Ventricular Shunt Research Articles

96 The Proportion of Patients with Cerebrospinal Fluid Biomarkers Consistent with Alzheimer’s Disease in a Cohort with Suspected Normal Pressure Hydrocephalus

Objective:Normal pressure hydrocephalus (NPH) is characterized by pathologically enlarged ventricles without elevated cerebrospinal fluid (CSF) pressure along with a triad of clinical symptoms including gait disturbances, urinary incontinence, and cognitive impairment. NPH is evaluated with lumbar drain trials (LDTs) where CSF is removed over several days to determine if patients would benefit from ventricular shunting. Candidate selection and success for these surgeries remains challenging because other diseases such as Alzheimer’s disease (AD) share common features with NPH in cognitive impairment and enlarged ventricles. Prior research has found that 20%-40% of presumed NPH cases have AD pathology as determined by brain biopsy or autopsy. CSF biomarkers of AD can be altered in NPH and are not always conclusive, complicating the interpretation of results when formulating diagnoses and prognoses. Studies to refine the analyses of AD CSF biomarkers in NPH are needed. We aimed to examine the frequency of CSF biomarker results among patients presenting for NPH evaluations with LDTs.Participants and Methods:62 patients presented for LDTs upon physician recommendations. CSF specimens were sent to Mayo Clinic Laboratories for Alzheimer Disease Evaluation (ADEVL) that utilizes Elecsys (Lenexa, KS) CSF electrochemiluminescence immunoassays (Roche Diagnostics, Basel, Switzerland) to measure levels of amyloid-beta 42 (Aβ42), total tau (t-tau), and phosphorylatedtau (p-tau), and p-tau:Aβ42 ratio. Results were classified based on interpretation through the Amyloid/Tau/Neurodegeneration (ATN) framework1: 1) AD - biomarker profile consistent with AD pathologic change, 2) non-AD profile - biomarker levels normal or inconsistent with AD pathologic change, or 3) indeterminate - biomarkers were incongruous with only one or two abnormal levels of Aβ42, t-tau, p-tau, or ptau: Aβ42. Indeterminate cases may represent altered protein levels due to CSF dynamics or AD-related pathologic change. In reviewing recent research on CSF dynamics and AD biomarkers in NPH2 a p-tau threshold of 15 pg/mL was derived and implemented such that cases with Aß42 <=1026 pg/mL and p-tau <15 pg/mL were designated as suspected non-AD, and those with Aß42 <=1026 pg/mL and p-tau >15 pg/mL were designated suspected AD.Results:Of the 62 LDT cases, 12 (19.35%) were classified as AD, 31 (50%) were indeterminate and 22 (35.48%) were non-AD. Of the 31 indeterminate cases, 21 (33.87% of the overall sample) were suspected non-AD and 7 (11.29% of the full sample) were categorized as suspected AD.Conclusions:Our findings show that 20%-30% of patients presenting for LDT showed evidence for AD-type pathologic change, consistent with prior reports of AD pathology in cases of possible NPH. Half of all LDT cases had indeterminate AD CSF biomarker results, the interpretations of which were confounded by the potential alterations of CSF biomarkers levels due to NPH independent of AD. Our findings emphasize the need to establish better approaches to interpreting CSF AD biomarkers in evaluating NPH. Future research should examine the discriminative utility of CSF AD biomarkers and the selected p-tau threshold in indeterminate cases for predicting response to LDT and shunting.

Effects of biventricular shunt on pump characteristics in a maglev total artificial heart.

