Ventriculopleural Shunting Research Articles

PLEURAL EFFUSION FOLLOWING VENTRICULO-PLEURAL SHUNT PLACEMENT

SESSION TITLE: Fellows Disorders of the Pleura Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Ventriculo-pleural shunts (VPLS), is an alternative management of hydrocephalus, where excess cerebrospinal fluid is drained to the pleural cavity. Imbalances between production and absorption of CSF will lead to the accumulation and development of pleural effusion. We describe a case of a pleural effusion related to a VPLS. CASE PRESENTATION: A 42 year old female with CSF leak managed by VPLS, previous STEMI with stent placement, and asthma, presented with retrosternal, right chest discomfort and dyspnea. Dyspnea began four months prior, and a right-sided thoracentesis had been performed two weeks earlier. Her pulmonologist previously noted small chronic pleural effusions insufficient for thoracentesis. From her previous thoracentesis, cultures were negative and cytology showed chronic inflammation. Cell profile, LDH, and protein were not tested. Subsequent thoracentesis yielded 165 WBC, <2000 RBC, 25 neutrophils, 39 lymphocytes. Cultures were negative and cytology showed acute and chronic inflammation. The fluid was transudative with an LDH of 109 U/L and a protein of 1.6 g/dL. She underwent a revision of her shunt to the peritoneal cavity. DISCUSSION: Extra-cranial shunts are used to divert CSF into an extracerebral compartment to relieve symptoms associated with hydrocephalus. The most widely used locations for shunt placement are the peritoneum and atrium. VPLS is an alternative when a peritoneal or atrial shunt is not suitable. This could be due to adhesions, infection, thrombosis or obliteration.(1) VPLS has a 7% complication rate and includes obstruction (functional or structural), pleural effusion, and pneumothorax.(2) The most common are pleural effusions; typically occurring within the first year of placement. Pleural fluid reabsorption by parietal lymphatics is estimated to be around 0.15 ml/k/h. This can increase as a response to increased pleural fluid filtration. Pleural effusions occur when filtration exceeds the maximum pleural lymph flow, typically 30 ml/kg/h.(3) The pleural fluid analysis shows a transudative effusion resembling CSF, but exudative effusions may also occur in chronic inflammation. Mild cases may resolve without intervention. Symptomatic cases with moderate or recurrent effusions may require thoracentesis, chest tube insertion, and occasionally shunt revisions (4). CONCLUSIONS: The pleural cavity is an alternative to peritoneal and atrial shunts for drainage of CSF in the treatment of refractory hydrocephalus. Pleural effusion is the most common complication typically occurring within the first year. While mild cases are self-limited, moderate or recurrent effusions will require intervention such as thoracentesis, chest tube insertion or possibly shunt revision. Reference #1: Ransohoff J. Ventriculopleural anastomosis in treatment of midline obstructed masses. J Neurosurg. 1954;11:295–301 Reference #2: Donald P. Megison & Edward C. Benzel (1988) Ventriculo-pleural Shunting for Adult Hydrocephalus, British Journal of Neurosurgery, 2:4, 503-505, DOI: 10.3109/02688698809029605 Reference #3: Miserocchi, G. “Physiology and Pathophysiology of Pleural Fluid Turnover.” European Respiratory Journal, vol. 10, no. 1, 1997, pp. 219–225., DOI:10.1183/09031936.97.10010219. DISCLOSURES: No relevant relationships by Sarah Cheyney, source=Web Response No relevant relationships by Gurjot Garcha, source=Web Response No relevant relationships by Ahmed Khan, source=Web Response No relevant relationships by Albert Magh, source=Web Response No relevant relationships by Crystal Verdick, source=Web Response

Reevaluation of Ventriculopleural Shunting: Long-Term Efficacy and Complication Rates in the Modern Era

