Shunt Revision Research Articles

Endoscopic Lavage for the Treatment of Multiple Shunt Failures in Children.

To compare the efficacy of neuroendoscopic lavage (NEL) and shunt revision (SR) in the treatment of multiple shunt failures in children with hydrocephalus. The data of 56 pediatric patients who underwent surgeries for the treatment of shunt failure were retrospectively reviewed. Patients were divided into two groups, i.e., the simple SR (Group A) and the NEL+SR (Group B) cohorts. Demographic characteristics, co-morbidities, surgical interventions, cerebrospinal fluid analyzes, and complications were recorded and statistically compared between the groups. Among the 56 enrolled patients, 51 presented with shunt dysfunction caused by infectious debris or clots at different times. Moreover, 28 of these 51 patients (54.9%) were female and 23 (45%) were male. The mean age was 7.3 months. Simple SR was performed in 30 cases (Group A), and NEL and simultaneous SR were performed in 21 patients (Group B). The risk of shunt dysfunction was significantly lower in Group B (p < 0.05).The risk of infection was elevated in Group A; however, this difference was not statistically significant (p > 0.05). Simultaneous endoscopic lavage and SR was an effective method for the treatment of shunt dysfunction in children. It was also superior to simple SR regarding the risk of shunt dysfunction. Additional clinical studies are needed to verify this outcome.

A Morphometric Analysis of Commonly Used Craniometric Approaches for Freehand Ventriculoperitoneal Shunting.

Ventricular catheter tip position is a predictor for ventriculoperitoneal shunt survival. Cannulation is often performed freehand, but there is limited consensus on the best craniometric approach. To determine the accuracy of localizing craniometric entry sites and to identify which is associated with optimal catheter placement. This is a retrospective analysis of adult patients who underwent ventriculoperitoneal shunting. The approaches were categorized as Kocher's, Keen's, Frazier's and Dandy's points as well as the parieto-occipital point. An accurately sited burr hole was within 10 mm from standard descriptions. Optimal catheter tip position was defined as within the ipsilateral frontal horn. A total of 110 patients were reviewed, and 58% (65/110) of burr holes were accurately sited. Keen's point was the most correctly identified (65%, 11/17), followed by Kocher's point (65%, 37/57) and Frazier's point (60%, 3/5). Predictors for accurate localization were Keen's point (odds ratio 0.3; 95% CI: 01-0.9) and right-sided access (odds ratio 0.4; 95% CI: 0.1-0.9). Sixty-three percent (69/110) of catheters were optimally placed with Keen's point (adjusted odds ratio 0.04; 95% CI: 0.01-0.67), being the only independent factor. Thirteen patients (12%) required shunt revision at a mean duration of 10 ± 25 mo. Suboptimal catheter tip position was the only independent determinant for revision (adjusted odds ratio 0.11; 95% CI: 0.01-0.98). This is the first study to compare the accuracy of freehand ventricular cannulation of standard craniometric entry sites for adult patients. Keen's point was the most accurately sited and was a predictor for optimal catheter position. Catheter tip location, not the entry site, predicted shunt survival.

Neuroendoscopic Navigated One-Step Removal of Crossed Ventricular Catheter Fragments: Technical Note

