Ventriculoperitoneal Research Articles

Intra-abdominal cystic lesions after ventriculoperitoneal shunting

Objectives: Definitive diagnosis is essential for the medical and surgical management of pediatric patients with ventriculoperitoneal (VP) shunt. In patients with a VP shunt, abdominal complications have been well described, among which abdominal pseudo cysts are uncommon. In this report, we present our experience in terms of the multi-disciplinary management of intra-abdominal cystic lesions associated with the VP shunt procedure. Methods: From 2016 to 2021, 245 VP shunt procedures were performed in our institution. Intra-abdominal cystic lesions were recorded as intra-abdominal complications (abdominal pseudocyst, intestinal subserosal bowel cyst, and scrotal cyst) in 3 patients. For these patients we retrospectively collected data on medical history, complaints, diagnosis, treatment procedure, and postoperative results. The study was performed on 2 male and 1 female patients. The average patient age was 11.6 months (5 months to 1.5 years). The most common complaint was that of abdominal distention with ileus symptoms. The average time of admission after the catheterization of VP shunt was 1 month; laparotomy was performed for 2 patients in whom treatment was needed for high ligation. Results: A VP shunt operation is followed by abdominal complications in about 5%-47% of all cases. These complications are manifested as ileus symptoms, such as vomiting, abdominal distension, and abdominal pain with intestinal obstruction. Conclusions: In pediatric patients with VP shunts, a shunt catheter-induced abdominal cystic formation should always be considered a complication. Management of these cystic lesions requires the use of a multi-disciplinary approach with neurosurgery and pediatric surgery for treatment.

Use of Ventriculoperitoneal Shunt Reservoir as an Alternative to Lumbar Puncture, Case Series

Hydrocephalus is a common neurological disorder in both childhood and adulthood. Non-communicating hydrocephalus may occur due to obstruction of the cerebrospinal fluid (CSF) flow pathways by structural anomalies such as tumors, infections, adhesions, and developmental defects while communicating hydrocephalus might develop due to CSF absorption disorders or excess production. In symptomatic cases, treatment is divided into two approaches as medical and surgical. The most commonly used method in surgical treatment is the ventriculoperitoneal (VP) shunt system. The VP shunt system can have numerous advantages and complications and is expected to yield continuous and long-term solutions. One of its advantages is that CSF samples can be taken from the reservoir located on it. In cases suspected of intracranial infection but for whom Lumbar puncture (LP) cannot be performed, the shunt reservoir in the patient provides sufficient opportunity for CSF retrieval.

Effects Of Shunt Types Used In Idiopathic Normal Pressure Hydrocephalus On Patients' Clinical Outcomes

Background: Idiopathic normal pressure hydrocephalus (iNPH) is a surgically reversible neurological disorder in adults. It is a neurological condition characterized by ventricular enlargement detected on cranial imaging as well as gait disturbance, cognitive decline and urinary incontinence, with no other reason to explain the clinical findings. Ventricular shunting, predominantly ventriculoperitoneal (VP) shunt, has been shown to be successful in relieving symptoms in patients. In this study, we aimed to investigate the effects of two VP shunts used in the iNPH patients treated in our clinic. Methods: Clinical and laboratory records of 28 patients who underwent VP shunting due to iNPH were reviewed retrospectively via the Enlyl system. A programmable shunt was inserted in 9 (32.1%) and a medium-pressure shunt was inserted in 19 (67.9%) patients. Results: There was no significant difference between the two shunt types with regard to patient age, gender, and preoperative tests (p>0.05). However, the prevalence of ataxic gait was significantly higher in the Programmable Shunt group compared to the Medium-Pressure Shunt group (p<0.05). On the other hand, no significant difference was found between the shunt types with regard to postoperative examination findings and additional neurological disorders (p>0.05 for both). Conclusion: In the present study, no significant difference was observed between the shunt types with regard to clinical outcomes and thus both types of shunts were revealed as viable options.