Ventriculopleural shunting (VPLS) is recognized as an alternative method when the standard ventriculoperitoneal shunting (VPS) is not applicable. Nevertheless, there is limited clinical evidence of its effectiveness including long-term patency. Data on 35 consecutive patients who underwent VPLS at a single institution were retrospectively analyzed. The rates of shunt survival and incidence of symptomatic pleural effusion were calculated, and risk factors were evaluated. Mean follow-up after VPLS was 64.1 months. The cumulative overall shunt survival rates were 70%, 44%, and 28% at 1, 3, and 5 years, respectively. Among patients with shunt failure, 3 (8.6%) with overdrainage underwent simple valve replacement (from fixed to programmable valve) and retained a VPLS. If these patients are excluded, shunt survival rates were 76%, 51%, and 34% at 1, 3, and 5years, respectively, and the median shunt survival time was 3.0 years. No factor was significantly associated with shunt survival. Cumulative rates of symptomatic pleural effusion were 18%, 23%, and 46% at 1, 2, and 3 years, respectively. Median time from VPLS placement to symptomatic pleural effusion was 1.1 years. It seems that VPLS survival has improved with more modern shunt technology. VPLS is a reasonable second-line option when VPS is not feasible. The possibility of pleural effusion is not negligible, but asymptomatic/mild effusions may be managed conservatively.

SYMPTOMATIC PLEURAL EFFUSION: TROUBLESHOOTING VENTRICULOPLEURAL SHUNT

SESSION TITLE: Disorders of the Pleura 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Ventriculopleural shunt (VPLS) is an alternative to the commonly used ventriculoperitoneal shunt (VPS). The pleural space has an excellent absorptive capacity. Pleural effusion is one of the most common complications following VPLS, likely due to inflammation causing an imbalance between cerebrospinal fluid (CSF) production and pleural space resorption. CASE PRESENTATION: A 55-year-old male with a PMH of VPS after surgical removal of a giant bi-frontal meningioma in 2015, complicated with enterococcus and Propionibacterium CSF infection requiring multiple shunt revision, modification of shunt valve and external drainage. He underwent placement of right VPLS in April of 2017. 10 months after placement of VPLS, he presented to ED with one week of flu-like symptoms and right-sided pleuritic chest pain. Physical examination revealed absent breath sounds over the right lung base and hypoxia needing 6 L of Oxygen via NC. Pleural ultrasound revealed moderate right-sided pleural effusion with fibrinous septations. Thoracentesis revealed un-complicated LDH discordant exudative pleural effusion. CSF culture was again positive for Propionibacterium acne, blood and pleural fluid culture were negative. He underwent chest tube placement with TPA/Dornase instillation. Neurosurgery proceeded with VPLS removal and placement of an external ventricular drain for a week followed by placement of a new antibiotic-impregnated VPS. DISCUSSION: The most common indication for using pleural cavity for drainage in a patient with a pre-existent ventriculoperitoneal shunt is due to the infection, adhesion or thrombosis of the shunt causing obliteration. Most of the complications including pleural effusion following VPLS occur within the first year of placement. Pleural fluid analysis showing clear transudative effusion resembling CSF, but exudative effusion can occur secondary to chronic inflammation. Most of the cases of mild effusion resolve spontaneously without any specific treatment but symptomatic cases with moderate effusion may require a thoracentesis, chest tube insertion and in recurrent cases even a shunt replacement. P. acnes is a part of the skin flora and most isolates in culture are considered as contaminant. On the contrary, P. acnes is frequently isolated in patients with shunt infections and evidence suggests that a P. acnes positive CSF culture should not be neglected and treated with appropriate antibiotics. The use of anti-siphon pressure control devices and acetazolamide have been proven to somewhat reduce the likelihood of developing the pleural effusion. CONCLUSIONS: The pleural cavity is the most common alternative to peritoneal cavity for drainage of CSF in a patient presenting with refractory hydrocephalus. He was also found positive for P. acnes on CSF culture. We suggest drainage of pleural cavity and revision/replacement of shunt as well as antibiotic therapy for P. acnes infection. Reference #1: Sahn SA. Pleural effusions of extravascular origin. Clin Chest Med. 2006;27:285–308. Reference #2: Nisbet M, Briggs S, Ellis-Pegler R, Thomas M, Holland D. 2007. Propionibacterium acnes: an under-appreciated cause of post-neurosurgical infection. J. Antimicrob. Chemother. 60:1097–1103. 10.1093/jac/dkm351 Reference #3: Martínez-Lage JF, Torres J, Campillo H, Sanchez-del-Rincón I, Bueno F, Zambudio G, et al. Ventriculopleural shunting with new technology valves. Childs Nerv Syst. 2000;16:867–71. DISCLOSURES: No relevant relationships by James Dean, source=Web Response No relevant relationships by Shuhong Guo, source=Web Response No relevant relationships by Brandon Murguia, source=Web Response No relevant relationships by Ali Saeed, source=Web Response No relevant relationships by Samarthkumar Thakkar, source=Web Response

