Shunt System Research Articles

P.028 Surgical Treatment for Idiopathic Intracranial Hypertension – Strategy for the Better Management

Background: Idiopathic intracranial hypertension (IIH) is a condition of increased intracranial pressure in the absence of a space-occupying lesion. The goal of this study is to investigate which factors may influence outcomes in order to improve surgical strategy. We hypothesized diabetes, hypertension, smoking, and obesity influence patients prognosis. Methods: This retrospective chart review included patients diagnosed with IIH who underwent surgical intervention. All patients receiving surgery between 2008 and 2018 were included, and divided into 2 cohorts. Cohort 1 representing favorable course and cohort 2 representing unfavorable course. Favorable course was defined as requiring single surgery for management. Unfavorable course required multiple surgical revisions. Results: Overall, 35/48 (73%) comprised the favorable group. Thirteen patients (27%) comprised the unfavorable group. Of the unfavorable group, 54% had LP shunts, with the remaining receiving VP shunts. There was no association between type of shunt and outcome. Common issues the unfavorable group encountered were persisting symptoms, infections, obstruction of shunt and replacement of shunt. Smoking and frequent follow-up were associated with unfavorable course. Gender, BMI, age, comorbidities and shunt type were not associated with outcome. Conclusions: We found smoking and patient follow-up had a significant association with unfavorable outcome. Other factors had no association with patient outcome.

Systematic Review of Surgical Management of Spinal Intradural Arachnoid Cysts

Spinal intradural arachnoid cysts (SIACs) are rare pathological lesions that can arise via outpouchings of the arachnoid layer in the spinal canal that can result in neurological deficits. We performed a systematic literature review regarding the current surgical techniques used in the management of SIACs and discussed the prevailing hypotheses surrounding the etiology of SIACs. A systematic search of the literature was performed in December 2020 using EMBASE and MEDLINE for reports regarding the surgical management of SIACs. Data were collected regarding the demographics of the patients, classification system used, presence or absence of syrinxes, preoperative imaging modality, surgical approach and extent of resection, and postoperative outcomes and follow-up. Our search yielded 19 reports for inclusion in the present study. The 19 studies included a total of 414 cases, with an overall male/female ratio of 0.93:1. The most common site for the SIACs was the thoracic spinal cord at 77.5%. The symptoms were very similar across the 19 studies. Of the 19 studies, 15 had used resection to manage the SIACs, 10 had used fenestration or marsupialization, and 4 had used cystoarachnoid or cystoperitoneal shunts. SIACs are rare and debilitating spinal pathological lesions, with the etiology of primary SIACs still not fully elucidated. Multiple surgical approaches have been effective, with the optimal operative strategy largely dependent on the individual patient and cyst factors on a case-by-case basis.

Prevalence and Associated Factors of Malnutrition in Patients with Intracranial Infections at Sanglah Hospital Denpasar

Malnutrition is a major health problem in developing countries, it can occur acutely, chronically or combination of both. Malnutrition aggravates the condition of infectious diseases, including intracranial infections. Hereby we aimed to determine the prevalence and factors associated with malnutrition in pediatric patients with intracranial infections in Sanglah Central General Hospital. This cross-sectional analytic study was conducted in patients with final diagnosis intracranial infection whom were treated from January 2019 to March 2021. The study was conducted in pediatric patients aged 1 month-18 years old and patient would be excluded if had any of these conditions: 1) incomplete medical records, 2) discharge by his/her own request, 3) hydrocephalus for which VP shunt had not been performed, 4) diagnosis of tumor or mass that could affect body weight measurement. Secondary data such as weight/height for children <5 years and BMI/age for children >5 years were measured in growth curve by using the WHO Anthro application. Total samples were 83 children with predominance age group was 0-5 years old. Malnutrition was found in 48.1% patients. Chronic malnutrition was more common than acute malnutrition (32.5% vs. 31.3%). Age below 5 years has relationship with the incidence of acute malnutrition in pediatric patients with intracranial infection (p: 0.008, 95% CI: 0.076-0.675). The incidence of malnutrition in children with intracranial infections in Sanglah Hospital during January 2019 to March 2021 was 48.1%, and age < 5 years had significant relation to the incidence of malnutrition in children with intracranial infections.

