Ventriculopleural Shunt Research Articles

Comparing ventriculoatrial and ventriculopleural shunts in pediatric hydrocephalus: a Hydrocephalus Clinical Research Network study.

When the peritoneal cavity cannot serve as the distal shunt terminus, nonperitoneal shunts, typically terminating in the atrium or pleural space, are used. The comparative effectiveness of these two terminus options has not been evaluated. The authors directly compared shunt survival and complication rates for ventriculoatrial (VA) and ventriculopleural (VPl) shunts in a pediatric cohort. The Hydrocephalus Clinical Research Network Core Data Project was used to identify children ≤ 18 years of age who underwent either VA or VPl shunt insertion. The primary outcome was time to shunt failure. Secondary outcomes included distal site complications and frequency of shunt failure at 6, 12, and 24 months. The search criteria yielded 416 children from 14 centers with either a VA (n = 318) or VPl (n = 98) shunt, including those converted from ventriculoperitoneal shunts. Children with VA shunts had a lower median age at insertion (6.1 years vs 12.4 years, p < 0.001). Among those children with VA shunts, a hydrocephalus etiology of intraventricular hemorrhage (IVH) secondary to prematurity comprised a higher proportion (47.0% vs 31.2%) and myelomeningocele comprised a lower proportion (17.8% vs 27.3%) (p = 0.024) compared with those with VPl shunts. At 24 months, there was a higher cumulative number of revisions for VA shunts (48.6% vs 38.9%, p = 0.038). When stratified by patient age at shunt insertion, VA shunts in children < 6 years had the lowest shunt survival rate (p < 0.001, log-rank test). After controlling for age and etiology, multivariable analysis did not find that shunt type (VA vs VPl) was predictive of time to shunt failure. No differences were found in the cumulative frequency of complications (VA 6.0% vs VPl 9.2%, p = 0.257), but there was a higher rate of pneumothorax in the VPl cohort (3.1% vs 0%, p = 0.013). Shunt survival was similar between VA and VPl shunts, although VA shunts are used more often, particularly in younger patients. Children < 6 years with VA shunts appeared to have the shortest shunt survival, which may be a result of the VA group having more cases of IVH secondary to prematurity; however, when age and etiology were included in a multivariable model, shunt location (atrium vs pleural space) was not associated with time to failure. The baseline differences between children treated with a VA versus a VPl shunt likely explain current practice patterns.

Ceftaroline Fosamil as a Potential Treatment for Central Nervous System Infections in Children

Abstract Ceftaroline has been reported to show efficacy in limited adult clinical case studies including a report of a patient with a methicillin-resistant Staphylococcus aureus (MRSA) infection of a ventriculopleural shunt, and in 2 reports for use as a salvage therapy in a case of an epidural abscess infected with MRSA, as well as a case of methicillin-resistant Staphylococcus epidermidis (MRSE) ventriculostomy-related infection. The pharmacokinetic (PK) and pharmacodynamic (PD) properties of ceftaroline in healthy adults and neurosurgical patients have been assessed to develop population PK models used to perform simulations to evaluate the probability of target attainment of different ceftaroline dosing regimens for central nervous system (CNS) infections. Results from the simulations indicated that the penetration of ceftaroline into the cerebrospinal fluid was dependent on the degree of meningeal inflammation, suggesting that inflammation associated with infection would provide adequate antibiotic exposure, similar to other β-lactam antibiotics. Ceftaroline has a potential, unique role as a β-lactam antibiotic in the treatment of MRSA and coagulase negative staphylococci causing CNS infections as an alternative to vancomycin, the current standard of care. Support for treatment of CNS infections may be derived from further cerebrospinal fluid PK studies followed by PK/PD modeling prior to the conduct of prospective phase 2/3 clinical studies aimed at assessing the efficacy and safety of ceftaroline for the treatment of pediatric CNS infections. Ceftaroline's penetration enhanced by meningeal inflammation suggests that the drug could be a candidate to treat MRSA CNS infections.