Severe left ventricular failure can progress to right ventricular failure, necessitating alternatives to heart transplantation, such as total artificial heart (TAH) treatment. Conventional TAHs encounter challenges associated with miniaturization and hemocompatibility owing to their reliance on mechanical valves and bearings. A magnetically levitated TAH (IB-Heart) was developed, utilizing a magnetic bearing. The IB-Heart features a distinctive biventricular shunt channel situated between the flow paths of the left and right centrifugal blood pumps, simplifying and miniaturizing its control system. However, the impact of these shunt channels remains underexplored. This study aimed to investigate the effects of shunt flow on pump characteristics and assess the IB-Heart's potential to regulate flow balance between systemic and pulmonary circulation. At a rotational speed of 2000 rpm and flow rate range of 0-10 L/min, shunt flow exhibited a minor impact, with a 1.4 mmHg (1.3%) effect on pump characteristics. Shunt flow variation of about 0.13 L/min correlated with a 10 mmHg pressure difference between the pumps' afterload and preload conditions. This variance was linked to changes in the inlet flow rates of the left and right pumps, signifying the ventricular shunt structure's capacity to mirror the function of an atrial shunt in alleviating pulmonary congestion. The IB-Heart's ventricular shunt structure enables passive regulation of left-right flow balance. The findings establish a fundamental technical groundwork for the development of IB-Hearts and TAHs with similar shunt structures. The innovative coupling of centrifugal pumps and the resultant effects on flow dynamics contribute to the advancement of TAH technology.

Successful Implantation of a Ventricular Shunt With Termination in the Iliac Bone in the Adult Patient With Obstructive Hydrocephalus

BACKGROUND AND IMPORTANCE: With the exception of the 3 classic shunt placement options (ventriculoperitoneal, ventriculopleural, and ventriculoatrial), surgically feasible alternative sites for distal catheter placement remain limited and often require the assistance of an access surgeon. Tubbs et al suggested the possibility of intraosseous cerebrospinal fluid diversion in the ilium, noting that ilium infusion in cadaveric specimens was possible without the development of body edema or fluid overflow. Since this publication, limited case reports have been published on the success of ventriculo-ilium (VI) shunt placement. Here, we describe the technique used for successful VI shunt placement in 2 adult patients. CLINICAL PRESENTATION: Here, we describe 2 patients with differing etiologies of hydrocephalus (obstructive and nonobstructive) and complex medical and surgical problems precluding traditional distal shunt termini. Both patients underwent successful placement of a VI shunt with distal catheter placement into the right iliac crest using a small right-angle connector and small cranial fixation plate to prevent backout of the catheter. DISCUSSION AND CONCLUSION: We report the first demonstration of successful placement of a VI shunt in 2 adult patients with evidence of shunt functionality and improved neurological outcome. We propose that the placement of a VI shunt is an easy and viable option when more traditional shunt methods are not available for use.

Extracranial metastasis of brain glioblastoma outside CNS: Pathogenesis revisited.

The most prevalent malignant tumor of the CNS in adults is glioblastoma. Despite undergoing surgery and chemoradiotherapy, the prognosis remains unfavorable, with a median survival period ranging between 15 and 20 months. The incidence of glioblastoma metastasis outside CNS is uncommon with only 0.4%-2% reported rate, compared to other tumors that exhibit a 10% incidence rate of metastasis to the brain. On average, it takes about 11 months from the time of initial diagnosis for the tumor to spread beyond CNS. Consequently, the prognosis for metastatic glioblastoma is grim, with a 6-month survival rate following diagnosis. The rarity of extracranial metastasis is attributed to the blood-brain barrier and lack of a lymphatic drainage system, although rare cases of hematogenous spread and direct implantation have been reported. The possible mechanisms remain unclear and require further investigation. Risk factors have been widely described, including previous craniotomy or biopsies, ventricular shunting, young age, radiation therapy, prolonged survival time, and tumor recurrence. Due to the lack of understanding about extracranial metastasis of glioblastoma pathogenesis, no effective treatment exists to date. Aggressive chemotherapies are not recommended for metastatic glioblastoma as their side effects may worsen the patient prognosis. The optimal treatment for extracranial metastasis of glioblastoma requires further investigation with a wide inclusion of patients. This review discusses the possible causes, factors, and underlying mechanisms of glioblastoma metastasis to different organs.