Ependymal lined paraventricular neuroglial cyst: an outcome of endoscopic cystoventriculostomy concomitant ventriculoperitoneal shunt procedures: a case report

Neuroglial cysts are one of the problems that might develop in the neuroaxis region. We present the case of a 79-year-old male with an acute decrease in consciousness, dysphagia, and seizure with a past medical history of a cystic mass in the frontal lobe since 5 years ago. A cystic lesion with a calcification component was found in the regio left frontal after the patient received a head CT without contrast. The periventricular white matter is where the lesion is found. Subsequent brain MRI with and without contrast showed hypointense T1 weighted image (T1W1), hyperintense T2-weighted imaging (T2W1), hypointense fluid-attenuated inversion recovery (FLAIR), and non-restricted diffusion-weighted imaging (DW1). A non-enhancing intra-axial lesion measuring 5.1 cm (AP) x 3.1 cm (LL) x 3.6 cm (CC). Following a discussion of the benefits and risks with his family, the decision was eventually made to proceed with Endoscopic Cystoventriculotomy (Cyst Fenestratum) and concurrent ventriculoperitoneal (VP)-shunting. This method produced positive results. The preferred method is endoscopic fenestration since it carries fewer risks and consequences than open craniotomies and fenestration.

Pregnancy complications in patients with ventriculoperitoneal (VP) shunts

Determine obstetrical and shunt-related complications in pregnant patients with a VP shunt. Retrospective cohort study of patients with a VP shunt that delivered at a large hospital system between 1988 and 2022. A clinical research repository was queried, and patients were reviewed if they had (a) billing code for a vaginal or cesarean delivery and (b) free text mention of VP shunt in any note. Prenatal records, discharge summaries, inpatient and outpatient notes were reviewed to identify neurologic and pregnancy complications. Our query flagged 220 patients for review, and 62 met inclusion criteria; others were excluded based on shunt placement following pregnancy or shunt mention due to a fetal anomaly. Among the 62 patients, there were 87 pregnancies delivering 92 infants (Table 1). No patients experienced a VP-shunt malfunction during pregnancy. Eight patients representing 10 pregnancies experienced symptoms concerning for shunt malfunction (e.g. papilledema, headache, abdominal pain, or visual symptoms), however there was no radiographic or shunt tap evidence suggestive of malfunction. Two shunt revisions were identified, both postpartum, and neither patient reported symptoms of shunt malfunction during pregnancy. Obstetrical complications included gestational diabetes (10.3%), preterm delivery (20.7%), and pregnancy-induced hypertension (4.6%). Cesarean section was the most common delivery method (58.6%), 29.4% of which were performed due to the shunt. Currently available case series report up to a 25-50% VP-shunt complication rate in pregnant patients, however they are dated and employ methodologies that may result in reporting bias. Our study includes the largest and most contemporary cohort identified systematically. Our low rate of shunt-related complications and favorable obstetric outcomes provides reassuring information and may be helpful for patient counseling.

Magnitude of Hydrocephalus in Neonates: Its Surgical Management and Complications

Abstract: Background: To determine magnitude of congenital or acquired hydrocephalus and its possible management and complications. Materials and Methods: This Hospital based Retrospective observational study was conducted in department of pediatric surgery King Edward medical university / Mayo hospital Lahore from January 2021 to March 2022. All patients presented from neonatal life till 3 months of age with hydrocephalus due to congenital or acquired reasons were included in this study. There were 55 male and 28 female patients with male predominance. A detailed Proforma was made giving patients information, associated congenital or acquired anomaly and surgical management of hydrocephalus. All patients were operated on elective operation theatre list. Post-operative complications were noticed on admission files and addressed. Results: During the study period, 83(n=1) patients with hydrocephalus were admitted in department of pediatric surgery Mayo hospital Lahore. Among these patients, 56(67.5%) patients have hydrocephalus associated with myelomeningocele while 10(12%) patients with encephalocele. 11(13.3%) patients showed hydrocephalus due to post tuberculosis meningitis while 3(3.6%) patients with Arnold chiari 2 malformation. 1(1.2%) patients presented with hydrocephalus due to Congenital obstruction of cerebral aqueduct while 2(2.4%) with Intracranial hemorrhage ventriculoperitoneal shunting was performed in 55(66.3%) patients to treat hydrocephalus. Conservative management of hydrocephalus was done in 24(28.9%) patients while in 4(4.8%) patients ventricular taping was done. Wound infection was major post-operative complication and was noted in in 13 (15.7%) patients. Conclusion: Ventriculo peritoneal shunting is main treatment modality for obstructed hydrocephalus. Major complication of ventriculo pertoneal shunting is infection which can be prevented by proper prophylactic antibiotics as well as sterile environment of operation theatre.