Analysis of non-ventriculoperitoneal shunts at Red Cross War Memorial Children’s Hospital

BackgroundAt Red Cross War Memorial Children’s Hospital (RCCH), it is the preferred practice to use non-ventriculoperitoneal (non-VP) shunts when the peritoneum is ineffective or contraindicated for cerebrospinal fluid (CSF) diversion and when endoscopy is not an option. The objective of this study is to evaluate the clinical course of patients having undergone these procedures.MethodA single-centre retrospective review at RCCH wherein 43 children with a total of 59 episodes of non-VP shunt placement over a 12-year period were identified for inclusion.ResultsTwenty-five ventriculoatrial (VA) and 32 ventriculopleural (VPL) shunts were analysed with a median age at insertion of 2.9 (0.3–14.9) and 5.3 years (0.5–13.4), respectively. The median number of previous shunt procedures prior to VA or VPL shunt insertion was 6.0 (2–28) versus 4.5 (2–17), respectively. Three VA (12.0%) and three VPL (9.4%) shunt patients were lost to follow-up. Of those remaining, 10 VA shunts (45.5%) compared to 19 (65,5%) VPL shunts required revision. One ventriculovesical shunt and one ventriculocholecystic shunt were placed in the same patient after 21 and 25 shunt-related procedures, respectively, and both were revised within 3 weeks of insertion. Median shunt survival was 8 months longer for the VA compared to the VPL shunts, being 13.5 (0–67) and 5 months (0–118), respectively. Complications for VA shunts were low, with the overall shunt sepsis rate in the VA group at 4% (n = 1) compared to 15.6% (n = 5) in the VPL group.ConclusionOur findings support that VA and VPL shunts are acceptable second-line options in an already compromised group of patients where safe treatment options are limited, provided attention is paid to the technical details specific to their placement.

Ventriculopleural shunt outcomes for pediatric hydrocephalus: a single-institution experience.

The aim of this study is to analyze rates of ventriculopleural (VPL) shunt failure and complications among patients with pediatric hydrocephalus, and to analyze which factors may predict early (< 1year) or late (> 1year) VPL shunt failure in this sample. A retrospective chart review was conducted of all consecutive VPL shunt placements from 2000 to 2019 at our institution. Data was collected on patient characteristics, shunt history, and shunt type. Primary endpoints include rates of VPL shunt survival and rates of symptomatic pleural effusion. The Kaplan-Meier method was used to calculate shunt survival, and Fisher's exact test and t-test were used to compare differences between categorical variables and means, respectively (p < 0.05). Thirty-one patients with pediatric hydrocephalus underwent VPL shunt placement (mean age 14.2years). Of the 27 patients with long-term follow-up (mean 46months), VPL shunt revision was required in 19, seven of which were due to pleural effusion. Overall shunt survival rates at 1, 3, 5, and 7years were 76%, 62%, 55%, and 46%, respectively. Mean duration of shunt survival was 26.74months. Overall pleural effusion rate was 26%. No patient-specific factors, including shunt valve type, were significantly associated with shunt survival, risk of early revision, or risk of pleural effusion. Our results are comparable to those reported in the literature and represent one of the largest case series on the topic. VPL shunts are a viable second-line option when ventriculoperitoneal (VP) shunt placement is not possible or desirable, though there are high rates of shunt revision and pleural effusion.

Intraventricular Pneumocephalus Complicating Pneumothorax in a Case of Ventriculopleural Shunt: A Rare Complication and Its Management

The peritoneal cavity is widely used as the destination of choice for cerebrospinal fluid (CSF) shunts. Various alternative distal sites have been used, particularly in the presence of certain contraindications, which include the cardiac atria, for ventriculoatrial (VA) shunt, or the pleural cavity for ventriculopleural (VPL) shunt.[1] Each procedure is associated with its own set of complications and the choice of selection of the distal site of CSF drainage is often based on surgeon's preference along with patient's factors.[2] While the historical literature describes pleural effusion and pneumothorax as complications of a VPL shunt, there is paucity of data justifying the application of one technique over the other. We report a rare case of postoperative pneumothorax in a case of VPL shunt being further complicated by pneumocephalus.