Abstract Introduction Neuroendoscopy plays an important role in minimally invasive neurosurgery. The authors reported an interesting case of a pediatric patient with multiple ventriculoperitoneal shunt (VPS) revision surgeries, presenting with VPS infection and with two crossed intraventricular floating catheter fragments, successfully removed through a neuroendoscopic navigated one-step procedure. A literature review regarding this exceedingly rare condition has also been discussed. Case Description An 11-year-old female patient with a history of congenital hydrocephalus was admitted to the emergency department with symptoms of intracranial hypertension, psychomotor agitation, and tetraparesis. She had a history of previous multiple VPS revisions. She had an urgent brain computed tomography scan that documented hydrocephalus; the VPS's intraventricular catheter tip was sited at the level of the right frontal horn. Two small floating catheter fragments, not connected to the VPS, were identified: the first close to the right lateral ventricle at the level of the right occipital horn, the second one between the right occipital horn and the third ventricle. First, she underwent an exteriorization of the distal catheter for VPS. Cerebrospinal fluid examination documented hyperproteinorrachia and a positive culture for Staphylococcus aureus. Then a navigated right transfrontal endoscopic approach to the right lateral ventricle was performed extending to the previous burr hole and achieving a wide range of working angle with a rigid 0-degree lens endoscope. Intermittent irrigation generating convective flow was performed such as to mobilize the catheters tip gently upward, to remove them by grasping. Finally, a whole VPS replacement has been performed. Conclusion Persistence of intraventricular floating catheter fragments can lead to subacute or chronic infections. Neuroendoscopic retrieval represents a safe and effective alternative to a more extensive and invasive surgical approach. However, the exact catheter tip identification, grasping, and removal can be difficult to achieve, due to the technical instrumentation characteristics and altered intraventricular anatomy in chronic congenital hydrocephalus. In our experience, endoscopic convective flow induction through saline irrigation can determine floating intraventricular catheter fragments movement aiming to their identification and subsequent successful endoscopic retrieval.

Risk factors for unchanged ventricles during pediatric shunt malfunction.

Children whose ventricles do not change during shunt malfunction present a diagnostic dilemma. This study was performed to identify risk factors for unchanged ventricular size at shunt malfunction. This retrospective 1:1 age-matched case-control study identified children with shunted hydrocephalus who underwent shunt revision with intraoperative evidence of malfunction at one of the three participating institutions from 1997 to 2019. Cases were defined as patients with a change of < 0.05 in the frontal-occipital horn ratio (FOR) between malfunction and baseline, and controls included patients with FOR changes ≥ 0.05. The presence of infection, abdominal pseudocyst, pseudomeningocele, or wound drainage and lack of baseline cranial imaging at the time of malfunction warranted exclusion. Of 450 included patients, 60% were male, 73% were Caucasian, and 67% had an occipital shunt. The median age was 4.3 (IQR 0.97-9.21) years at malfunction. On univariable analysis, unchanged ventricles at malfunction were associated with a frontal shunt (41% vs 28%, p < 0.001), programmable valve (17% vs 9%, p = 0.011), nonsiphoning shunt (85% vs 66%, p < 0.001), larger baseline FOR (0.44 ± 0.12 vs 0.38 ± 0.11, p < 0.001), no prior shunt infection (87% vs 76%, p = 0.003), and no prior shunt revisions (68% vs 52%, p < 0.001). On multivariable analysis with collinear variables removed, patients with a frontal shunt (OR 1.67, 95% CI 1.08-2.70, p = 0.037), programmable valve (OR 2.63, 95% CI 1.32-5.26, p = 0.007), nonsiphoning shunt at malfunction (OR 2.76, 95% CI 1.63-4.67, p < 0.001), larger baseline FOR (OR 3.13, 95% CI 2.21-4.43, p < 0.001), and no prior shunt infection (OR 2.34, 95% CI 1.27-4.30, p = 0.007) were more likely to have unchanged ventricles at malfunction. In a multicenter cohort of children with shunt malfunction, those with a frontal shunt, programmable valve, nonsiphoning shunt, baseline large ventricles, and no prior shunt infection were more likely than others to have unchanged ventricles at shunt failure.

Programmable Shunt Valves for Pediatric Hydrocephalus: 22-Year Experience from a Singapore Children's Hospital.

(1) Background: pediatric hydrocephalus is a challenging condition. Programmable shunt valves (PSV) have been increasingly used. This study is undertaken to firstly, to objectively evaluate the efficacy of PSV as a treatment modality for pediatric hydrocephalus; and next, review its associated patient outcomes at our institution. Secondary objectives include the assessment of our indications for PSV, and corroboration of our results with published literature. (2) Methods: this is an ethics-approved, retrospective study. Variables of interest include age, gender, hydrocephalus etiology, shunt failure rates and incidence of adjustments made per PSV. Data including shunt failure, implant survival, and utility comparisons between PSV types are subjected to statistical analyses. (3) Results: in this case, 51 patients with PSV are identified for this study, with 32 index and 19 revision shunts. There are 3 cases of shunt failure (6%). The mean number of adjustments per PSV is 1.82 times and the mean number of adjustments made per PSV is significantly lower for MEDTRONIC™ Strata PSVs compared with others (p = 0.031). Next, PSV patients that are adjusted more frequently include cases of shunt revisions, PSVs inserted due to CSF over-drainage and tumor-related hydrocephalus. (4) Conclusion: we describe our institutional experience of PSV use in pediatric hydrocephalus and its advantages in a subset of patients whose opening pressures are uncertain and evolving.

