability following PHH is urgently required. Long-term follow-up is essential to optimise support and outcomes.

MO885APP BASED DOCUMENTATION AND SUPPORT OF A GERMAN HOME DIALYSIS PROGRAMM - A PILOT STUDY

Abstract Background and Aims Telemedicine is advancing. However, studies that examine the integration into home dialysis care are still scarce. This multicenter, Germany-wide prospective observational pilot-study investigated the effects, acceptance and usability of an app as a new care concept compared to conventionally cared-for patients. Method Here, we employed the “DiaApp”, a tablet based documentation, communication, information and supply ordering system developed by the PHV – a non-profit dialysis network in Germany with around 7,000 patients. During a pilot rollout phase of the app between 2018 and 2019, 25 patients participated in four dialysis practices. Participants were free to choose between app use (app) and the previous paper-based documentation (control). We collected prospective data on demographics, adverse events as well as questionnaires regarding quality of life (KDQL v1.3), affinity for technology (TA-EG), satisfaction with the app (UTAUT), and self-confidence in dealing with chronic illness (SES6G). Furthermore, 5 app users were interviewed in a qualitative interview over 90 min about their attitude towards technology, illness and the app. Results Of the 25 participants, 13 used the app (52%). App users tended to be younger, more likely to be male (60.0%) and on peritoneal dialysis (n=15, 60.0%). Median age and dialysis vintage for app users and controls were 51 (38-60; 0) vs. 59 (37-64; 1) years and 51.5 (34-68; 3) vs. 38 (28-66; 5) months, respectively. Mean follow-up durations were 6.5 months and 12 months. All participants continued to use the app. One exit site infection (app), 3 hospitalizations (peritonitis and shunt revision, controls; inguinal hernia, app) and no serious app-related adverse event occurred. App users exhibited small trends (n.s.) towards lower quality of life (median SF-12 physical composite app: 43, IQR 40-48 controls: 47, IQR 38-50; SF-12 mental composite median app: 53, IQR 35-55; controls: 56, IQR 42-59;) greater self-confidence in managing chronic illness (SESG6 Score app: 7.33, IQR: 6-8.83; controls:7.17, IQR 6-7.83) and higher affinity for technology (in all four TA-EG dimensions). App users were more likely to have completed a master’s degree, while non-users mostly had a bachelor's degrees (Chi-square 14.183, df 6, p=0.028). Overall, the educational level of participants was high. There was a tendency (n.s.) for actual app users to have slightly lower performance expectations (median control arm 5.5 vs. app arm 5.88 on a Likert scale 1-7), a slightly higher assessment of their own and other available resources (supportive conditions median control arm 6 vs. app arm 6.67 on a Likert scale 1-7). In the qualitative interviews, all app users surveyed stated that they regularly used digital offerings in all areas of their lives. Therefore, expectations were similar to other apps to be more efficient in terms of time, material and effort than paper-based documentation. The attitude towards the app was that towards an auxiliary tool, “it should simply work”, and found it to be useful. Patients disliked the necessity of a dedicated (in this case a tablet) device for running the app. Information about the disease was more likely to be outside of the app in e.g. the internet. Conclusion In this study, we found no significant differences between app users and controls. No adverse events occurred. Via trends and interviews, the picture emerges that an upcoming, younger generation of dialysis patients appreciates the advantages of flexible home dialysis procedures and, as in other areas of life, expects simple, digital and thus resource-saving options for self-management and communication. At the same time, such applications are also subject to the expectations of digital user experiences from other areas of life. This poses enormous challenges for the often-costly development of such applications by non-commercial providers and limited number of target audiences.

Aqueous Shunt Revision with Autologous Capsular Patch Graft: Surgical Technique Description and Preliminary Results

This brief report describes 5 cases and demonstrates my novel technique for harvesting autologous capsular patch graft material from prior valved and non-valved aqueous shunts for use during subsequent tube revisions for a variety of indications.

Craniosynostosis Develops in Half of Infants Treated for Hydrocephalus with a Ventriculoperitoneal Shunt.

Craniosynostosis following placement of a ventriculoperitoneal shunt for hydrocephalus has been sporadically described. The purpose of this investigation was to determine the general risk of developing craniosynostosis in this patient population. The authors retrospectively reviewed records and radiographs of infants who underwent ventriculoperitoneal shunt placement for hydrocephalus from 2006 to 2012. Recorded variables included date of shunt placement, demographics, comorbidities, cause of hydrocephalus, shunt type, and number of shunt revisions. Axial computed tomographic images obtained before and immediately after shunt placement and 2 to 4 years after shunt placement were evaluated by a panel of clinicians for evidence of craniosynostosis. Patients with preshunt craniosynostosis, craniosynostosis syndromes, or poor-quality computed tomographic images were excluded. Data were analyzed using STATA Version 15.1 statistical software. One hundred twenty-five patients (69 male and 56 female patients) were included. Average age at shunt placement was 2.3 ± 2.58 months. Sixty-one patients (48.8 percent) developed craniosynostosis at a median of 26 months after shunt placement. Of these, 28 patients fused one suture; the majority involved the sagittal suture (n = 25). Thirty-three patients fused multiple sutures; the most common were the coronal (n = 32) and the sagittal (n = 30) sutures. Multivariable logistic regression identified older age at shunt placement and more shunt revisions as independent predictors of craniosynostosis. Shunt valve type was not significant. Craniosynostosis developed in nearly half of infants who underwent ventriculoperitoneal shunt placement for hydrocephalus. The sagittal suture was most commonly involved. The effect of suture fusion on subsequent cranial growth, shunt failure, or the development of intracranial pressure is unclear. Risk, III.