A RARE CASE OF ABDOMINAL CEREBROSPINAL FLUID PSEUDOCYST (CSFOMA) : A RARE COMPLICATION OF VENTRICULO-PERITONEAL SHUNT IN PREVIOUSLY TREATED TUBERCULOUS MENINGITIS HYDROCEPHALUS

Ventriculo-peritoneal shunt is a common neurosurgical procedure used in treatment of hydrocephalus in which shunt is created for draining excess of cerebrospinal uid into peritoneal cavity for its absorption through the peritonium. One of its rare but dangerous complication is abdominal pseudocyst which occurs mainly due blockage or obstruction of the shunt and may present as acute abdomen. Here we present a case of post tubercular hydrocephalus treated with ventriculo-peritoneal shunt at the age of 2 years, later developed abdominal cerebrospinal uid pseudocyst (CSFoma) at the age of 14 years. He presented with abdominal distension, ultrasonography showed pseudocyst formation which was conrmed with contrast enhanced computed tomography of abdomen. Ventriculo-peritoneal shunt was later diverted to right pleural cavity forming ventriculo-pleural shunt. Gradually pseudocyst resolved. On further follow up he was found to be doing well with no further complications.

VP Shunts:Do's and Don'ts in Case of Shunt Failure

Hydrocephalus is a relatively common pediatric neurosurgical disease. Although congenital hydrocephalous is the most common cause, cerebral bleeding, infection of the central nervous system or brain tumors can also cause hydrocephalous in children. As timing of initial treatment varies depending on the cause of hydrocephalous, customized therapeutic strategy should be considered on a case-by-case basis to cope with growth and development. After the initiation of treatment such as shunt, most patients should be placed under clinical observation for life, as permanent devices which can adapt children's growth are not available, and shunt troubles such as occlusion, infection, disconnection, and inappropriate drainage are common during long term observation. Overall, ventriculoperitoneal shunt is a standard treatment. Other options such as ventriculoatrial or ventriculopleural shunt are selected to treat various shunt complications. In this article, we describe the characteristics of shunt complications in pediatric patients, as well as the symptoms, diagnosis, and treatments for various possible shunt complications. In addition, what kinds of attention should be paid for treating shunt trouble due to infection is discussed using a complicated case report.

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.

A Newborn With a Mass on the Brain.

A Newborn With a Mass on the Brain.

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

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

Ventriculoatrial and ventriculopleural shunts as second-line surgical treatment have equivalent revision, infection, and survival rates in paediatric hydrocephalus.

Ventriculoatrial (VA) and ventriculopleural (VPL) shunts are used as alternatives when CSF diversion to the peritoneal compartment with a ventriculoperitoneal (VP) shunt is not possible. The objective of this study is to compare directly the shunt survival and complications for both procedures in this setting in children. A retrospective analysis of 54 consecutive patients who underwent VA (36) or VPL (18) shunt insertion between January 2002 and December 2017 was conducted. The overall mean follow-up was 4.1 (SD 4.3) years, 2.8 (SD 4.1) for VPL and 4.7 (SD 4.4) for VA shunts, respectively (p = 0.11). Twenty-four (66.7%) patients in the VA group and 9 (50.0%) in the VPL group underwent shunt revision (p = 0.236); mean number of revisions was 2.2 (SD 3.0) and 0.94 (SD 1.4) in the VA and VPL groups (p = 0.079). Median time to failure was 8.5 (IQr 78, range 0-176) months for VA and 5.50 (IQr 36, range 0-60) for VPL shunts (log rank (Mantel-Cox) 0.832). Shunt survival at 3, 6, 12 and 30months was 60.6, 51.5, 36.4 and 27.3%, respectively, for VA and 56.3, 43.8, 37.5 and 37.5% for VPL shunts (log rank (Mantel-Cox) test value 0.727). The infection rate was 13.8% for VA and 5.6% for VPL shunts (p = 0.358). Four patients with VPL shunts (22.2%) developed pleural effusions. Fourteen deaths (25.9%) were recorded during follow-up, 8 (22.2%) in the VA and 6 (33.3%) in the VPL group (p= 0.380); two of the deaths in the VA group were shunt-related. This study demonstrates that the outcomes of VA and VPL shunts, when used as second-line surgical treatment in paediatric hydrocephalus, were similar, as were the revision, infection and survival rates. The shorter longevity of these shunts compared with the general shunted population may reflect the complex nature of these children.