Intraventricular endoscopy and intraventricular antibiotics in the treatment of multiloculated hydrocephalus with ventriculitis in a neonate and an infant: Two case reports

Background: We present two pediatric cases, a neonate and an infant, who presented with treatment-refractory ventriculitis and multiloculated hydrocephalus treated with simultaneous intraventricular endoscopy and antibiotics. This is the first report of this combined therapy in children. Case Description: Using intraventricular endoscopic surgery and antibiotics, hydrocephalus was treated with a minimum number of ventricular shunt systems. In addition, treatment-refractory ventriculitis was treated in both patients using intraventricular antibiotics. Conclusion: Endoscopic surgery and intraventricular antibiotic administration are useful strategies for treating multiloculated hydrocephalus and ventriculitis in children.

Long-term seizure and developmental outcomes of epilepsy surgery in children under 3 years old: A single-center study of 113 patients.

To investigate the clinical characteristics, surgical strategy, developmental and seizure outcomes, and predictors of surgical outcome in children with drug-resistant epilepsy (DRE) under 3 years old. One hundred thirteen consecutive children younger than 3 years of age with DRE underwent curative surgical treatment after multidisciplinary preoperative evaluation using the strategy developed in the pediatric epilepsy center of Peking University First Hospital (PKFHPEC) between 2014 and 2018. These patients were selected for retrospective study. The relevant clinical data were collected and analyzed. The surgical prognoses were classified using the Engel classification, and the developmental assessment results were collected. Statistical analysis of the clinical data was performed to analyze the predictors of seizure outcomes and their correlation with developmental outcomes. All the patients were followed up for more than 3 years, and 98 (86.7%) patients had no seizure recurrence. One year after surgery, the seizure-free rate was 86.7%, which was as high as that at the last follow-up. Cortical dysplasia was the most frequent etiology of DRE in this cohort, accounting for 77.0%. According to the Engel classification, acute postoperative seizure (APOS; p < 0.001) was a predictor of seizure recurrence. No deaths occurred. No unpredicted long-term severe complications occurred except for one ventricular peritoneal shunt. The patients' neurodevelopmental statuses were improved after successful surgery, while the scores of the pre- and postoperative developmental assessments were closely correlated. For children who are younger than 3 years old and have DRE and structural abnormalities, early curative treatment can lead to long-term good seizure outcomes and a low complication rate. The development of appropriate strategies for both presurgical evaluation and resection is crucial for the success of surgery.

Healthcare-Associated Ventriculitis in Children during COVID-19 Pandemic: Clinical Characteristics and Outcome of a First Infection.

During the COVID-19 pandemic, patients in need of neurosurgical care suffered. Elective procedures were postponed, and emergency care visits decreased. Healthcare-associated ventriculitis (HAV) is a serious problem in children, with poor outcomes and frequent relapses. Our objective was to describe the clinical characteristics and the factors associated with a first HAV in children during two years of the pandemic. A retrospective cross-sectional study was performed from January 2021 to December 2022. The inclusion criteria were patients who developed a first HAV after a primary cerebrospinal fluid diversion procedure. The controls included patients without a first infection. Intraoperative and clinical data were extracted from medical records. A total of 199 CSF diversion surgeries were registered. A first infection occurred in 17 patients (8.5%), including 10 with external ventricular drain (EVD) and 6 with ventricular shunts. Gram-positive cocci were identified in 70.6%. Six patients recovered uneventfully, eight had relapse or superinfections, and three eventually died. Twenty patients were included as controls. Factors associated with a first infection were a younger age (median 9 vs. 102 months, p < 0.01), malnutrition (23.5% vs. 0%, p = 0.03), and an EVD placement (58.8% vs. 10%, p = 0.03). None of the intraoperative factors showed statistically significant differences. The rate of HAV was high. Most cases presented in children <1 year and with an EVD.