Study of Relationship between Location of Ventricular Catheter Tip and Function of the Ventriculoperitoneal (VP) Shunt in Hydrocephalus in Children

Objective: To determine the relationship between location of the ventricular catheter tip and functional status of the ventriculo-peritoneal (VP) shunt in children. Methods: This prospective observational study was conducted in Faculty of Paediatric Surgery under the Department of Paediatric Neurosurgery in Bangladesh Shishu Hospital and Institute (BSH&I) from January 2017 to December 2021. The study included 140 patients who underwent ventriculo-peritoneal shunt using free hand technique. Data obtained for each patient included age, sex, diagnosis including site and side of ventricular catheter placement. Postoperative CT scan of brain were done in all cases and followed up over 2½ to 4½ years. Sixty-three patients were available for follow up. The relationship of location of ventricular catheter tip and function of the ventriculo-peritoneal shunt was analyzed in all 63 patients. Results: Number of the patients included in the study was 140. Accuracy of ventricular catheter tip placement were 55(39.28%) using freehand technique. VP shunts function well in 43(68.25%) patients. Among the 43 patients with well-functioning shunts, 19 were in accurate group, 7 were in suboptimal group and 17 were in inaccurate group. Twenty-six (41.27%) patients had good outcome with normal development. Conclusion: Mechanical malfunction and infection are the most significant problems associated with VP shunts for the treatment of hydrocephalus. A significant proportion of shunt failure is due to inaccurate placement of the ventricular catheter tip. Accurate placement of the catheter tip is highly important to reduce the incidence of shunt malfunction.

2144. Duration of perioperative antibiotic prophylaxis in ventriculoperitoneal shunt surgery in children

Abstract Background Placement of ventriculoperitoneal (VP) shunt is an important treatment for pediatric hydrocephalus. Although prolonged perioperative antibiotic prophylaxis has theoretically no benefit in reducing device-associated infections, duration of antibiotic prophylaxis for VP shunt placement in pediatrics is not well established. As a part of antimicrobial stewardship program (ASP), our ASP team recommended to stop perioperative antibiotic prophylaxis for sterile medical placement within 48 hours following surgery in April 2017. Our aim of this study was to evaluate rate of VP shunt-associated infections following shunt placement between children received < 48 hours and ≧ 48 hours of perioperative antibiotic prophylaxis. Methods Children aged 15 years old or younger who underwent VP shunt insertion between April 2014 and November 2021 were enrolled at Tokyo Metropolitan Children's Medical Center. Children with co-existing infection at time of surgery were excluded. Rates of VP shunt-associated infections following 1 month and 6 months of post-surgical periods were compared between children who received < 48 hours and ≧ 48 hours of perioperative antibiotic prophylaxis. Results A total of 110 children were identified. Among them, 11 cases with VP shunt-associated meningitis and 15 cases with other infections were excluded. Girl ratio was 44%. Median age was 4.5 months old (IQR 8-40). Numbers of children with cefazolin and vancomycin-contained regimen were 83 (98.8%) and 1 (1.2%), respectively. Numbers of children who received perioperative antibiotic prophylaxis for < 48 hours and ≧ 48 hours were 43 (51.2%) and 41 (48.8%), respectively. Incidence of VP shunt-associated infections for 1 month of post-surgical period in < 48 hours and ≧ 48 hours antibiotic prophylaxis groups were 4.65% (2/43) and 12.2% (5/41), respectively. (P=0.211) Incidence of VP shunt-associated infections for 6 months of post-surgical period in < 48 hours and ≧ 48 hours antibiotic prophylaxis groups were 11.6% (5/43) and 12.2% (5/41), respectively. (P=0.936). Conclusion Shorter duration of < 48 hours of perioperative antibiotic prophylaxis did not increase rates of VP shunt-associated infections among children in short and long terms. Disclosures All Authors: No reported disclosures.