Predictors of adverse outcomes and cost after surgical management for idiopathic normal pressure hydrocephalus: Analyses from a national database

IntroductionWe utilized a national administrative database to investigate drivers of immediate adverse economic and hospital outcomes, including non-routine discharge, prolonged length of stay (LOS), and admission costs among patients undergoing surgery for idiopathic normal pressure hydrocephalus (iNPH). MethodsThe National Inpatient Sample (NIS) was queried from 2007 to 2017 for patients aged ≥60 with a diagnosis code for iNPH undergoing surgery. Multivariable logistic-regression models and Wald χ2 were used to identify drivers of non-routine discharge, prolonged length of stay (LOS) (>75th percentile) and higher admission costs (>90th percentile). ResultsA total of 13,363 patients with iNPH undergoing surgical management were identified. The most common comorbidity reported in the cohort was a cardiovascular pathology (56.9 %, n = 7,787), followed by urinary pathology (37.2 %, n = 5,084), osteoarthritis (7.8 %, n = 1,071), Alzheimer’s disease (4.6 %, n = 626) and cerebrovascular pathology (4.2 %, n = 569). The most frequently employed procedure was ventriculo-peritoneal (VP) shunt placement (65.6 %, n = 8,942) of which 89.8 % (n = 8,027) were performed open and 10.2 % (n = 915) laparoscopically. This was followed by lumbo-peritoneal (LP) shunting (15.5 %, n = 2,115), lumbar puncture alone (screened, serial CSF removal) (14.8 %, n = 2,013), endoscopic third ventriculostomy (ETV) (2%, n = 274), ventriculo-atrial (VA) shunt (0.95 %, n = 130) and ventriculo-pleural (Vpleural) shunt (0.46 %, n = 64). The median (IQR) LOS was 3 days (2–5), the rate of non-routine discharge was 37.3 % and median (IQR) cost was $11,230 ($7,735–15,590).On multivariable-analysis, emergent-admission (OR 2.91), older age (76–90: OR 1.55; 90+: OR 2.66), VP shunt (open: OR 3.09; laparoscopic: OR 2.32), ETV (OR 3.16), VA/VPleural shunt (OR 2.73) and hospital admission in Northeast-region compared to Midwest (OR 1.27) were found to be associated with increased risk of non-routine discharge. Some of the highly significant associated factors for prolonged LOS included emergent-admission (OR 11.34), ETV (OR 10.92), VA/VPleural shunt (OR 7.79) and open VP shunt (OR 8.24). For increased admission costs, some of the highly associated factors included VA/VPleural shunt (OR 18.48), laparoscopic VP shunt (OR 9.92), open VP shunt (OR 12.72) and ETV (OR 9.34). Predictor importance analysis revealed emergent admission, number of diagnosis codes (comorbidities) open VP shunt, hospital region, age] and revision or removal of shunt to be the most important drivers of these outcomes. ConclusionAnalyses from a national database indicate that among patients with iNPH, an emergent-admission may be the most significant risk-factor of adverse economic outcomes and higher costs.

Ultrasound-guided percutaneous ventriculopleural shunt placement: a minimally invasive technique

Ventriculopleural shunt is still considered a third-line option for CSF diversion, when both peritoneal and atrial cavity are contraindicated. Different approaches have been used and in modern surgery, lesser invasive techniques are predominant. The goal of this manuscript is to present a minimally invasive placement of a pleural catheter. We describe a minimally invasive approach to the pleural space using an a-traumatic peel-away introducer under ultrasonographic intraoperative control. Furthermore, consideration about complications, follow-up and advantages of the abovementioned technique will be discussed. Percutaneous US guided placement for pleural catheter is a safer and modern minimally invasive approach to the pleural space. Pleural effusion is the predominant complication, encountered especially in younger children.