Pediatric cerebral cysts: comparison of early complications following fenestration versus shunting procedures

ABSTRACT Objective: Characterize practice patterns and acute (30-day) surgical complications following fenestration and shunt procedures for the treatment of cerebral cysts in pediatric patients. Methods: This study utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database. Patients were identified by International Classification of Disease codes for cerebral cysts and Current Procedural Terminology codes for shunting or fenestration. Demographic data, preoperative comorbidities, and postoperative complications were compared between the two procedures. Results: 741 patients were included in the data analysis, with a majority aged 4 years or younger (55.9%) and a male predominance (62.6%). Fenestration was performed in 590 (79.6%) patients. Primary shunting was performed in 151 (20.4%) patients. Patients who received shunts were more commonly aged 0–4 years and had proportionately worse preoperative health status. No statistically significant differences in postoperative complications were detected. Reoperation rate was 7.9% and 8.6% in the shunt and fenestration groups, respectively. Common reasons for reoperation were shunt revision or replacement and shunt placement after fenestration. Patients requiring shunting after a failed fenestration tended to be younger with higher American Society of Anesthesiologists (ASA) classification. Discussion: Fenestrations are performed more often than shunting. Generally, children who receive shunts are younger than those who undergo fenestration. Acute surgical risk appears to be similar for both operations.

Idiopathic Intracranial Hypertension: Evaluation of Admissions and Emergency Readmissions through the Hospital Episode Statistic Dataset between 2002-2020.

With increasing incidence and prevalence of Idiopathic intracranial hypertension in the UK, the aim of this study was to explore emerging themes in Idiopathic intracranial hypertension using the Hospital Episode Statistics dataset and to quantify recent change in hospital admissions and surgeries performed within England. Methods: Hospital Episode Statistics national data was extracted between 1 April 2002 and 31 March 2019, and followed up until 31 March 2020. All those within England with a diagnosis of Idiopathic Intracranial Hypertension were included. Those with secondary causes of raised intracranial pressure such as tumors, hydrocephalus and cerebral venous sinus thrombosis were excluded. Results: 28,794 new IIH cases were diagnosed between 1 January 2002 and 31 December 2019. Incidence rose between 2002 to 2019 from 1.8 to 5.2 per 100,000 in the general population. Peak incidence occurred in females aged 25–29 years. Neurosurgical shunt was the commonest procedure performed (6.4%), followed by neovascular venous sinus stenting (1%), bariatric surgery (0.8%) and optic nerve sheath fenestration (0.5%). The portion of the total IIH population requiring a shunt fell from 10.8% in 2002/2003 to 2.46% in 2018/2019. The portion of the total IIH population requiring shunt revision also reduced over time from 4.84% in 2002/2003 to 0.44% in 2018/2019. The mean 30 days emergency readmissions for primary shunt, revision of shunt, bariatric surgery, neurovascular stent, and optic nerve sheath fenestration was 23.1%, 23.7%, 10.6%, 10.0% and 9.74%, respectively. There was a peak 30 days readmission rate following primary shunt in 2018/2019 of 41%. Recording of severe visual impairment fell to an all-time low of 1.38% in 2018/19. Conclusions: Increased awareness of the condition, specialist surgery and expert guidance may be changing admissions and surgical trends in IIH. The high 30 readmission following primary shunt surgery for IIH requires further investigation.

CSF shunt valve occlusion-does CSF protein and cell count matter?

Shunt obstruction is a common cause of shunt failure in the treatment of hydrocephalus. Valve occlusion is traditionally believed to originate from elevated CSF protein or cellular components, although detailed evidence is scarce and contradictory. Therefore, this study aimed to examine CSF protein and cell count as risk factors for valve obstruction. We retrospectively examined 274 patients who underwent shunt placement for hydrocephalus between 2009 and 2018 and had at least 1year follow-up. Age, aetiology of hydrocephalus, valve type, occurrence of revision, reason for revision and CSF protein and cell count at the time of shunt insertion and revision surgery were analysed. Thirty-two of 274 patients (11.7%) required revision surgery due to valve occlusion. Mean time to revision was 143days. CSF white blood cell (WBC) count but not protein was associated with valve occlusion overall. Of all obstructed valve patients, 25% showed CSF protein level within the normal range, whereas 13.6% of the patients overall showed greatly elevated CSF protein level without evidence of valve obstruction. Persistently elevated CSF protein level at the time of shunt revision was significantly associated with valve obstruction within 90days of initial insertion (early occlusion). Children with congenital malformations and post-haemorrhagic patients were significantly overrepresented in the occlusion group, particularly in the early occlusion group. Pathological CSF values such as WBC count and persistently elevated protein level serves as a risk factor for early valve obstruction. Late obstruction occurs independent of normal CSF values. Infants are particularly prone to early and late valve obstructions. CSF protein level at shunt insertion is not predictive of valve occlusion.