Comparison of Programmable and Non-Programmable Shunts for Normal Pressure Hydrocephalus: A Meta-Analysis and Trial Sequential Analysis.

The use of programmable ventriculoperitoneal shunt (P-VPS) in idiopathic normal pressure hydrocephalus (iNPH) has increased over the last two decades, however, there is no definitive evidence to favor them over non-programmable VPS (NP-VPS). Thus, there is a growing need for studies comparing these two procedures for their efficacy and safety profile in iNPH. In this study, we attempt to quantitatively summarize the findings of all the prospective and retrospective studies that have directly compared the P-VPS and NP-VPS in terms of efficacy, complications, or overall healthcare expenditure. A systematic search was performed of PubMed, the Cochrane Library databases, and Google Scholar for studies till June 2021 comparing the outcomes of P-VPS with NP-VPS. Four studies were finally included in the quantitative analysis. A trial sequential analysis was done to evaluate the need for further studies. The total rates of subdural collection (odds ratio (OR) 1.03; 95% Confidence interval (CI): 0.73-1.46; P = 0.85; I2 = 12%) as well as surgically evacuated subdural collection (OR 0.46; 95% CI: 0.14-1.55; P = 0.21; I2 = 75%) were not significantly different for P-VPS compared to NP-VPS with pooled data. Similarly, the rate of postoperative infection was found to be similar between the two types of VPS (OR 0.98; 95% CI: 0.39-2.5; P = 0.97; I2 = 0%). The trial sequential analysis (TSA) for the need of surgical evacuation of subdural collection and shunt revision revealed that the meta-analysis of the currently accrued information is not conclusive. Though, associated with higher initial costs, P-VPS does not seem to result in increased healthcare costs in the long run while enabling the surgeon to titrate the opening pressure and avoiding additional surgical procedures like shunt revision or evacuation of subdural collection at least theoretically. However, further trials with a greater sample size are needed to confirm these findings as the current accrued information size is insufficient to reach an unequivocal verdict.

Readmissions after ventricular shunting in pediatric patients with hydrocephalus: a Nationwide Readmissions Database analysis.

Cerebrospinal fluid diversion via ventricular shunting is a common surgical treatment for hydrocephalus in the pediatric population. No longitudinal follow-up data for a multistate population-based cohort of pediatric patients undergoing ventricular shunting in the United States have been published. In the current review of a nationwide population-based data set, the authors aimed to assess rates of shunt failure and hospital readmission in pediatric patients undergoing new ventricular shunt placement. They also review patient- and hospital-level factors associated with shunt failure and readmission. Included in this study was a population-based sample of pediatric patients with hydrocephalus who, in 2010-2014, had undergone new ventricular shunt placement and had sufficient follow-up, as recorded in the Nationwide Readmissions Database. The authors analyzed the rate of revision within 6 months, readmission rates at 30 and 90 days, and potential factors associated with shunt failure including patient- and hospital-level variables and type of hydrocephalus. A total of 3520 pediatric patients had undergone initial ventriculoperitoneal shunt placement for hydrocephalus at an index admission. Twenty percent of these patients underwent shunt revision within 6 months. The median time to revision was 44.5 days. Eighteen percent of the patients were readmitted within 30 days and 31% were readmitted within 90 days. Different-hospital readmissions were rare, occurring in ≤ 6% of readmissions. Increased hospital volume was not protective against readmission or shunt revision. Patients with grade 3 or 4 intraventricular hemorrhage were more likely to have shunt malfunctions. Patients who had private insurance and who were treated at a large hospital were less likely to be readmitted. In a nationwide, population-based database with longitudinal follow-up, shunt failure and readmission were common. Although patient and hospital factors were associated with readmission and shunt failure, system-wide phenomena such as insufficient centralization of care and fragmentation of care were not observed. Efforts to reduce readmissions in pediatric patients undergoing ventricular shunt procedures should focus on coordinating care in patients with complex neurological diseases and on reducing healthcare disparities associated with readmission.