Alobar holoprosencephaly: A case report

Introduction: Holoprosencephaly (HPE) is a rare brain malformation, which results from a cleavage defect of the prosencephalon. Three forms have been described as: alobar, semi-lobar, and lobar forms. Case Report: We report a rare case of holoprosencephaly, diagnosed at the maternity of the Ibn Rochd Hospital Center in Casablanca. Conclusion: Holoprosencephaly is secondary to a cleavage anomaly of the prosencephalon, the diagnosis is based on echotomography, computed tomography (CT) scan and nuclear magnetic resonance imaging (MRI). It is important to perform a karyotype to look for a chromosomal anomaly. Holoprosencephaly, although rare, should be recognized and diagnosed; minor forms are likely to benefit from medical replacement therapy or ventricular shunting.

Venous sinus stenting for idiopathic intracranial hypertension patients with functioning ventriculoperitoneal shunts: A case series

Idiopathic intracranial hypertension (IIH) is a disease defined by increased intracranial pressure and associated with a variety of symptoms ranging from headaches to tinnitus. Ventricular peritoneal shunting has been the mainstay treatment for patients with IIH. Although VPS’s have shown efficacy in treating IIH, some patients complain of refractory symptoms even with functioning VPS’s. Venus stenting has emerged as a new technique for treating these refractory symptoms. Despite the scarce literature pertaining its efficacy and safety profile, several small studies have shown promising results. In this case series, four patients with IIH complained of refractory symptoms despite functioning VPS’s and were treated with venous stenting.

Polyvinylpyrrolidone-coated catheters decrease choroid plexus adhesion and improve flow/pressure performance in an in vitro model of hydrocephalus.

Proximal catheter obstruction is the leading cause of ventricular shunt failure in pediatric patients. Our aim is to evaluate various types of shunt catheters to assess in vitro cellular adhesion and obstruction. Four catheter types were tested: (1) antibiotic and impregnated, (2) barium-stripe polyvinylpyrrolidone coated (PVP), (3) barium-stripe, and (4) barium-impregnated. Catheters were seeded with choroid plexus epithelial cells to test cellular adhesion and inoculated with the same cells to test flow/pressure performance under choroid plexus growth conditions. Ventricular catheters were placed into a three-dimensional printed phantom ventricular replicating system through which artificial cerebrospinal fluid (CSF) was pumped. Differential pressure sensors were used to measure catheter performance. PVP catheters had the lowest median cell attachment (10 cells) compared to antibiotic-impregnated (230 cells), barium stripe (513 cells), and barium-impregnated (146 cells) catheters after culture (p < 0.01). In addition, PVP catheters (- 0.247cm H2O) and antibiotic-impregnated (- 1.15cm H2O) catheters had significantly lower pressure in the phantom ventricular system compared to the barium stripe (0.167cm H2O) and barium-impregnated (0.618cm H2O; p < 0.01) catheters. PVP catheters showed less cellular adhesion and, together with antibiotic-impregnated catheters, required less differential pressure to maintain a consistent flow. Our findings suggest clinical relevance for using PVP ventricular catheters in patients with recurrent catheter obstruction by choroid plexus.

Trigone point as an alternative location for ventricular shunt insertion

Link of Video Abstract: https://youtu.be/BtHvICeUONYBackground: Hydrocephalus is a condition in which cerebrospinal fluid (CSS) buildup in the ventricles is caused by excessive CSS production or disturbance of CSS circulation or absorption. Insertion of a shunt catheter into the lateral ventricle can be performed at the Kocher, Keen, Dandy, Frazier, Kaufmann, or Tubbs points. This study aims to evaluate the trigone point as an alternative location for ventricular shunt insertion Methods: This is a retrospective study. We performed a three-dimensional head CT scan reconstruction of hydrocephalus patients; then, we calculated the vertical and horizontal distances perpendicular to each other from the upper edge of the auricle that intersects the trigone point on the right and left sides of the patient. Data were analyzed using SPSS version 26.0 for Windows. Results: A total of 30 hydrocephalus patients at Kariadi Hospital Semarang from 2021 – 2022 were enrolled in this study. We got the averages of the vertical line is 25.05 mm and the horizontal is 33.00 mm for the right trigone point. In addition, the average vertical line is 25.78 mm and the horizontal line is 34.72 mm for the left trigone point. There was no significant difference between the vertical distance of the right and left trigone points (p=0.578) and the horizontal distance of the right and left trigone points (p=0.185). We found no significant difference between the location of the right and left trigone points. Conclusion: Trigone point can be an alternative location for ventricular shunt installation.