Cisto intra-abdominal como complicação de derivação ventrículo-peritoneal

O desenvolvimento do cisto intra-abdominal devido a complicações de derivação ventrículo-peritoneal é raro. Geralmente se manifesta por distensão abdominal, dor, náuseas e sinais de pressão intracraniana elevada. Os autores apresentam dois casos de cistos intra-abdominais que foram diagnosticados através de exames radiológicos convencionais e de ultra-sonografia abdominal. Ambos foram submetidos à intervenção cirúrgica, sendo em um derivação ventrículo-pleural e em outro, derivação ventrículo-atrial, com resultados excelentes. É feita uma revisão do assunto e discutem-se os meios de diagnóstico e tratamento.

Hydrothorax Due to Ventriculopleural Shunting in a Child with Spina Bifida on Chronic Dialysis: Third Ventriculostomy as an Alternative of Cerebrospinal Diversion

The purpose of this paper is to describe the risks of ventriculopleural shunt in patients with spina bifida and end-stage-renal-diseases (ESRD), and to describe endoscopic third ventriculostomy as an alternative for the combination of cerebrospinal shunt and dialysis modality. We report a 16-year-old boy with spina bifida on chronic dialysis with a massive unilateral hydrothorax and respiratory distress complicating a ventriculopleural (VPL) shunt. Two thoracocenteses were performed, draining 3200 ml of a clear fluid. The VPL shunt was removed and revised successfully to a third ventriculostomy (TVE). Peritoneal dialysis (PD) was the initial dialysis modality. After 12 months on PD, the patient was transferred to hemodialysis (HD) because of refractory peritonitis. Hydrothorax developed while the patient was on PD, reaching its maximum 2 months after the transference to HD. To our knowledge there has been no other report of ventriculopleural (VPL) shunt failure, and endoscopic TVE, as a cerebrospinal fluid (CSF) diversion alternative in patients on chronic dialysis.

Ventriculopleural shunting with new technology valves

Ventriculoperitoneal shunting constitutes the standard procedure for draining cerebrospinal fluid (CSF) in children with hydrocephalus. Ventriculoatrial and ventriculopleural shunting are alternative methods of CSF drainage, which have gained less acceptance. Ventriculopleural shunts are seldom used owing to justified fears of pneumothorax and symptomatic effusions of CSF. The addition of an antisiphon device to standard shunt systems seems to have prevented CSF pleural effusion. From 1988 to 1998, we treated each of six hydrocephalic children with a ventriculopleural shunt. In five cases we used new-technology valves designed to prevent the effects of siphoning with current differential pressure valves. Peritoneal adhesions, recent peritonitis, ascites, and obstruction of a previous ventriculoatrial shunt were the indications for pleural shunting. After a mean follow-up period of 2.5 years all shunts were functioning adequately. Only one patient showed transient symptoms of CSF overdrainage, which were corrected by up-grading the valve setting with the magnet. A late death was unrelated to the pleural shunting procedure. The use of valves of a new design designed to prevent overdrainage seems to account for the satisfactory outcomes observed in this series. We suggest that ventriculopleural shunting should be considered as the preferred alternative to peritoneal drainage in children with intra-abdominal adhesions or with a history of recent peritoneal infection.