P.207 Reducing the risks of proximal and distal shunt failure in adult hydrocephalus: A Shunt Outcomes Quality Improvement (ShOut-QI) Study

Background: Ventriculoperitoneal (VP) shunt failures in adult patients are common and subject patients to multiple surgeries and a decreased quality of life. A prospective cohort Shunt Outcomes Quality Improvement (ShOut-QI) initiative was implemented to reduce shunt failure incidence through neuronavigation-assisted proximal catheter insertion and laparoscopy-guided distal catheter anchoring over the liver dome to drain CSF away from the omentum. Methods: “Pre-ShOut” and “Post-ShOut” groups of patients included those with and without neuronavigation/laparoscopy, respectively for insertion of a new VP shunt. The primary outcome was shunt failure which was defined as any return to surgery for shunt revision as determined with a standardized clinical and radiology follow-up protocol. Results: 244 patients (97 Pre-ShOut, 147 Post-ShOut), mean age 73 years, were enrolled over a 7-year interval and observed for a mean duration of 4 years after shunt insertion. Neuronavigation improved proximal catheter placement accuracy by 20% (p&lt;.001), and shunt failure occurred in 57% vs 23% in the Pre-ShOut and Post-ShOut groups, respectively (p=.008), representing a 53% relative risk reduction in the incidence of shunt failure. Conclusions: Adult shunt failure incidence may be significantly reduced by improving the accuracy of proximal catheter placement with neuronavigation and reducing the risk of distal catheter failure with laparoscopic-guided placement.

Long-term risk of shunt failure after brain tumor surgery

Long-term risks and survival times of ventriculoperitoneal (VP) shunts implanted due to hydrocephalus (HC) after craniotomy for brain tumors are largely unknown. The aim of this study was to establish the overall VP shunt survival rates during a decade after shunt insertion and to determine risks of shunt failure after brain tumor surgery in the long-term period. In this population-based cohort from a well-defined geographical region, all adult patients (> 18 years) from 2004 to 2013 who underwent craniotomies for intracranial tumors leading to VP shunt dependency were included. Our brain tumor database was cross-linked to procedure codes for shunt surgery (codes AAF) to extract brain tumor patients who became VP shunt dependent after craniotomy. The VP shunt survival time, i.e. the shunt longevity, was calculated from the day of shunt insertion after brain tumor surgery until the day of its failure. A total of 4174 patients underwent craniotomies, of whom 85 became VP shunt dependent (2%) afterwards. Twenty-eight patients (33%) had one or more shunt failures during their long-term follow-up, yielding 1-, 5-, and 10-year shunt success rates of 77%, 71%, and 67%, respectively. Patient age, sex, tumor location, primary/repeat craniotomy, placement of external ventricular drainage (EVD), ventricular entry, post-craniotomy hemorrhage, post-shunting meningitis/infection, and multiple shunt revisions were not statistically significant risk factors for shunt failure. Median shunt longevity was 457.5 days and 21.5 days for those with and without pre-craniotomy HC, respectively (p < 0.01). This study can serve as benchmark for future studies.

Use of Helicopter Medical Transportation to the Neuroscience Intensive Care Unit.