2312. Utility of Intrathecal Antibiotic Administration in the Reduction of Ventriculoperitoneal (VP) Shunt Infections in our Urban Referral Health Center

Abstract Background Infection is one of the primary causes of VP shunt failure, with an incidence rate of 7%-14%. Systemic antibiotics, administered intravenously (IV), are considered the standard of care (SOC) for perioperative prophylaxis. Prophylactic intrathecal (IT) administration of antibiotics, in addition to SOC, is practiced by some surgeons at our institution. Our objective was to study the impact of this modality on VP shunt infections. Methods A retrospective review of all VP shunt procedures at our institution from 2018–2020 was performed. Patients with active VP shunt infection were excluded. We compared the incidence of 90-day postoperative shunt infection in patients who received IT and SOC antibiotics (intervention group) to patients who only received SOC IV antibiotics (control group). Data collection included demographics, comorbidities, prophylactic antibiotics used, and pathogens implicated in shunt infections. T-test or Mann-Whitney U test was used for comparison of continuous variables; chi-square or Fisher’s exact test was used to assess the relationship between categorical variables. A value of p < 0.05, on two-tailed testing, was considered statistically significant. Results A total of 112 patients were included in the study. Control and intervention arms comprised 54 (48.2%) and 58 patients (51.8%), respectively. All patients received parenteral perioperative antibiotics. The most commonly used agent was cefazolin (83.9%). Patients in the intervention arm received 4 mg of gentamicin and 5 mg of vancomycin intrathecally. Baseline characteristics were not statistically different between the groups. Among the 112 patients, 12 (10.7%) developed shunt infection; 4 in the intervention and 8 in the control arm. Infection rates were not statistically different in these groups (χ2 (1) =1.83, p= 0.176). However, there was a statistically significant association between history of prior shunt (uninfected) placement and post-operative shunt infection (Fisher’s exact test, p = 0.025). Conclusion Our study did not reveal additional benefit of prophylactic IT antibiotic use in decreasing VP shunt infections. History of prior shunt placement was identified as risk factor, however. Limitations include relatively small sample size, retrospective, and a single-center study. Disclosures All Authors: No reported disclosures.

Retrospective analysis of bladder perforation risk in patients after augmentation cystoplasty using an extraperitoneal approach

Initial management of pediatric patients with neurogenic bladder is focused on clean intermittent catheterization and medical therapies. Those with more hostile or small capacity bladders require surgical intervention including bladder augmentation that can result in significant clinical sequelae. This study examines a rarely described approach wherein the bladder reconstruction is extraperitonealized by bringing bowel segments through a peritoneal window and then closed. The aim of this study was to determine if the rate of bladder rupture and subsequent morbidity differed between patients who have undergone an intraperitoneal versus extraperitoneal bladder augmentation. We hypothesized that an extraperitoneal approach reduced the risk of intraperitoneal bladder perforation, downstream Intensive Care Unit (ICU) admission, small bowel obstruction (SBO) requiring exploratory laparotomy, and ventriculoperitoneal (VP) shunt-related difficulties as compared to the standard intraperitoneal technique. A retrospective chart review was conducted to assess surgical approach and outcomes in patients who underwent bladder augmentation performed between January 2009 and June 2021. Patients were identified through an existing database and manual chart review was conducted to extract data through imaging studies, operative notes, and clinical documentation. The primary outcome was bladder perforation. Secondary outcomes were ICU admission, exploratory laparotomy, and VP shunt externalization, infection, or revision for any cause. Nonparametric statistical analyses were performed. A total of 111 patients underwent bladder augmentation with 37 intraperitoneal and 74 extraperitoneal procedures. Median follow up was 5.8 years [IQR 3.0-8.6 years] and did not vary between groups (P=0.67). Only one patient was found to have a bladder perforation in the intraperitoneal group (log-rank P=0.154). There were no significant differences in time to post-augmentation ICU admission, exploratory laparotomy, or VP shunt events between the two groups (log-rank P=0.294, log-rank P=0.832, and log-rank P=0.237, respectively). Furthermore, a Kaplan-Meier analysis assessing time to composite complication demonstrated no significant difference between the two techniques (log-rank P=0.236). This study provides important data comparing the rate of bladder perforation and subsequent morbidity between intraperitoneal and extraperitoneal bladder augmentation. As expected, with a complex procedure, both groups suffered complications, but these data showed no difference between the two procedures. Rates of prior (abdominal) surgery may influence the decision to perform this procedure extraperitoneal. Outcomes related to bladder perforation and secondary consequences do not differ significantly between patients who had bladder augmentation performed with an intraperitoneal versus extraperitoneal approach. Given the low number of adverse events in this study, larger studies are warranted.