Negative-Pressure Hydrocephalus Treated with a Modified Shunt System: A Case Report

Negative-Pressure Hydrocephalus Treated with a Modified Shunt System: A Case Report

Case of Endoscopic Surgical Treatment of Thoracic Arachnoid Cyst

Spinal arachnoid cysts are the benign intradural extramedullary lesions that usually occur at the thoracic region. Such cysts can cause compression of spinal cord with symptoms of myelopathy. The diagnosis is clinical and radiological with the use of MRI. Nowadays there are some surgical options to eliminate compression of spinal cord: laminectomy and total removal of the arachnoid cyst, puncture aspiration, cyst fenestration, cystoperitoneal shunting.

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

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

Single and Repeated Episodes of Candida Species Isolated From Cerebrospinal Fluid for Diagnosing Probable Candida meningitis.

Background: The clinical relevance of single or repeated episodes of Candida spp. in cerebrospinal fluid (CSF) in adult patients is debatable.Methods: Forty-two patients with positive Candida episodes in CSF were enrolled in this retrospective study.Results: A total of 42.9% (18/42) were determined to have probable Candida meningitis (PCM). Neurosurgery [odds ratio (OR) (95% confidence interval), OR: 14.4 (1.6–126.1), P = 0.004], lumbar drainage [OR: 5.8 (1.5–23.3), P = 0.009], VP shunt [(OR: 5.6 (1.2–25.8), P = 0.020)], external ventricular drainage [OR: 4.7 (1.3–17.7), P = 0.018], CRP ≥ 10.0 mg/L [OR: 4.9 (1.3–18.1), P = 0.034], and postsurgical broad-spectrum antibiotics [OR: 9.5 (1.8–50.5), P = 0.004] were risk factors associated with PCM. A single CSF Candida episode for the diagnosis of PCM had 7.7% (0.4–37.9%) sensitivity and 20.7% (8.7–40.3%) specificity, whereas repeated episodes of Candida had 66.7% (41.2–85.6%) sensitivity and 95.8% (76.9–99.8%) specificity. No significant difference was found in radiological imaging or CSF profiles between PCM and non-PCM patients. A total of 37.5% (9/24) of patients without PCM received empirical antifungal treatment, and 88.9% (16/18) of patients with PCM received preemptive antifungal treatment. PCM patients had hospitalized mortality rates of 50.0% (9/18). The odds ratio of mortality was 23.0 (2.5–208.6) for PCM patients compared with non-PCM patients (P = 0.001).Conclusion: Both single and repeated positive CSF samples have low validity for the diagnosis of PCM, suggesting that novel strategies for diagnosis algorithms of PCM are urgently needed. Empirical antifungal treatment should be started immediately for suspicious patients with risk factors.

Fetal therapy of LUTO (lower urinary tract obstruction) – a follow-up observational study

Purpose Fetal megacystis (MC) can be severe and is mainly caused by fetal lower urinary tract obstruction (LUTO). Mortality of fetal LUTO can be high as a result of pulmonary hypoplasia and/or (chronic) renal insufficiency. Several technical procedures for vesicoamniotic shunting (VAS) were developed to improve fetal MC outcomes. Material and methods We present the outcome of nine fetuses with MC who received VAS in the prenatal period (14 + 6 to 27 + 6 weeks GA) using the Somatex® intrauterine shunt system. MC was defined as an increased longitudinal measurement of the bladder >15 mm. The median follow-up time after birth was 18 months. Results Eight Fetuses had uncomplicated VAS intervention. One case developed PPROM 24 h after VAS leading to abortion. Pregnancy was later terminated in further two cases. All six live-born infants received intensive care treatment. Invasive-mechanical ventilation was necessary in one case who died 24 h post-partum of severe cardiac depression. Five infants who survived the follow-up time developed chronic renal insufficiency (CRI), with one infant developing end-stage renal failure requiring peritoneal dialysis. Conclusion Overall, 5 of 9 LUTO fetuses (55%) undergoing VAS with the Somatex® intrauterine shunt system showed long-term survival beyond the neonatal period of 28 d (5/9; 55%) with varying morbidity.