Helicopter medical transportation (HMT) is a valuable resource that can expedite medical care by shortening transferring times. However, there is conflicting evidence regarding its cost and efficacy. No specific studies have addressed its use in patients transferred to the neuroscience intensive care unit (NSICU). This was a retrospective study performed at a university hospital in the coastal southeastern USA. The flight logs for the air ambulance company were reviewed, and all patients undergoing HMT to the NSICU during a 1-year period were identified. Flight logs and medical records were reviewed to obtain basic demographics, diagnosis, mortality, transportation distance, and performance of time-sensitive interventions (TSIs) to include ventriculostomy placement, emergency craniotomy, emergency craniectomy, emergency aneurysm obliteration, emergency spine surgery, emergent endovascular procedures, subdural drain placement, emergent shunt revision, and continuous electroencephalography (EEG) performed within 4h of admission. We analyzed the cost of HMT and correlated the clinical variables with the performance of TSIs. A total of 101 patients underwent HMT during a 12-month period; 26 underwent 30 TSIs (4 underwent 2 TSIs) and an additional 4 were transported for EEG monitoring. The only clinical variable associated with a TSI was subarachnoid hemorrhage with ventriculostomy placement. Continuous EEG monitoring performed in four patients with suspected status epilepticus did not show status epilepticus in any of them (one was performed after 4h). Transportation distance was less than 60 miles in four patients who underwent TSIs. The total cost of HMT was $3,360,573: $842,672 for those who underwent TSIs and $2,517,901 for those who did not. When compared with ground transportation, an excess cost of $3,129,415.25 was incurred by using HMT. There was no difference in the median cost of transportation between patients who underwent TSIs and those who did not ($30,210 vs. $30,211). The median cost transportation difference between HMT and ground transportation was significantly different (p < 0.001), with a median excess cost of $28,023 (range $15,553-76,155) per patient. The majority of patients who were transferred via HMT did not undergo TSIs, and among those who underwent TSIs, approximately one in six was transported from a hospital located less than 60 miles away from the NSICU; the distances of ground and air transportation are equivalent. Helicopter transfers may play a role in subarachnoid hemorrhage management. A significant expense was incurred by using HMT for the majority of patients (75%) who did not undergo TSIs.

Hydrocephalus and Cerebrospinal Fluid Analysis Following Severe Traumatic Brain Injury: Evaluation of a Prospective Cohort.

The development of hydrocephalus after severe traumatic brain injury (TBI) is an under-recognized healthcare phenomenon and can increase morbidity. The current study aims to characterize post-traumatic hydrocephalus (PTH) in a large cohort. Patients were prospectively enrolled age 16–80 years old with Glasgow Coma Scale (GCS) score 8. Demographics, GCS, Injury Severity Score (ISS), surgery, and cerebrospinal fluid (CSF) were analyzed. Outcomes were shunt failure and Glasgow Outcome Scale (GOS) at 6 and 12-months. Statistical significance was assessed at p < 0.05. In 402 patients, mean age was 38.0 ± 16.7 years and 315 (78.4%) were male. Forty (10.0%) patients developed PTH, with predominant injuries being subdural hemorrhage (36.4%) and diffuse axonal injury (36.4%). Decompressive hemicraniectomy (DHC) was associated with hydrocephalus (OR 3.62, 95% CI (1.62–8.07), p < 0.01). Eighteen (4.5%) patients had shunt failure and proximal obstruction was most common. Differences in baseline CSF cell count were associated with increased shunt failure. PTH was not associated with worse outcomes at 6 (p = 0.55) or 12 (p = 0.47) months. Hydrocephalus is a frequent sequela in 10.0% of patients, particularly after DHC. Shunt placement and revision procedures are common after severe TBI, within the first 4 months of injury and necessitates early recognition by the clinician.

Shunt complications and revisions in children: A retrospective single institution study.

IntroductionShunt surgery in children is associated with high revision and complication rates. We investigated revision rates and postoperative complications to specify current challenges associated with pediatric shunt surgery.MethodsAll patients aged < 18 years admitted to St. Olavs University Hospital, Norway, from January 2008 through December 2017, who underwent primary shunt insertions, were reviewed. Follow‐up ranged from 1 to 10 years. Ventriculoperitoneal, cystoperitoneal, and ventriculoatrial shunts were included. All subsequent shunt revisions and 30‐day postoperative complication rates were registered.Results81 patients underwent 206 surgeries in the study period. 47 patients (58%) required minimum one revision during follow‐up. In 14 (29.8%), the first revision was due to the misplacement of hardware. Proximal occlusion was the most common cause of revision (30.4%), followed by misplacement (18.5%) and infection (9.6%). Young age and MMC were associated with revision surgery in a univariable analysis, but were not significant in multivariable analyses. Congenital hydrocephalus was associated with infection (p = .028). In approximately 30% of procedures, complications occurred within 30 days postoperatively, the most common being revision surgery. In approximately 5% of the procedures, medical complications occurred.ConclusionChildren are prone to high revision and complication rates, and in this study, misplacement of hardware and proximal occlusion were the most common. Complication rates should not be limited to revision rates only, as 30‐day complication rates indicate a significant rate of other complications as well. Multi‐targeted approaches, perhaps focusing on measures to reduce misplacement, may be key to reducing revision rates.