The positive impact of cisternostomy with cisternal drainage on delayed hydrocephalus after aneurysmal subarachnoid hemorrhage

BackgroundHydrocephalus is one of the major complications of aneurysmal subarachnoid haemorrhage (aSAH). In the acute setting, an external ventricular drain (EVD) is used for early management. A cisternal drain (CD) coupled with the micro-surgical opening of basal cisterns can be an alternative when the aneurysm is clipped. Chronic hydrocephalus after aSAH is managed with ventriculo-peritoneal (VP) shunt, a procedure associated with a wide range of complications. The aim of this study is to analyse the impact of micro-surgical opening of basal cisterns coupled with CD on the incidence of VP shunt, compared to patients treated with EVD.MethodsThe authors conducted a retrospective review of 89 consecutive cases of patients with aSAH treated surgically and endovascularly with either EVD or CD between January 2009 and September 2021. Patients were stratified into two groups: Group 1 included patients with EVD, Group 2 included patients with CD. Subgroup analysis with only patients treated surgically was also performed. We compared their baseline characteristics, clinical outcomes and shunting rates.ResultsThere were no statistically significant differences between the two groups in terms of epidemiological characteristics, WFNS score, Fisher scale, presence of intraventricular hemorrhage (IVH), acute hydrocephalus, postoperative meningitis or of clinical outcomes at last follow-up. Cisternostomy with CD (Group 2) was associated with a statistically significant reduction in VP-shunt compared with the use of an EVD (Group 1) (9.09% vs 53.78%; p < 0.001). This finding was confirmed in our subgroup analysis, as among patients with a surgical clipping, the rate of VP shunt was 43.7% for the EVD group and 9.5% for the CD group (p = 0.02).ConclusionsCisternostomy with CD may reduce the rate of shunt-dependent hydrocephalus. Cisternostomy allows the removal of subarachnoid blood, thereby reducing arachnoid inflammation and fibrosis. CD may enhance this effect, thus resulting in lower rates of chronic hydrocephalus.

Complications of Paediatric Ventriculoperitoneal (VP) Shunt: Experience in A Tertiary Care Hospital

Background: Ventricloperitoneal (VP) shunt is the most commonly used shunt procedure in children because of the capacity of the peritoneum to resorb fluid like Cerebrospinal fluid (CSF). Primary and subsequent peritoneal catheter placement is relatively easy procedure to be done. VP shunt procedures are associated with varieties of complications.&#x0D; Methods: A prospective study was done from July 2017 to June 2021 in Faculty of Paediatric Surgery, Bangladesh Shishu Hospital &amp; Institute. A total number of cases underwent VP shunt surgery were 192. We had analyzed 82(42.71%) patients of VP shunt surgery who had various shunt related complications and analyzed the predisposing risk factors and spectrum of complications.&#x0D; Results: The mean age was 16±14 months and median age was11.75 months. Out of 82 patients 56 (68.29%) were male and 26(31.71%) were female. Seventy (85.37%) patients had single complication and 12(14.63%) had more than 1 complications. Twenty four (29.27%) patients had infective complication and 58(70.73%) had mechanical complication. Infective complications (24, 29.27%) include shunt tract abscess (41.66%), CSF leak (16.67%) exposure of shunt tube through anus (16.67%), wound infection (16.67%). Mechanical complications were present in 58(70.73%) cases and 40(48.78%) had ventricular end malformation, 24(29.27%) peritoneal end and 18(21.95%) had both end malformation.&#x0D; Conclusion: With this prospective study of complications of VP shunt, age at initial shunt surgery, insertion and important patient-related predictors of shunt failure. The different predominant etiological factors the interval between the age of initial shunt placement and onset of complications were the most responsible for early and late shunt failure were infective and mechanical complications respectively.&#x0D; DS (Child) H J 2021; 37(2): 129-134