607 A Close Loop Audit on Proper Documentation of Ventriculo-Peritoneal (VP) Shunt Valve Settings in Operation Note

Abstract Aim Re-audit the practice of proper documentation of shunt type and settings in VP shunt surgery in Queen's Medical Centre, Nottingham for the period of 1st November 2019 – 31st October 2020. It is very important as programmable shunt setting could get changed during MRI, causing shunt failure. Method It was a retrospective collection of data of patients admitted to Queens medical Centre, Nottingham who had undergone VP shunt procedure. Exceptions: 4 files were excluded from study as they did not undergo VP shunt procedure. Results Total number of patients: 98. 4 patients were excluded. Actual sample size 94. Total VP shunt procedure done: 107. In 96 out of 107 procedures the shunt valve type and settings were properly documented. In 11 out of 107 procedures the shunt valve type and settings were not documented. In 33 out of 107 procedures programmable shunt valves were used. All 33 procedures had proper documentations. Previous audit result Duration of data collection: 2 years (from March 2016 to February 2018). Sample size 200. Total VP shunts done 247. Proper documentation of shunt valve type and settings were done in 209 out of 247 procedures. In 38 out of 247 procedures shunt valve type and settings were not documented. In 55 out of 247 procedures programmable shunt valves were used. 3 out of these 55 procedures (programmable shunt valves) lacked proper documentation. Conclusions There is an overall improvement in the practice of documentation of VP shunt valve type and settings in operative notes after implementing the plan of actions decided on first audit.

Complete intraventricular migration of ventriculoperitoneal shunt: A case report and review of literature

Abstract Ventriculoperitoneal shunt (VP shunt) is a commonly performed surgery for hydrocephalus, and like for any other surgery, complications are an inseparable part of this surgery as well. Here, we present a rare complication of VP shunt in a six-month-old child where complete shunt assembly had migrated into the lateral ventricle. Endoscopic retrieval of the migrated shunt with simultaneously endoscopic third ventriculostomy was performed. Operative steps for the procedure have been described. A detailed literature review of the migrated intraventricular shunt and its possible pathogenesis has been discussed.

ОДНОМОМЕНТНОЕ ВЫПОЛНЕНИЕ ЭНДОСКОПИЧЕСКОЙ ВЕНТРИКУЛОЦИСТЕРНОСТОМИИ ДНА III ЖЕЛУДОЧКА, АКВЕДУКТОПЛАСТИКИ, ФЕНЕСТРАЦИИ СУПРАЦЕРЕБЕЛЛЯРНОЙ КИСТЫ ПРИ ОККЛЮЗИОННОЙ ГИДРОЦЕФАЛИИ У РЕБЕНКА ПЕРВОГО МЕСЯЦА ЖИЗНИ

The article presents a clinical case of the simultaneous execution of endoscopic ventriculocisternostomy of the third ventricle floor (ETV), aqueductoplasty, fenestration of the supracerebellar cyst in occlusive hydrocephalus using a semi-rigid needle neuroendoscope. The authors describe a child who, at the age of 1 month, was admitted to Neurosurgical Department No. 1 of the Federal Center for Neurosurgery of the Ministry of Health of the Russian Federation in Tyumen with a diagnosis of congenital internal occlusive hydrocephalus, subcompensated course. MRI scan of the brain: triventricular occlusive asymmetric hydrocephalus is visualized, adhesions in the upper parts of the aqueduct, supracerebellar arachnoid cyst were visualised. ETV, aqueductoplasty, fenestration of the supracerebellar cyst were performed. There were no postoperative neurological, endocrine and infectious complications. The observation period after surgery is 7 years from today. Conclusion: preoperative MRI analysis of the structures of the third ventricular floor, interventricular and prepontine cisterns is important for understanding endoscopic, microsurgical anatomy and surgical planning. The use of modern improved endoscopic instruments, low-traumatic performance of all stages of the operation allow to restore cerebrospinal fluid circulation and achieve high efficiency in the treatment of occlusive hydrocephalus in the long-term period. This, in turn, relieves patients of the shunt-dependent state, constant correction of the dysfunctions of the shunt system and long-term, and often ineffective, treatment performed by neurologists and pediatricians.

Ventriculoperitoneal Shunt versus Endoscopic Third Ventriculostomy in the treatment of Obstructive Hydrocephalus in Pediatric Midline Posterior Fossa tumors