Developing Predictive Models to Anticipate Shunt Complications in 33,248 Pediatric Patients with Shunted Hydrocephalus Utilizing Machine Learning

Introduction: Hydrocephalus is a common pediatric neurosurgical pathology, typically treated with a ventricular shunt, yet approximately 30% of patients experience shunt failure within the first year after surgery. As a result, the objective of the present study was to validate a predictive model of pediatric shunt complications with data retrieved from the Healthcare Cost and Utilization Project (HCUP) National Readmissions Database (NRD). Methods: The HCUP NRD was queried from 2016 to 2017 for pediatric patients undergoing shunt placement using ICD-10 codes. Comorbidities present upon initial admission resulting in shunt placement, Johns Hopkins Adjusted Clinical Groups (JHACG) frailty-defining criteria, and Major Diagnostic Category (MDC) at admission classifications were obtained. The database was divided into training (n = 19,948), validation (n = 6,650), and testing (n = 6,650) datasets. Multivariable analysis was performed to identify significant predictors of shunt complications which were used to develop logistic regression models. Post hoc receiver operating characteristic (ROC) curves were created. Results: A total of 33,248 pediatric patients aged 6.9 ± 5.7 years were included. Number of diagnoses during primary admission (OR: 1.05, 95% CI: 1.04–1.07) and initial neurological admission diagnoses (OR: 3.83, 95% CI: 3.33–4.42) positively correlated with shunt complications. Female sex (OR: 0.87, 95% CI: 0.76–0.99) and elective admissions (OR: 0.62, 95% CI: 0.53–0.72) negatively correlated with shunt complications. ROC curve for the regression model utilizing all significant predictors of readmission demonstrated area under the curve of 0.733, suggesting these factors are possible predictors of shunt complications in pediatric hydrocephalus. Conclusion: Efficacious and safe treatment of pediatric hydrocephalus is of paramount importance. Our machine learning algorithm delineated possible variables predictive of shunt complications with good predictive value.

Evaluation of Overshunting between Low and Medium Pressure Ventriculoperitoneal Shunts in Dogs with Severe Hydrocephalus Using Frameless Stereotactic Ventricular Shunt Placement

Hydrocephalus is a neurological disorder characterized by an abnormal accumulation of cerebrospinal fluid (CSF) within the ventricular system of the brain, leading to cerebral ventricular dilation, brain parenchyma compression, and neuronal cell loss. Surgery is an effective method of draining excessive amounts of CSF. Ventriculoperitoneal shunt (VPS) allows excess CSF to divert into the abdomen; this device is the most commonly used in the treatment of hydrocephalus both in veterinary and human patients. This study aims to describe the application of two types of VPS, low-pressure valve and medium-pressure valve, using a frameless stereotactic neuronavigational system in eight severe hydrocephalus in dogs and, in particular, analyze the prevalence of postoperative overshunting. Non-communicating hydrocephalus was found in seven dogs, whereas the rest of them had communicating hydrocephalus caused by traumatic brain injury with a skull fracture. The criteria for pressure valve selection depended on the intraoperative intraventricular pressure (IVP) that was determined by the adaptive manometer, according to the human protocol. Low-pressure valve placement was performed in five dogs, and the others received medium-pressure valve placement. The follow-up period was 2 weeks, 4–12 weeks, and 12 weeks to 12 months. Pre- and postoperative information including neurological signs, CT-Scan or MRI, medical treatment, complications, and ventricular volume were compared in all dogs. Seven dogs showed neurological improvement within 2 weeks after surgery. Overshunting was seen in four dogs who received low-pressure valve placement. Three of them had shunt infections within 4 to 6 weeks after surgery. One dog underwent shunt revision from a low-pressure valve to a medium-pressure valve caused by severe overshunting and progressive neurological signs. In addition, cognitive and learning improvements were evaluated based on the owners’ feedback, and neurological signs were examined during the follow-up period in two dogs that received low-pressure valve placement. We conclude that a medium-pressure valve is recommended for overshunting prevention. However, low-pressure valve placement seems to improve cognitive function and learning ability, which is related to an increase in the brain parenchyma observed during long-term monitoring. Moreover, we also report our experience and surgical procedure for frameless stereotactic ventricular shunt placement (FSVSP) in VPS surgery in dogs affected by hydrocephalus.