Hydrocephalus classification in brain computed tomography medical images using deep learning

Recent technological advancements, like big data analytics, is driving the growing adoption of cyber-physical systems and digital twins in the area of healthcare. Congenital hydrocephalus is one important example of recent healthcare data analytics. Congenital hydrocephalus is a buildup of excess cerebrospinal fluid (CSF) in the brain at birth. Congenital hydrocephalus can be lethal without treatment and represents an urgent issue in present-day clinical practice. Congenital hydrocephalus has a significant effect on a human entire life since it causes damage to the brain. It is important to accurately diagnose hydrocephalus early, which will help in the early treatment of the infant by a surgical procedure called ventriculoperitoneal (VP) shunt which will reduce the damage caused by hydrocephalus on the brain. Deep Learning is an evolving technology that is currently actively researched in the field of radiology. Compared to the traditional hydrocephalus diagnosing techniques, automatic diagnosing algorithms in deep learning can save diagnosis time, improve diagnosing accuracy, reduce cost, and reduce the radiologist's workload. In this paper, we have used a novel dataset collected from king Hussein medical center hospital in Jordan that consists of CT scans for hydrocephalus and non-hydrocephalus infants, the dataset has gone through multiple stages in preprocessing which are; cropping and filtering, normalization, segmentation (three segmentation techniques have been applied), and augmentation. These data have been used to build deep learning and machine learning models that will help physicians in the early and accurate diagnosing of congenital hydrocephalus which will lead to a decrease in the death rate and brain damage. The results of our models were impressive with a 98.5% accuracy for congenital hydrocephalus classification in infants' brain CT images.

Endoscopic Evacuation of Massive Intraventricular Hemorrhages Reduces Shunt Dependency: A Meta-Analysis.

Intraventricular hemorrhage (IVH) is characterized by severe prognosis. The amount of intraventricular blood is the most important, disease-specific, prognostic factor, as acute complications are strictly dependent on clot formation. Although external ventricular drain (EVD) placement is the standard treatment, in the past 15 years neuroendoscopic (NE) evacuation of IVH has been advocated, but available comparative data are limited. A systematic review of the literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included articles compare the treatment of primary and secondary IVH with NE and EVD. The meta-analysis was performed in terms of shunt dependency. Cochran's Q-test and I2 statistics were used to assess heterogeneity in the studies. No heterogeneity was considered for p greater than 0.05 and I2 less than 20%. A random-effect model was used, with restricted maximum likelihood to estimate the heterogeneity variance. After screening 744 articles, 5 were included in the meta-analysis. A total of 303 patients presenting with primary or pure (50 patients) and secondary (253 patients) IVH, undergoing either NE (151) or EVD (152), were included in the metanalysis. The risk of ventriculoperitoneal (VP) shunt was higher in the EVD group (relative risk: 1.93, 95% confidence interval: 1.28-2.92, p = 0.0094). The risk of VP shunt was higher in the EVD group, but the overall outcome remains poor for patients with IVH, with a moderate-to-high disability. Large randomized controlled trials are needed to evaluate more deeper both advantages and effects on the outcome of NE over EVD.

Bacterial Meningitis among Intracranial Surgery Patients at a University Hospital in Northern India.