Sheath formation around peritoneal tube: possible explanation for unknown cause of ventriculoperitoneal shunt failure.

Ventriculoperitoneal (VP) shunt failures are common and are frequently associated with an obstruction of the peritoneal tube. This study aimed to explore the possible causes of peritoneal tube obstruction, which are largely unknown. From January 1981 to June 2018, we performed VP shunting in 646 patients with hydrocephalus. Among the procedures performed, 148 shunt revision procedures were performed in 98 patients with VP shunt failure. Of the study participants, 64 (43.2%) patients were diagnosed with peritoneal tube obstruction and five patients developed sheath formation that obstructed the end of the peritoneal tubes. Sheath formation around the peritoneal tube is a possible cause of VP shunt dysfunction.

Readmission and reoperation rates after resection of malignant primary brain tumours in England 2013-2017

Abstract Aims Morbidity and mortality following resection of malignant primary brain tumours is high. The benefits of reoperation for recurrent tumours are uncertain and it is not known how frequently patients in England undergo further tumour resections. The aim of this study was to describe 30-day and one-year readmission rates, the clinical reasons for readmission and the rate of resections for recurrent tumours. Method Patient data was extracted from Hospital Episode Statistics (the hospital administrative data for NHS hospitals in England) for all supratentorial, malignant, primary brain tumour resections performed from April 2013 to March 2017. All subsequent non-elective readmissions to any NHS hospital and all readmissions for further tumour resection within 30 days and one year were analysed for the primary clinical diagnosis and primary procedure performed. Results A total of 6,982 patients were identified and the 30-day and one-year readmission rates were 18.6% (n=1,298) and 57.4% (n=4,007), respectively. The rates of reoperation for tumour resection were 0.5% (n=33) and 6.2% (n=432), respectively. The commonest reasons for 30-day readmission were post-operative complications (17.9% of admissions), general medical complications (17.3%) and surgical site infection (9.6%). The most frequently performed neurosurgical procedures were for treatment of surgical site infection (37.6% of procedures). The commonest reasons for readmission within one year were general medical complications (17.4%), seizures (14%), systemic infections (11.4%) and post-operative complications (11%). Almost half of all neurosurgical procedures performed within one year were reoperation for tumour resection (45.6%), while treatment of surgical site infection (17.9%) and CSF shunt insertions and revisions (9.1%) were also common. Conclusion This study provides a descriptive analysis of the rates of readmission, diagnosis on readmission, and the need for further neurosurgical procedures. The rate of non-elective readmissions within one year is high and these data may be useful for service planning and for counselling patients about their treatment. Additionally, these data contribute to the development of quality indicators, for benchmarking and comparing quality of care provision between neurosurgical units. Further research, with linkage to histology data and performance status, would support an analysis of the role of resection of recurrent, malignant, primary brain tumours.

Ventriculoatrial Shunting: An Escape Option in Patients with Idiopathic Normal Pressure Hydrocephalus Failing Ventriculoperitoneal Drainage

Ventriculoperitoneal (VP) shunting is widely accepted as the gold-standard treatment for idiopathic normal pressure hydrocephalus (iNPH). However, a restricted group of patients experience only minimal or no improvement after the operation. In such cases, the question whether the diagnosis was incorrect or the shunt is malfunctioning remains unanswered. We retrospectively collected data on a 10-year series of VP-shunted patients with iNPH showing transient or minimal improvement of symptoms within 3weeks from surgery. A full workup (including noninvasive diagnostic, cognitive, and invasive tests) was performed. After ruling out mechanical malfunction, we performed a tap test followed by a Katzman test 2 weeks later. The confirmed persistence of disturbance of cerebrospinal fluid dynamics was treated by shunt revision and, if found working, by its replacement into the atrial cavity. Twenty patients were diagnosed with shunt insufficiency. At surgery, the distal end of the shunt was easily extruded and found working in all cases. It was then repositioned into the right atrium (the first 8 patients of the series also underwent failed contralateral abdominal replacement). Early postoperative clinical improvement was always confirmed. In 1 case, shunt overdrainage was corrected by valve upregulation. According to our experience, inadequate distal end placement of a shunt might be one of the reasons needing investigation in patients with iNPH failing improvement after surgery. In such situations, the conversion to a ventriculoatrial shunt proved to be a low-cost and successful treatment option.