Early Readmission After Ventricular Shunting in Adults with Hydrocephalus: A Nationwide Readmission Database Analysis

Ventricular shunting is one of the primary modalities for addressing hydrocephalus in both children and adults. Despite advances in shunt technology and surgical practices, shunt failure is a persistent challenge for neurosurgeons, and shunt revisions account for a substantial proportion of all shunt-related procedures. There are a wealth of studies elucidating failure patterns and patient demographics in pediatric cohorts; however, data in adults are less uniform. We sought to determine the rates of all-cause and shunt failure readmission in adults who underwent the insertion of a ventricular shunt. We queried the Nationwide Readmissions Database from 2010 to 2014 to evaluate new ventricular shunts placed in adults with hydrocephalus. We sought to determine the rates of all-cause and shunt revision-related readmissions and to characterize factors associated with readmissions. We analyzed predictors including patient demographics, hospital characteristics, shunt type, and hydrocephalus cause. Analysis included 24,492 initial admissions for shunt placement in patients with hydrocephalus. Of patients, 9.17% required a shunt revision within the first 6 months; half of all revisions occurred within the first 41 days. There were 4044 (16.50%) 30-day and 5758 (28.8%) 90-day all-cause readmissions. In multivariable analysis, patients with a ventriculopleural shunt, Medicare insurance, and younger age had increased likelihood for shunt revision. Notable predictors for all-cause readmission were insurance type, length of hospitalization, age, comorbidities, and hydrocephalus cause. Most shunt revisions occurred during the first 2 months. Readmissions occurred frequently. We identified patient factors that were associated with all-cause and shunt failure readmissions.

Disproportionately Large Communicating Fourth Ventricle: Pearls for Diagnosis and Management.

IntroductionDisproportionately large communicating fourth ventricle (DLCFV) is an unusual presentation of communicating hydrocephalus, in which patients with hydrocephalus have a disproportionately enlarged fourth ventricle in the absence of obstructive pathology. We present six cases of DLCFV which, to date, is the largest series of this relatively rare condition. We highlight the significance of diagnosis and its differentiation from trapped fourth ventricle (TFV) and discuss the nuances for optimal management of DLCFV.MethodsRetrospective case series of consecutive patients with DLCFV, managed by the senior author (LT) over a 10-year period.ResultsSix cases were identified, five of whom had previous posterior fossa surgery and one with previous encephalitis. All patients presented with cerebellar signs, the initial group had unsuccessful initial management with typical cerebrospinal fluid (CSF) diversion. Consistent symptom resolution was achieved by the application of negative CSF pressures via external ventricular drainage (EVD), maintained with subsequent ventriculopleural shunt (VPL), valveless lumbopleural shunt (LPS) or valveless ventriculoperitoneal shunt (VPS), or proceeding directly to a low-pressure system.ConclusionsDLCFV is a diagnosis characterised by cerebellar dysfunction, with or without cranial nerve palsies, often in the setting of previous posterior fossa pathology. Optimal management relies on knowledge of this unique diagnostic entity, and use of an EVD at negative pressures to confirm symptomatic and radiological improvement prior to definitive treatment.

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

200 Age as a Novel Risk Factor for Revision of Ventriculopleural Shunt in Pediatric Patients

INTRODUCTION:The first choice for distal end location of a cerebrospinal fluid-diverting device is the abdomen. However, for patients in whom the peritoneal cavity is not suitable, a ventriculopleural shunt (VPl) is an alternative.METHODS:With institutional review board approval we performed a retro

Case series of ventriculopleural shunts in adults: a single-center experience.