Cerebrospinal infections are the cause of poor prognosis among post-neurosurgery patients owing to delay in improvement of neurological functions, leading to increased length of hospital stay, proceeding to disability or death. This retrospective observational study was performed at a tertiary care center in Northern India, where all patients with bacterial cerebrospinal infections from July 2019 to July 2022 were evaluated for post-neurosurgery cerebrospinal shunt infections, and all demographic data and risk factors were extracted from the hospital information system (HIS). The study includes 150 (150/1986, 7.55%) culture-confirmed cases of bacterial meningitis out of 1986 cases of suspected bacterial meningitis patients. Ninety-six (96/150, 64.0%) post-neurosurgery patients with cerebrospinal fluid (CSF) leaks were managed using external ventricular drain (EVD) or ventriculoperitoneal (VP) shunt. Seventy-four (74/96, 77.08%) patients were managed only on EVD, whereas 22 (22/96, 22.92%) patients were managed only on VP shunt. Eighty-two (82/96, 85.4%) multidrug-resistant microorganisms (MDROs) were isolated and 70 (70/82, 85.36%) were gram-negative bacteria, of which 56 (56/74, 75.68%) gram-negative bacteria showed extended-spectrum beta-lactamase (ESBL)-producing character in those with an EVD, 14 (14/22, 63.63%) with a VP shunt. Among gram-negative bacteria, Acinetobacter baumannii showed high rates of resistance: 21 (21/23, 91.30%) and 8 (8/8, 100%) were ESBL-producing A. baumannii in patients managed on EVD and VP shunt, respectively. This study determines the risk factors, the spectrum of pathogenic microorganisms, multidrug resistance, and the nature of intracranial lesions isolated among the patients who developed bacterial cerebrospinal infections in post-neurosurgery patients. Kar M, Jamwal A, Dubey A, Sahu C, Patel SS. Bacterial Meningitis among Intracranial Surgery Patients at a University Hospital in Northern India. Indian J Crit Care Med 2022;26(12):1244-1252.

A Case Report VP shunt in Non Communicating Hydrocephalus due to Intracerebral Hemorrhage

Stroke is one of the top three cause of death and disability globally. Approximately, only 10% to 15% of first-ever stroke are intracerebral hemorrhages (ICHs), but the rates of disability and death are significantly higher. Hydrocephalus may occur in more than 50% of patients with intraventricular hemorrhage (IVH), which is secondary to ICH. Intraventricular hemorrhage (IVH), an accumulation of blood to ventricles that may be cause by extension of ICH, occurs in up to 50% of patients with primary ICH. Hydrocephalus itself may serves as a predictor of poor outcome after ICH.1,2,3&#x0D; A 71 years old male came to the hospital with the complaint of loss of consciousness, difficulty in communicating, and weakness of extremities on the left side of the body since 12 hours ago. The complaint was preceded by headache that did not alleviate with medication since 1 day before admission and there was history of slurred speech. A head CT scan without contrast was done and the result showed an intracerebral hemorrhage and a suggestive obstructive hydrocephalus. The patient was diagnosed noncommunicating hydrocephalus due to spontaneous intracerebral haemorrhage (ICH) at the right thalamus with intraventricular haemorrhage due to suspect hypertension with differential diagnosis of cerebral amyloid angiopathy with emergency hypertension. The patient was advised to underwent an emergency VP shunt placement.&#x0D; Implantation of a ventriculoperitoneal (VP) shunt is the most widely used treatment of hydrocephalus. Considered to be a major privonce of neurosurgery, it accounts for 70.000 hospital admission in the US. Even though, VP shunting of CSF reduces the morbidity and mortality of post-hemorrhagic. hydrocephalus, it is associated with potential complications requiring multiple surgical procedures, as well as shunt revision due to its failure during the patient’s lifetime.4

The role of surgery in relieving calcified shunt site-related pain in patients with functioning VP shunt.