Cerebrospinal fluid galactorrhea after ventriculopleural shunting: Case report

A complication of ventriculopleural shunting in which the pleural end of the catheter retracted out of the pleural cavity is described. Continued drainage of the cerebrospinal fluid into the subcutaneous and breast tissue led to the development of breast enlargement and drainage via the nipple. The mechanism of production and guidelines to avoid this complication are discussed, and a brief review of ventriculopleural shunting complications is presented.

Ventriculopleural shunting used as a temporary diversion

Due to the limited absorptive capacity of the pleural cavity, infants and young children are not generally ideal candidates for ventriculopleural shunts. We report using chest cavities as alternate for temporary diversion of CSF in a young child. Venous access to the cervical region could not be utilized because of scarring from previous procedures, while peritoneal access was contraindicated due to repeated pseudocyst formation. Pleural effusions were removed by thoracentesis when necessary, and the shunt catheter was changed to the opposite side of the chest when the effusions reaccumulated within one week. Utilizing the ventriculopleural shunts allowed us to temporize her non-communicating hydrocephalus for a period of one year, until a definitive CSF procedure by direct intracardiac placement of the distal catheter could be performed.

Ventriculo-pleural shunting for adult hydrocephalus.

In order to evaluate the efficacy and safety of ventriculo-pleural shunting as an alternative to conventional atrial and peritoneal procedures, we have carried out a retrospective study of 88 pleural shunting procedures. There was a 7% complication rate related to the use of the pleural space as the shunt terminus. Complications at the pleural end included shunt obstruction (functional or structural), pleural effusion, pneumothorax, and other technical problems. There were no deaths associated with shunt dysfunction or other complications. Ventriculo-pleural shunting for hydrocephalus, when used with appropriate precautions and with careful patient selection is a viable alternative for the treatment of adult hydrocephalus. The complications that are unique to this procedure are pneumothorax and pleural effusion. They were encountered infrequently in this series. Ventriculo-pleural shunting may be indicated when other routes are not available.

Experience with ventriculo-pleural shunts.

Ventriculo-pleural shunting for the management of hydrocephalus was initially introduced by Ransohoff in 1954. However, because of the reported cases of pleural effusion with this procedure, the operation has not achieved popularity in the management of hydrocephalus. In the course of a review of 1,500 patients with hydrocephalus treated at the Hospital for Sick Children over the years 1960-1981, we encountered 59 patients who had been treated with a ventriculo-pleural shunt during the years 1971-1981. The commonest reason for insertion of the ventriculo-pleural shunt was a preexisting infected ventriculo-peritoneal shunt. 12 of the 59 patients developed pleural effusions, and 6 of these 12 patients were under 11 months of age. The incorporation of an antisiphon device in the shunting system seemed to decrease the possibility of a pleural effusion. 23 of the 59 patients continue to function on their inserted ventriculo-pleural shunt, and in 9 of these the shunts have been functioning for over 5 years. Ventriculo-pleural shunting seems to be a safe and simple form of diversionary CSF bypass. The risk of pleural effusion seems to be highest in the infant, but can occur at any age. However, even in the infant the ventriculo-pleural shunt provides a good temporary site for diversion of CSF when the peritoneal cavity is contaminated or hazardous to shunt function. Ventriculo-pleural shunting provides a valuable alternative for the management of hydrocephalus in those patients where the heart or the peritoneal cavity are unsuitable sites.

Ventriculopleural Shunting in the Management of Hydrocephalus

6 cases of ventriculopleural shunting for control of hydrocephalus are presented. In the other child and adult, drainage of cerebrospinal fluid into the pleural cavity seems to be well tolerated in exceptional circumstances where other shunt procedures, including intracranial shunts, are contraindicated. In the infant and young child, accumulation of fluid in the pleural space is enchanced by a poorly understood immune-related mechanism and may lead to significant pulmonary dysfunction. On the basis of our experience, this procedure appears contraindicated in this age-group.