Treatment optimization by monitoring vancomycin concentration in the serum and cerebrospinal fluid in a child with cystoperitoneal shunt-related infection caused by methicillin-resistant Staphylococcus aureus: a case report and literature review

BackgroundCerebral ventricular shunt infections caused by methicillin-resistant Staphylococcus aureus (MRSA), especially strains with elevated minimum inhibitory concentration (MIC) values, have a poor prognosis. Monitoring serum vancomycin (VCM) levels with therapeutic drug monitoring and maintaining high VCM concentrations in the cerebrospinal fluid (CSF) are critical to treatment success. However, there have been a few reports about the CSF penetration and the pharmacokinetics of VCM in children.Case presentationHere, we report the case of a pediatric patient with cysto-peritoneal shunt-related meningitis caused by MRSA with an MIC of 2 μg/mL. The adequate VCM concentration was maintained by monitoring the VCM concentration in the CSF via the external ventricular drain, and frequent blood taking was avoided. VCM showed a good CSF penetration in our patient, and she was discharged without complications.DiscussionTherapeutic drug monitoring of VCM concentration in the CSF may result in successful treatment even if MRSA shows a higher MIC. Therapeutic drug monitoring of VCM concentration in the CSF may also reduce the side effects.

Assessment of the Factors Influencing the Survival of the Ventricular Shunt in Infantile Hydrocephalus

The purpose of the present research is to perform a retrospective analysis of 242 ventricular shunts implanted in childhood due to infantile hydrocephalus, submitted to a long-term follow-up (27.84 ± 6.13 years) and investigate the factors influencing the survival of the shunt, applying modern mathematical approaches. The contingent consists of 242 patients who were shunted due to infantile hydrocephalus in childhood, 55% of whom were under 6 months old when the shunt was implanted. For the entire follow-up period, patients underwent 375 revisions (average 1.55 revisions per shunt), 38% are without shunt failure, with only one revision – 26%, with two – 14%. The remaining 22% have 3 or more revisions (4.58 shunt revisions) and they make 65% of all revisions. 68.5% of all revisions are due to mechanical complications; to functional (inadequate drainage) – 7.5%. 9.1% of the patients had inflammatory complications. We found that the age at shunting (under 3 months – the worst trend) and the interval to the first revision (over 6 months – a smaller number of revisions) are of the biggest importance for the number of the following revisions. If the patient survives one year after shunting without failure, the risk of such is under 50% during the whole shunt existence.

Effects of Intraventricular Vancomycin Administration on the Prevention of Ventricular Shunt Infection.