Shunt calcification is a known late sequela of ventriculoperitoneal (VP) shunt insertion and is associated with shunt malfunction. However, in some patients, while shunt functionality is preserved despite calcification of the catheters, they experience nociceptive symptoms. In this paper, the authors present their surgical experience in managing patients with a functional VP shunt and experiencing pain secondary to shunt calcification. We analysed outcomes of patients presenting with pain at the level of a calcified shunt who underwent surgical untethering of the calcified catheter from the soft tissues. This procedure was commenced by the senior author in 2015. Patients were collected prospectively from the databases of two institutions. Evidence of shunt calcification was confirmed on neuroimaging. Seven patients, two male and five female, were included. The mean age at untethering was 13.5years. The mean time interval between primary shunt surgery and symptom onset was 12years (range 6-16years). The commonest site of tethering was the neck (50%) followed by abdomen and chest (both 25%). Six patients underwent untethering of the catheter from soft tissues. One patient had removal of a redundant segment of calcified shunt left in situ during a previous revision. All patients experienced pain relief following shunt untethering. Untethering of calcified VP shunt catheters from soft tissue can be considered an effective treatment of shunt site pain and offered to patients presenting with a functional VP shunt.

Chest wall abscess with intestinal perforation and distal catheter migration of Ventriculoperitoneal (VP) shunt without anal extrusion: A case report

Hydrocephalus is the symptomatic accumulation of cerebrospinal fluid (CSF) within the brain ventricles. Common treatments include direct etiological procedure e.g. a Ventriculoperitoneal (VP) shunt, which can potentially lead to complications such as infection, obstruction, cerebrospinal fluid pseudocyst, bowel perforation, shunt catheter migration, peritoneal inclusion cyst, and spontaneous VP shunt catheter extrusion. A rare case of extrusion on a 2 years old boy was reported; the individual in question came with a lump on his chest and was diagnosed with hydrocephalus on the patent right VP shunt. From a theoretical perspective, treatment of extrusion can be done via emergency removal, antibiotic treatment, nil per oral, and reinsertion if needed. From the particular case, it was concluded that treatment is possible with removal of the catheter and reinsertion of the VP shunt and through postoperative monitoring.

Original Ventriculoperitoneal Shunt for Pediatric Hydrocephalus

Although the use of newly developed procedures such as endoscopic third ventriculostomy or coagulation of the choroid plexus has gradually expanded, ventriculoperitoneal(VP)shunts are still not obsolete. They are the most commonly performed surgery for treating pediatric hydrocephalus. Young neurosurgeons may frequently encounter this CSF diversion procedure in clinical practice. However, the VP shunt remains a failure-prone procedure, as exemplified by obstruction, infection, mechanical shunt failure, over drainage, and distal catheter site-specific failures. Therefore, surgery requires exquisite techniques, especially in the pediatric population, to meet the needs of the child's growth. This article sheds light on the refined methodology for pediatric VP shunting with meticulous details of the surgical technique. Neurosurgeons must always remember that appropriate ICP control has a major impact on patient development and that a stably functioning VP shunt can deliver the full potential of children with hydrocephalus.

Ventriculoperitoneal Shunt Treatment Increases 7 Alpha Hy-Droxy-3-Oxo-4-Cholestenoic Acid and 24-Hydroxycholesterol Concentrations in Idiopathic Normal Pressure Hydrocephalus.

Idiopathic normal pressure hydrocephalus (iNPH) is the most common form of hydrocephalus in the adult population, and is often treated with cerebrospinal fluid (CSF) drainage using a ventriculoperitoneal (VP) shunt. Symptoms of iNPH include gait impairment, cognitive decline, and urinary incontinence. The pathophysiology behind the symptoms of iNPH is still unknown, and no reliable biomarkers have been established to date. The aim of this study was to investigate the possible use of the oxysterols as biomarkers in this disease. CSF levels of the oxysterols 24S- and 27-hydroxycholesterol, as well as the major metabolite of 27-hydroxycholesterol, 7 alpha hydroxy-3-oxo-4-cholestenoic acid (7HOCA), were measured in iNPH-patients before and after treatment with a VP-shunt. Corresponding measurements were also performed in healthy controls. VP-shunt treatment significantly increased the levels of 7HOCA and 24S-hydroxycholesterol in CSF (p = 0.014 and p = 0.037, respectively). The results are discussed in relation to the beneficial effects of VP-shunt treatment. Furthermore, the possibility that CSF drainage may reduce an inhibitory effect of transiently increased pressure on the metabolic capacity of neuronal cells in the brain is discussed. This capacity includes the elimination of cholesterol by the 24S-hydroxylase mechanisms.