Active singling out of shunt independence

Shunt Fractures Associated with Intermittent Hydrocephalus: Case Reviews and New Solutions

OBJECTIVE

Although ventriculoperitoneal shunt surgery is the most common method for hydrocephalus treatment, it may lead to serious complications and require surgical interventions. Peritoneal catheter fracture is one of the common complications that may cause intermittent hydrocephalus. If patients with peritoneal catheter fracture have symptoms of hydrocephalus and ventricular dilatation, the treatment algorithm is clear. However, the diagnosis and treatment protocol remains unclear otherwise. In this article, the possible mechanisms of hydrocephalic symptoms, the diagnosis, as well as treatment algorithms are examined.

METHODS

Eight patients with a ventriculoperitoneal shunt who had intermittent hydrocephalic symptoms due to peritoneal catheter fracture but without any radiologically significant ventricular dilatation at Niğde Ömer Halisdemir University from 2018 to 2021 were collected. A new diagnostic algorithm was created. Patient follow-up was performed in each patient as a procedure.

RESULTS

The method that we determined was successful in all our patients. No complications were observed. We have followed the patients with a normal clinic for at least 6 months.

CONCLUSIONS

The provocation test we have formulated always revealed the true cause of the clinic. Thus, on the one hand, with a positive provocation test we recommend revision surgery without waiting for the ventricular dilatation or hydrocephalic symptoms in patients with a fractured peritoneal catheter, considering the results of asymptomatic shunt revision surgery have been reported to be better than those with symptomatic shunt dysfunction; on the other hand, patients with negative provocation tests are saved from unnecessary surgical intervention as well as benefit from true etiologic fast treatment.

Ventriculoperitoneal shunt malfunction caused by fractures and disconnections over 10 years of follow-up

PURPOSE

We have discussed the diagnosis and treatment approaches in patients with discontinued (disconnected or fractured) ventriculoperitoneal (VP) shunts that caused mechanical dysfunction.

METHODS

Between 2006 and 2016, VP shunt surgery was performed on 1357 pediatric patients in our clinic. In follow-up examinations, we retrospectively reviewed patients who underwent revision surgery. Except for diagnosis of discontinued VP shunt, by excluding revision-surgery patients, only those patients who underwent surgical treatment owing to discontinued (fracture or disconnection) catheter were included in the study. Age at first surgery, sex, reason for shunt discontinuity, anatomical region of pathology, time to discontinuity diagnosis after first surgery, and presence or absence of symptoms were evaluated.

RESULTS

One thousand three hundred fifty-seven VP shunt surgeries were performed in total, with 305 (22.4%) patients requiring revision surgery. Of these 305 patients, after accounting for other complications like obstruction, infection, overdrainage, and so on, 25 (8.1%) patients (14 male, 11 female) required re-surgery due to discontinuity. The mean age of these patients was 5.4 ± 2.1 months during the first VP shunt surgery, and the mean age during revision surgery was 71.7 months. The mean duration until discontinuity was diagnosed was 66.3 ± 24.1 months (76.1 months for catheter fractures and 45.6 months for disconnections (p 0.021)).

CONCLUSION

Disconnection and fracture are two significant mechanical VP shunt dysfunctions and must be adequately researched and understood even during routine follow-ups. A disconnected or fractured shunt may be working and it is not safe to state that the shunt is no longer needed.

Pediatric hydrocephalus outcomes: a review

The outcome of pediatric hydrocephalus, including surgical complications, neurological sequelae and academic achievement, has been the matter of many studies. However, much uncertainty remains, regarding the very long-term and social outcome, and the determinants of complications and clinical outcome. In this paper, we review the different facets of outcome, including surgical outcome (shunt failure, infection and independence, and complications of endoscopy), clinical outcome (neurological, sensory, cognitive sequels, epilepsy), schooling and social integration. We then provide a brief review of the English-language literature and highlighting selected studies that provide information on the outcome and sequelae of pediatric hydrocephalus, and the impact of predictive variables on outcome. Mortality caused by hydrocephalus and its treatments is between 0 and 3%, depending on the duration of follow-up. Shunt event-free survival (EFS) is about 70% at one year and 40% at ten years. The EFS after endoscopic third ventriculostomy (ETV) appears better but likely benefits from selection bias and long-term figures are not available. Shunt infection affects between 5 and 8% of surgeries, and 15 to 30% of patients according to the duration of follow-up. Shunt independence can be achieved in 3 to 9% of patients, but the definition of this varies. Broad variations in the prevalence of cognitive sequelae, affecting 12 to 50% of children, and difficulties at school, affecting between 20 and 60%, attest of disparities among studies in their clinical evaluation. Epilepsy, affecting 6 to 30% of patients, has a serious impact on outcome. In adulthood, social integration is poor in a substantial number of patients but data are sparse. Few controlled prospective studies exist regarding hydrocephalus outcomes; in their absence, largely retrospective studies must be used to evaluate the long-term consequences of hydrocephalus and its treatments. This review aims to help to establish the current state of knowledge and to identify conflicting data and unanswered questions, in order to direct future studies.

Intelligent shunt agent for gradual shunt removal

When passive shunts, which divert cerebrospinal fluid (CSF) from the ventricles in the brain to another part of the body, were developed, apparently they change favourably the treatment of hydrocephalus, then it becomes of great importance to overcome the drawbacks of such shunts, and the gradual rising use of various shunts are accompanied by total shunt dependency with several problems and shortcomings has understandably become obvious among physicians as well as surgeons to rehabilitate and upgrade these shunts. There is a little use of carrying out arrested hydrocephalus which is subject to many aspects, ranging from problems of immediate clinical concern to the more unknowable areas of cerebrospinal fluid CSF dynamics, and it is not always as easy to define indications for arrested hydrocephalus or to evaluate the results of such treatment. However, it is important to attempt to define as precisely as possible a technique to measure the ability of arresting hydrocephalus, while current solutions estimations are based on long time procedure, evaluate parameters such as head growth, or ventricle sizes using CT or MRI scan. This paper proposes a new treatment approach and shunting system that helps improving diagnosis and treatment of Hydrocephalus patients. This approach suggests a developing and utilising an intelligent shunt agent (i-Shunt) that can learn from the patient's status and initiate a weaning program, and based on the response evaluation, the parameters of the shunt can be modified to accommodate the patient's needs. Therefore, a novel shunt could be build to satisfy the patient's need instantaneously by keeping the intracranial pressure (ICP) within normal levels, where it is actually directed toward shunt independency.