Shunt infection causes death in many patients diagnosed with hydrocephalus and increases the duration of hospitalization and treatment costs. A high percentage of children are forced to undergo re-surgery due to shunt dysfunction or infection. The present study aimed to investigate the role of intraventricular (IVT) vancomycin in the prevention of ventricular shunt infection in children with hydrocephalus who were referred to Akbar Hospital in Mashhad, Iran, between the years 2017 and 2021. The present descriptive cross-sectional study was conducted on 192 children with hydrocephalus who underwent shunt surgery at Akbar Hospital in Mashhad, Iran, between the years 2017 and 2021. Patients were divided into two groups of intervention (n=69) and control (n=123). The patients in the intervention group received 30 mg of IVT vancomycin during shunt surgery. The rate of shunt obstruction and infection were then compared between the two study groups. The two study groups were matched in terms of demographic and clinical information except for gender (P=0.02). Moreover, no significant difference was reported between the two groups in terms of intelligence development (χ2=0.51; P=0.47), verbal development (χ2=0.1; P=0.75), and movement development (χ2=1.05; P=0.3). The frequency of shunt infection and shunt obstruction was estimated at 8.8% and 18.2%, respectively. The shunt infection rate was lower in the vancomycin IVT group than in the control group (χ2=4.07; P=0.04), while no difference was observed between the two groups in terms of shunt obstruction (χ2=3.66; P=0.056). The comparison of the two study groups indicated no significant difference between them in terms of mortality (χ2=0.004; P=0.95). It seems that IVT vancomycin should be recommended for inclusion in hydrocephalus surgery protocol to reduce postoperative shunt infection. It is recommended that shunt protocols be adopted in future multicenter prospective randomized controlled trials on the reduction of ventriculoperitoneal shunt infections to further evaluate the efficacy of IVT antibiotics.

Risk Factors Associated with Ventricular Peritoneal Shunt Infections and their Clinical Outcome in Children: A Case-Control Study of the Past 5 Years

Objectives: To determine the risk factors associated with the development of ventricular peritoneal shunt infection and time to infection, as the number of days from most recent shunt intervention to the diagnosis of the infection and clinical outcomes and the antimicrobial susceptibility pattern in children admitted with the ventricular peritoneal shunt. Study Design: Retrospective case-control study Place and duration of study: Aga Khan University Hospital Karachi, Pakistan between January 2015 to December 2020 Results: A total of 460 patients of ages 0-20 years with ventricular peritoneal shunt were selected. Out of 460, 52 individuals met the criteria of the case and were recruited for the study. The findings from multivariable logistic regression, after accounting for potential confounding factors, indicated that the odds of shunt infection were extremely high for patients undergoing surgery in the current admission (adjusted OR 167.3, 95% CI: 8.96 – 3130.86). Likewise, the odds of infection were approximately 12 times more for patients with fever (95% CI: 1.28 – 113.26) and tory of shunt removal (95% CI: 2.06– 67.20). Conclusion: Through a thorough analysis of medical records, the study revealed that several risk factors, such as younger age, previous shunt infections, surgery in current admission, shunt removal/replacement, previous revisions, current complication and fever were associated with a higher risk of shunt infection. Keywords: Risk factors, ventricular peritoneal, shunt infections, clinical outcome,

What has changed in pediatric neurosurgical care in spina bifida? A 30-year UAB/Children's of Alabama observational overview.

Spina bifida (SB) remains the most serious and most common congenital anomaly of the human nervous system that is compatible with life. The open myelomeningocele on the back is perhaps the most obvious initial problem, but the collective impact of dysraphism upon the entirety of the nervous system and innervated organs is an equal or greater longitudinal threat. As such, patients with myelomeningocele (MMC) are best managed in a multi-disciplinary clinic that brings together experienced medical, nursing, and therapy teams that provide high standards of care while studying outcomes and sharing insights and experiences.Since its inception 30years ago, the spina bifida program at UAB/Children's of Alabama has remained dedicated to providing exemplary multi-disciplinary care for affected children and their families. During this time, there has been great change in the care landscape, but many of the neurosurgical principles and primary issues have remained the same. In utero myelomeningocele closure (IUMC) has revolutionized initial care and has favorable impact on several important co-morbidities of SB including hydrocephalus, the Chiari II malformation, and the functional level of the neurologic deficit. Hydrocephalus however is not solved by IUMC, and hydrocephalus management remains at the center of neurosurgical care in SB. Ventricular shunts were long the cornerstone of treatment for hydrocephalus, but we came to assess and incorporate endoscopic third ventriculostomy with choroid plexus coagulation (ETV-CPC).Educated and nurtured by an experienced senior mentor, we dedicated ourselves to fundamental concepts but persistently evaluated our care outcomes and evolved our protocols and paradigms for improvement. Active conversations amidst networks of treasured colleagues were central to this development and growth. While hydrocephalus support and treatment of tethered spinal cord remained our principal neurosurgical charges, we evolved to embrace a holistic perspective and approach that is reflected and captured in the Lifetime Care Plan. Our team engaged actively in important workshops and guideline initiatives and was central to the development and support of the National Spina Bifida Patient Registry.We started and developed an adult SB clinic to support our patients who aged out of pediatric care. Lessons there taught us the importance of a model of transition that emphasized personal responsibility and awareness of health and the crucial role of dedicated support over time. Support for sleep, bowel health, and personal intimate cares are important contributors to overall health and care. This paper details our growth, learning, and evolution of care provision over the past 30years.