Severity of upper limb discrepancies affect the postural balance in children with obsteric brachial plexus palsy (pilot study)

Ventriculoperitoneal (VP) shunting is widely accepted as the gold-standard treatment for idiopathic normal pressure hydrocephalus (iNPH). However, a restricted group of patients experience only minimal or no improvement after the operation. In such cases, the question whether the diagnosis was incorrect or the shunt is malfunctioning remains unanswered.We retrospectively collected data on a 10-year series of VP-shunted patients with iNPH showing transient or minimal improvement of symptoms within 3 weeks from surgery. A full workup (including noninvasive diagnostic, cognitive, and invasive tests) was performed. After ruling out mechanical malfunction, we performed a tap test followed by a Katzman test 2 weeks later. The confirmed persistence of disturbance of cerebrospinal fluid dynamics was treated by shunt revision and, if found working, by its replacement into the atrial cavity.Twenty patients were diagnosed with shunt insufficiency. At surgery, the distal end of the shunt was easily extruded and found working in all cases. It was then repositioned into the right atrium (the first 8 patients of the series also underwent failed contralateral abdominal replacement). Early postoperative clinical improvement was always confirmed. In 1 case, shunt overdrainage was corrected by valve upregulation.According to our experience, inadequate distal end placement of a shunt might be one of the reasons needing investigation in patients with iNPH failing improvement after surgery. In such situations, the conversion to a ventriculoatrial shunt proved to be a low-cost and successful treatment option.

Ventriculopleural shunts in a pediatric population: a review of 170 consecutive patients.

The authors sought to determine the outcome of using the pleural space as the terminus for ventricular CSF-diverting shunts in a pediatric population. All ventriculopleural (VPl) shunt insertions or revisions done between 1978 and 2018 in patients at Children's Hospital Los Angeles were identified. Data recorded for analysis were age, sex, weight, etiology of hydrocephalus, previous shunt history, reason for VPl shunt insertion or conversion from a ventriculoperitoneal (VP) or ventriculoatrial (VA) shunt, valve type, nature of malfunction, presence of shunt infection or pleural effusion, and conversion to a different distal site. A total of 170 patients (mean age 14 ± 4 years) with a VPl shunt who were followed up for a mean of 57 ± 53 months were identified. The reasons for conversion to a VPl shunt for 167 patients were previous shunt infection in 57 (34%), multiple abdominal procedures in 44 (26%), inadequate absorption of CSF in 34 (20%), abdominal pseudocyst in 25 (15%), and obesity in 7 (4%). No VPl revisions were required in 97 (57%) patients. Of the 73 (43%) patients who did require revision, the most common reason was proximal obstruction in 32 (44%). The next most frequent complication was pleural effusion in 22 (30%) and included 3 patients with shunt infection. All 22 patients with a clinically significant pleural effusion required changing the distal end of the shunt from the pleural space. Pleural effusion was more likely to occur in VPl shunts without an antisiphon valve. Of the 29 children < 10 years old, 7 (24%) developed a pleural effusion requiring a revision of the distal catheter to outside the pleural space compared with 15 (11%) who were older (p = 0.049). There were 14 shunt infections with a rate of 4.2% per procedure and 8.2% per patient. VPl shunts in children younger than 10 years of age have a significantly higher rate of symptomatic pleural effusion, requiring revision of the shunt's terminus to a different location. VPl shunt complication rates are similar to those of VP shunts. The technical difficulty of inserting a VPl shunt is comparable to that of a VP shunt. In a patient older than 10 years, all else being equal, the authors recommend that the distal end of a shunt be placed into the pleural space rather than the right atrium if the peritoneal cavity is not suitable.