Abstract Background Treatment of secondary hydrocephalus due to posterior fossa tumors in these children is still a matter of controversy, although preoperative ventriculo-peritoneal shunt (VP shunt) insertion before tumor excision is widely accepted among neurosurgeons but many attempts are rising to minimize permanent VP shunt insertion and associated complications and introducing third endoscopic ventriculostomy (ETV) as one of the options of 2ry hydrocephalus. Objectives Comparing the post-operative clinical success with resolution of the manifestations and post-operative complications between endoscopic third ventriculostomy and ventriculoperitoneal shunt as different modes of CSF diversion in children with 2ry hydrocephalus due to midline posterior fossa tumors. Methods The following electronic databases were searched from June 2009 to june2019: PubMed, Google scholar search engine. Cochrane database of systematic reviews, EMBASE and science Direct, using the keywords ―hydrocephalus; posterior fossa tumors; pediatrics; ventriculoperitoneal shunt; endoscopic third ventriculostomy‖. Studies were eligible if they contain the target keywords in title or abstract, addressing the Pediatric age group with 2ry hydrocephalus due to de novo posterior fossa tumor manifested by signs of increase the intra cranial tension including persistent headache and vomiting, blurred vision, 6th nerve palsy, papilledema in fundus examination, acute DCL and 2ry hydrocephalus confirmed by brain imaging. Exclusion criteria included studies including age group below 1yr or above 18 yr, or patients with recurrent post fossa tumors and operated before or patients presented by failed previously attempt of CSF diversion. Results: A total of 1255 citations were screened for eligibility,6 studies were included in our systematic review discussing, comparing and evaluating the durability of ETV versus VP shunt in treatment the 2ry hydrocephalusdue to pediatric posterior fossa tumor.. Overall study population reached 474 patients. the overall clinical findings at presentation and postoperative outcomes regarding the clinical findings improvement, radiological improvement and postoperative complications between ETV and VP shunt are compared and showing that ETV should be considered as an alternative procedure to VP shunt in controlling severe hydrocephalus related to posterior fossa tumors to relieve symptoms quickly during the preoperative period when patients should wait for their definite tumor excision. Conclusion The shorter duration of surgery, the lower incidence of morbidity, the absence of mortality, the lower incidence of procedure failure of endoscopic third ventriculostomy as compared to ventriculoperitoneal shunt, and the significant advantage of not becoming shunt dependent make endoscopic third ventriculostomy to be recommended as the first choice in the treatment of pediatric patients with marked obstructive hydrocephalus due to posterior fossa tumors. It is a preliminary, simple, safe, effective, physiological, minimally invasive procedure for the relief of elevated intracranial pressure before direct tumor removal.

Outcome Comparison of Endoscopic Third Ventriculostomy versus Ventriculoperitoneal Shunt in Obstructive Hydrocephalus

Background and Objectives: To assess the outcome of Endoscopic Third Ventriculostomy (ETV) versus Ventriculoperitoneal Shunt (VPS) in Obstructive Hydrocephalus in terms of infections, foreign bodies, cost-effectiveness, and length of hospital stay.&#x0D; Materials and Methods: It was a Randomized Controlled Trial study, in which 30 patients with Obstructive Hydrocephalus were divided into two groups one was treated with (ETV) and the other was treated with VP Shunt and the patients were followed up for 1 year.&#x0D; Results: Patients were divided into 2 groups, 15 were treated with ETV, and 15 were treated with VP Shunt. Length of stay for VP shunt was 7 ± 0.85 days and for ETV mean stay was 2.93 ± 1.1 days. The complication was observed in 4 (26.7%) treated with VP Shunt and in 3 (20%) patients with Endoscopic Third Ventriculostomy. In ETV, 3 (20%) patients had recurrence whereas in VP shunt in 1 (6.67%) had an infection and in 3 (20%) patients had recurrence (upper-end blockage) and the overall success rate was 76% in both the procedures and in VP Shunt 73.3% and ETV 80%. Overall there were no complications found in 23 (76.6%) patients, in 3 (10%) patient’s complications were found at 1st month, in 3 (10%) complications were observed at 3rd month, and in 1(3.3%) complication was recorded at 6th month.&#x0D; Conclusion: ETV was found better in terms of length of hospital stay, cost-effectiveness as well as minimal complication rate as compared to VP shunt.