OBJECTIVE The peritoneal cavity is widely used as the destination of choice for cerebrospinal fluid shunts. Various alternative sites have been used, particularly in the presence of certain contraindications. The pleural cavity has been used; however, a paucity of evidence details ventriculopleural (VPL) shunt survival, complication, and revision rates in adults. The aim of this study was to present a single center's experience with VPL shunts, identifying complication, revision, and survival rates. METHODS A single-center, retrospective case series analysis was conducted for VPL shunt insertions and revisions over a period of 5 years. Demographic as well as clinical data were collected. Ventriculopleural shunt survival was assessed using Kaplan-Meier curves and the log rank (Cox-Mantel) test. RESULTS Twenty-two VPL shunts were inserted in 19 patients. Median survival of the VPL shunts was 14 months. Pathological indication for the VPL shunt did not significantly affect survival. A total of 10 complications was observed: 2 infections, 2 cases of overdrainage, 2 obstructions, 1 distal catheter retraction, 2 symptomatic pleural effusions, and 1 asymptomatic pleural effusion. CONCLUSIONS Ventriculopleural shunting is a safe and viable second-line procedure for cases in which ventriculoperitoneal shunts are unsuitable. While VPL shunts have a high revision rate, their complication rate is comparable to that of VP shunts. Ventriculopleural shunt survival can be improved by careful patient selection and the implementation of a combination of valves with antisiphon devices.

Failed Ventriculoperitoneal Shunt: Is Retrograde Ventriculosinus Shunt a Reliable Option?

Currently, the treatment of hydrocephalus is mainly carried out through a ventriculoperitoneal shunt (VPS) insertion. However, in some cases, there may be surgical revisions and requirement of an alternative distal site for shunting. There are several described distal sites, and secondary options after VPS include ventriculopleural and ventriculoatrial shunt, which have technical difficulties andharmful complications. In this preliminary report we describe our initial experience with retrograde ventriculosinus shunt (RVSS) after failed VPS. In 3 consecutive cases we applied RVSS to treat hydrocephalus in shunt-dependent patients who had previously undergone VPS revision and in which peritoneal space was full of adhesions and fibrosis. RVSS was performed as described by Shafei etal., with some modifications to each case. All 3 patients kept the same clinical profile after RVSS, with no perioperative or postoperative complications. However, revision surgery was performed in the first operative day in 1 out of 3 patients, in which the catheter was not positioned in the superior sagittal sinus. We propose that in cases where VPS is not feasible, RVSS may be a safe and applicable second option. Nevertheless, the long-term follow-up of patients and further learning curve must bring stronger evidence.

Cross-sectional imaging of thoracic and abdominal complications of cerebrospinal fluid shunt catheters.

This study aims to review the imaging findings of distal (thoracic and abdominal) complications related to ventriculo-peritoneal (VP), ventriculo-pleural (VPL), and ventriculo-atrial (VA) cerebrospinal fluid (CSF) shunt catheter placement. Institution review board-approved single-center study of patients with thoracic and abdominal CSF catheter-related complications on cross-sectional imaging examinations over a 14-year period was performed. Clinical presentation, patient demographics, prior medical history, and subsequent surgical treatment were recorded. The presence or absence of CSF catheter-related infection and/or acute hydrocephalus on cross-sectional imaging was also recorded. There were 81 distal CSF catheter-related complications identified on 47 thoracic or abdominal imaging examinations in 30 patients (age 5-80 years, mean 39.3 years), most often on CT (CT = 42, MRI = 1, US = 4). Complications included 38 intraperitoneal and 11 extraperitoneal fluid collections. Extraperitoneal collections included nine abdominal wall subcutaneous (SC) pseudocysts associated with shunt migration and obesity, an intrapleural pseudocyst, and a breast pseudocyst. There were also two large VPL-related pleural effusions, a fractured catheter in the SC tissues, and a large VA shunt thrombus within the right atrium. Ten patients (33.3 %) had culture-positive infection from CSF or shunt catheter samples. Ten patients (33.3 %) had features of temporally related acute or worsening hydrocephalus on neuroimaging. In four of these patients, the detection of thoracic and abdominal complications on CT preceded and predicted the findings of acute hydrocephalus on cranial imaging. Thoracic and abdominal complications of CSF shunts, as can be identified on CT, include shunt infection and/or obstruction, may be both multiple and recurrent, and may be predictive of concurrent acute intracranial problems.