Cerebrospinal fluid transcripts may predict shunt surgery responses in normal pressure hydrocephalus.

Molecular biomarkers for neurodegenerative diseases are critical for advancing diagnosis and therapy. Normal pressure hydrocephalus (NPH) is a neurological disorder characterized by progressive neurodegeneration, gait impairment, urinary incontinence and cognitive decline. In contrast to most other neurodegenerative disorders, NPH symptoms can be improved by the placement of a ventricular shunt that drains excess CSF. A major challenge in NPH management is the identification of patients who benefit from shunt surgery. Here, we perform genome-wide RNA sequencing of extracellular vesicles in CSF of 42 NPH patients, and we identify genes and pathways whose expression levels correlate with gait, urinary or cognitive symptom improvement after shunt surgery. We describe a machine learning algorithm trained on these gene expression profiles to predict shunt surgery response with high accuracy. The transcriptomic signatures we identified may have important implications for improving NPH diagnosis and treatment and for understanding disease aetiology.

P256 AN UNUSUAL CASE OF PACEMAKER MALFUNCTION WITH NON COMMON ELCTROCARDIOGRAPHIC PRESENTATION AND UNEXPECTED ECHOCARDIOGRAPHIC FINDING

Abstract This clinical case shows the diagnostic challenge and the management of a 79 y–o male with recent hospitalization for infero–lateral STEMI undergoing primary PCI of Right Coronary Artery with 2 DES and following DDDR MRI PM (pacemaker) implantation due to the development of persistent 2:1 Atrio–Ventricular Block. One month later, admission at Emergency Department for syncope. Normal parameters were found at laboratory analyses. The electro–stimulator activity evaluation showed a PM malfunction with ventricular capture failure. Thus, the increase of PM output up to electric ventricular capture (8 Volt/120 msec) was performed, but the following Electrocardiogram showed a PM–induced rhythm with RBBB–morphology. Then, the bedside Echocardiogram showed an apparent presence of a linear hyper–echogenic image into left ventricle with no inter–ventricular septal defect neither inter–ventricular shunt, inter–atrial septal hypermobility with no evident inter–atrial shunt at rest; while a chest Radiography identified the atrial and ventricular leads with no accurate individuation of their position. The patient was admitted in Intensive Cardiac Care Unit with confirmation of intermittent failure to ventricular capture and RBBB–morphology during PM–induced rhythm at telemetry monitoring. Due to Electrocardiographic and Echocardiographic findings, a strong suspect of abnormal position of the ventricular lead into left ventricle through a possible PFO has been raised. A chest Computed Tomography was performed confirming the anomalous position of the ventricular lead: it reached the left atrium through an inter–atrial defect/patent foramen ovale (PFO), then crossing the mitral valve up to left ventricle. The PM–lead repositioning was scheduled two days after. After positioning of temporary stimulator lead in right ventricle, the ventricular lead has been withdrawn from left–side chambers and positioned into septal–apical right ventricle; furthermore, the position of right atrial lead has been optimized (because of frequent spontaneous passage to the left atrium through the PFO, during manual maneuvers) thus obtaining good stability of the device. During the following days, the telemetry monitoring showed a PM–induced rhythm, without capture nor sensing failure. The chest Radiography confirmed the correct position of leads and the pre–discharge Echocardiography showed a LVEF 57% with no valvular pathology and with atrial and ventricular leads into right–side chambers.