Pioneer shunt implantation surgery in Brazil

One of the first experiences of shunt implantation in the world occurred in 1949, by Nulsen and Spitz, who implanted a rubber catheter with a ball valve system, from the lateral ventricle to the internal jugular vein [1]. In the 1950s, the shunt systems had great development, especially the Spitz-Holter system, first used in 1956, consisting of the first system produced on a large scale. The second patient who benefited from this new system was Holter's son Casey, who had myelomeningocele [2,3]. From these first American reports, the shunt surgery had great worldwide dissemination in the 1960s. One of the first CSF shunts in Brazil and Latin America occurred in 1966, in the city of Uberaba, Minas Gerais, by Prof. Francisco Mauro Guerra Terra, founder of the Chair of Neurosurgery at Triângulo Mineiro Medical School, today part of Federal University of Triângulo Mineiro (UFTM). The procedure was performed at the Children's Hospital of Uberaba, at the time one of University Hospitals, and the patient was a 7-month-old baby named Maria Beatriz. The child suffered from hydrocephalus, as a complication of tuberculous meningitis, and was diagnosed by pneumoventriculography, a procedure described by Dandy, and widely used in the era before tomography [4] (Fig. 1). The child was submitted to a ventriculo-atrial shunt (Figs. 2, 3 and 4), with implantation of a catheter without a valve, an option widely used at the time. Besides Prof. Guerra, the surgical team was composed by the then medical students Jaime Olavo Marquez, later titular of the Neurology Department of UFTM, Antônio Luiz da Costa Sobrinho, later a neurosurgeon, who later settled in Presidente Prudente, São Paulo, Brazil Carlos Antunes de Paula, also later a neurosurgeon, who settled in the city of Santos, São Paulo, Brazil and the anesthesiologist Dr. Newton Camargo Araújo, from Uberaba (Fig. 5). There is a postoperative image of the case, showing the success of the procedure (Fig. 6). The surgery had great repercussion in the national media at the time (Fig. 7).

Rapid closure technique in suboccipital decompression

ObjectiveSuboccipital decompression has been established as standard therapeutic procedure for raised intracranial pressure caused by mass-effect associated pathologies in posterior fossa. Several different surgical techniques of dural closure have been postulated to achieve safe decompression. The aim of this study was to examine the differences between fibrin sealant patch (FSP) and dural reconstruction (DR) in suboccipital decompression for acute mass-effect lesions.MethodsWe retrospectively analyzed our institutional data of patients who underwent suboccipital decompression due to spontaneous intracerebellar hemorrhage, cerebellar infarction and acute traumatic subdural hematoma between 2010 and 2019. Two different dural reconstruction techniques were performed according to the attending neurosurgeon: (1) fibrin sealant patch (FSP), and (2) dural reconstruction (DR) including the use of dural patch. Complications, operative time, functional outcome and the necessity of a ventriculoperitoneal shunt (VP Shunt) were assessed and further analyzed.ResultsOverall, 87 patients were treated at the authors’ institution (44 in FSP group, 43 in DR group). Glasgow coma scale on admission and preoperative coagulation state did not differ between the groups. Postoperatively, we found no difference in cerebrospinal fluid leakage or chronic hydrocephalus between the groups (p = 0.47). Revision rates were 2.27% (1/44 patients) in the FSP group, compared to 16.27% (7/43) in the DR group (p < 0.023). Operative time was significantly shorter in the FSP group (90.3 ± 31.0 min vs. 199.0 ± 48.8 min, p < 0.0001).ConclusionRapid closure technique in suboccipital decompression is feasible and safe. Operative time is hereby reduced, without increasing complication rates.

Case Report on: Dandy Walker Malformation Syndrome

Introduction: Dandy Walker Syndrome is a congenital brain malformation that affects the cerebellum and the fluid filled areas that accompany it. The cerebellum is a part of the brain that deals with movement coordination as well as cognition and behavior.&#x0D; Case Presentation: The male patient 8 year old who was apparently admitted in A.V.B.R.H on 18/8/2019 is diagnosed with a known case of dandy walker malformation and came with the complaints of headache since 4 days, fever since 3 days, vomiting since 5 days and 3 episodes of seizures. All the necessary blood investigations has been done. The CT scan as well as MRI reports has shown that large posterior fossa cyst with open communication with fourth ventricle with hypoplastic left cerebellar hemisphere and no visualized cerebellar vermis. Before taking this case, information was given to the patients and their relatives and Informed consent was obtained from patient as well as relatives.&#x0D; Therapeutic Intervention: The patient was treated with NSAIDS, antibiotics, anticonvulsant, antiemetic and antacid and physical therapy to help keep muscle strength and flexibility The patient underwent VP shunt head circumference assessed regularly, vital signs hourly, provided vitamins enriched diet as per dietician’s order assisted dressing for drainage and physical therapy. Conclusion: The patient was admitted in A.V.B.R.H in a critical condition with the diagnosis of dandy walker syndrome, after providing the required treatment by the health care team members of hospital the patient condition was improved and satisfactory.