Pattern of oculomotor and visual function in children with hydrocephalus

To investigate the ocular motility disturbances, optic nerve changes, and refractive errors in children with or without surgically treated hydrocephalus. This retrospective study included 63 subjects diagnosed with hydrocephalus between 2007 and 2019 at the Baskent University Hospital. Full orthoptic and ophthalmic examination and brain magnetic resonance imaging were performed in all subjects. The mean age of patients was 68.4±27.6 months, and the mean follow-up time was 21.3±5.2 months. Twenty-one (51.2%) patients had esotropia (ET), and 14 (34.1%) had exotropia (XT). Of the patients with ET, 9 (14.2%) had a sixth nerve palsy. Four patients (6.3%) had a fourth nerve palsy, and 1 had a superior rectus palsy. Eleven patients had manifest, and 2 latent, nystagmus. Thirteen (20.6%) patients had optic disc abnormalities. The mean BCVA was 0.4±0.2 (0.05-1.0) in the right eye and 0.5±0.2 (0.1-1.0) in the left eye. Of the 19 (30.1%) patients who had a significant refractive error, 9 (47.3%) had hyperopia. Thirty-six (57.1%) patients had ventriculoperitoneal shunt surgery, and 11 (30.5%) of them had shunt revision due to occlusion. Ocular motility disorders were found to be significantly more common in patients who underwent single shunt surgery and shunt revision than those who had no surgical procedure (P=0.041and P=0.032, respectively). The evaluation of ocular motility disorders and visual dysfunction in hydrocephalic children can be a source of valuable information when diagnosing and following the disease.

Local 3-Dimensional Printing of a Calvarium-Anchored Ventricular Catheter Occlusion Device

ABSTRACT Three-dimensional (3D)-printed objects have been incorporated into many surgical specialties for various purposes. These devices can be customized and used as implants or surgical instruments. This study describes the use of a 3D-printed device that eliminates the need for a surgical assistant to occlude and retain the intracranial catheter during ventriculoperitoneal shunt creation and revision. After we identified design considerations and solutions, we modeled the device dimensions using computer-aided design software. Prototypes were 3D printed using stereolithography. Iterative design improvements were tested on cadaveric cranial samples. A final design was established, prepared by the in-hospital sterile processing department, and deployed successfully for clinical use. The design process for 3D-printed surgical instruments can produce straightforward idea-to-prototype pipelines. Because 3D-printed devices are easily duplicated and modified, small adjustments and new models can be developed, printed, and tested in a short time span.

Early Intraocular Pressure Control Via Capsule Revision of a Failed Valved Aqueous Shunt During Concurrent Placement of a Nonvalved Aqueous Shunt

To describe the novel strategy of performing a concurrent capsule revision of a failed pre-existing valved aqueous shunt with implantation of an additional nonvalved aqueous shunt for early postoperative intraocular pressure (IOP) control. Case report of a single patient. An 87-year-old man with severe primary open-angle glaucoma in both eyes presented to our clinic. His pseudophakic left eye had a failed superonasal trabeculectomy and an encapsulated superotemporal Ahmed FP7 (New World Medical) aqueous shunt in the anterior chamber. He had previously undergone micropulse cyclophotocoagulation 3 times and excisional goniotomy. Visual acuity in his left eye was 20/30, and IOP was 24 mmHg on 4 topical IOP-lowering medications. An inferonasal Baerveldt 350 (Advanced Medical Optics) aqueous shunt was placed with concurrent revision of the Ahmed capsule. A large block of capsule tissue was excised from the surface of the plate, and 20 mg of subtenon triamcinolone acetonide (Kenalog, Bristol-Myers Squibb) was injected overlying the plate. His IOP ranged between 6 and 15 mmHg in the immediate postoperative period. There were no hypotony-associated complications at any time point. At postoperative month 18, his IOP was 10 mmHg on zero medications. In patients with a failed valved aqueous shunt undergoing an additional nonvalved aqueous shunt, a concurrent capsule revision of the valved aqueous shunt can provide early IOP lowering before the nonvalved tube opens.