Improving the detection of ventricular shunt disruption using volume-rendered three-dimensional head computed tomography

Hydrocephalus is the most common neurosurgical disorder in children, and cerebrospinal fluid (CSF) diversion with shunt placement is the most commonly performed pediatric neurosurgical procedure. CT is frequently used to evaluate children with suspected CSF shunt malfunction to assess change in ventricular size. Moreover, careful review of the CT images is important to confirm the integrity of the imaged portions of the shunt system. Subtle shunt disruptions can be missed on multiplanar two-dimensional (2-D) CT images, especially when the disruption lies in the plane of imaging. The use of volume-rendered CT images enables radiologists to view the extracranial shunt tubing within the field of view as a three-dimensional (3-D) object. This allows for a rapid and intuitive method of assessing the integrity of the extracranial shunt tubing. The purpose of this pictorial essay is to discuss how volume-rendered CT images can be generated to evaluate CSF shunts in the pediatric population and to provide several examples of their utility in diagnosing shunt disruption. We also address the potential pitfalls of this technique and ways to avoid them.

Endoscopic management of periventricular and intraventricular arachnoid cysts

IntroductionThe most successful surgical management of periventricular and intraventricular cysts is still a matter of debate. Up to the early 1990s, open cyst fenestration and cystoperitoneal shunts were the only options available. Recently, different endoscopic approaches to these lesions have gained popularity.MethodsEighteen endoscopic procedures were performed for the treatment of arachnoid cysts in 18 patients. Sylvian fissure arachnoid cysts were excluded from this study. Ten of them were females and eight were males with their ages ranging from 6 months to 50 years with a mean of 16 years. All patients were prospectively observed.ResultsSeven of the arachnoid cysts were in the suprasellar region, 5 in the quadrigeminal region, 2 in the posterior fossa, 2 parietal, and 2 intraventricular. Seventeen cases (94%) had hydrocephalus. The main presenting manifestations were those of increased intracranial pressure. All fenestrations were done in the lateral ventricle except for the 2 cases with posterior fossa arachnoid cysts, the fenestrations were done to the fourth ventricle. Endoscopic ventriculocytostomies (VC) were performed in 14 cases without operative complications and no stents were placed. Endoscopic cystocisternostomies (C) were done in all suprasellar cases. Endoscopic cystoventriculostomies (CV) were done in 4 cases. The mean surgical time was 1 h. The mean follow-up period was 15 months. Symptoms improved in 17 cases. Seventeen cases demonstrated a significant decrease of the cysts’ size in the postoperative computed tomography (CT) and magnetic resonance imaging (MRI). A single case developed a complication in the form of subdural hygroma which required no intervention and was managed conservatively.ConclusionEndoscopic management of periventricular and intraventricular arachnoid cysts is a useful safe option in the management of arachnoid cysts related to the ventricular system.

Cerebral Salt Wasting Syndrome: A Complication of Meningitis in Hydrocephalus with VP Shunt:

Cerebral salt wasting syndrome (CSWS) is an important cause of persistent hyponatremia in children admitted to the intensive care unit. It needs to be promptly differentiated from the syndrome of inappropriate antidiuretic hormone (SIADH) secretion as a cause of hyponatremia in pediatric neurological patients. These two entities often have similar presenting symptoms however the treatment of both can be drastically different, which makes the distinction critical. We present a 6-month-old male child with hydrocephalus secondary to aqueductal stenosis, a blocked VP shunt, meningitis, and hyponatremia. A diagnosis of CSWS was considered and fludrocortisone was started. The patient improved gradually with a reduction in urine output and a gradual increase in serum sodium levels. A diagnosis of CSWS should be strongly considered in hyponatremic pediatric patients with significant natriuresis and suitable treatment should be initiated promptly to prevent long-term neurologic sequelae.

Trans-anal protrusion of the distal end of ventriculo-peritoneal (VP) shunt – The role of ommaya shunt

Transanal protrusion of the distal end of ventriculoperitoneal shunt is an extremely rare complication associated with this procedure. Such complication only reported once in Malaysia since 1987. Instead of usual external ventricular drain (EVD) insertion as temporary CSF diversion post VP shunt removal, does Ommaya shunt play a better role in this? This unfortunate boy had undergone a right VP shunt due to communicating hydrocephalus secondary to bilateral intraventricular haemorrhage at 7 months old. He then experienced transanal VP shunt protrusion five months following the surgery. Apart from a literature review on the diagnosis and treatment for this rare complication, we further discuss the role of ommaya shunt as compared to usual EVD insertion. Early detection and prompt management are warranted to prevent further devastating damage from such complication. Although this single Case showed a favourable result, more studies are required to confirm the role of the Ommaya shunt.