Cerebrospinal fluid shunt malfunctions: A reflective review

Poor Surgical Outcomes Following Paenibacillus Infant Infectious Hydrocephalus

Objective

We previously identified Paenibacillus species in the cerebrospinal fluid of 44% of infants presenting for neurosurgical evaluation with findings consistent with postinfectious hydrocephalus (PIH) in Eastern Uganda. Here we sought to compare outcomes among hydrocephalic infants with and without Paenibacillus detection at the time of hydrocephalus surgery.

Methods

In a prospective observational study, 78 infants with PIH who underwent a cerebrospinal fluid (CSF) diversion prior to 90 days of age had a positive CSF polymerase chain reaction result for Paenibacillus species (PP), and 111 had a negative result (PN). The primary outcome was diversion failure-free survival defined as being alive without diversion failure at last patient contact. Secondary outcomes included overall survival and diversion success.

Results

After a median follow-up period of 35.7 months, the primary outcome was observed in 42 PP patients (54%) and in 76 PN patients (68%) (adjusted hazard ratio (aHR), 2.45; 95% confidence interval [CI], 1.42 to 4.22; P=0.001). PP patients who underwent endoscopic diversion had the worst primary event rate (aHR, 6.47; 95% CI, 2.40 to 17.42; P<0.001). Death from any cause occurred in 16 PP patients (20%) and 9 PN patients (8%) (aHR, 3.47; 95% CI, 1.44 to 8.37; P=0.006). Diversion failure occurred in 28 PP patients (36%) and in 29 PN patients (26%) (aHR, 2.24; 95% CI, 1.31 to 3.85; P=0.003).

Conclusions

In this study, Paenibacillus detection in the CSF at the time of hydrocephalus surgery was associated with a significantly increased rate of the composite of diversion failure or death, death, and diversion failure, and was particularly increased for patients who had an endoscopic diversion.

Ventriculosagittal sinus shunt for treating hydrocephalus with elevated cerebrospinal fluid protein

This study aimed to investigate the feasibility, acceptability, and preliminary efficacy of a ventriculosagittal sinus (VSS) shunt in the treatment of hydrocephalus with elevated cerebrospinal fluid (CSF) protein content. In this single-center retrospective analysis, we enrolled 80 patients with hydrocephalus and elevated CSF protein levels. Based on these procedures, primary cohort was divided into two groups using CSF protein (CSFP) for subsequent analysis to determine the relationship between the clinical effect and CSFP. Preoperative and postoperative computer tomography (CT) scans, clinical symptoms, and CSF laboratory test were compared. Clinical records of 80 patients were analyzed; 44 patients received VSS shunt, 30 patients received ventriculoperitoneal (VP) shunt, and 6 patients received ventriculobladder (VB) shunt. The most significant changes in ventricular size in the VSS shunt group were detected on the 7th day postoperatively from the collected imaging data. Six months after shunt surgery, the overall success rate for VSS shunt (35 of 44, 79.5%) was markedly higher than that for VP shunt (12 of 30, 40%) and VB shunt (1 of 6, 16.7%). The VSS shunt has a positive clinical effect in hydrocephalus with abnormal CSF laboratory results (elevated protein levels), which is more significant than the clinical success rate of VP shunt in terms of both symptoms and imaging results. The degree of relief and improvement of imaging and symptoms were unrelated to the CSFP content. There was no significant difference in the efficacy of VSS shunt between the CSFP < 1.0 g/L group and the CSFP > 1.0 g/L group. No intracranial or extracranial complications related to the surgery were noted during follow-up. The VSS shunt should be considered the first-line treatment option in cases of hydrocephalus with elevated CSFP levels. Moreover, VSS shunt can immediately improve symptoms and alleviate hydrocephalus even though the CSFP was elevated.

Assessing the Quality of Life in Hydrocephalic Children: A Study from Tertiary Care Hospitals in Pakistan

BACKGROUND

Hydrocephalus is a neurological disease with higher prevalence in the pediatric population, often managed by placing a shunt. This hollow tube drains excess cerebrospinal fluid from the brain to other body parts, resulting in several complications, including neurological and psychometric manifestations and a compromised quality of life (QoL). This study aimed to evaluate QoL in patients with hydrocephalus shunt placement within the pediatric population.

METHODS

This prospective observational study was conducted in two major Pakistani tertiary care hospitals. A total of 100 subjects were enrolled, of which 52 were found eligible. A validated questionnaire, Hydrocephalus Outcome Questionnaire, was used to evaluate patients' QoL.

RESULTS

This study included pediatric patients with a mean age of 6.54 years and a standard deviation of ± 2.64. The male-to-female ratio was 27:25; 2% of patients had congenital or tumor-induced hydrocephalus, while cases of meningitis, encephalocele, and encephalitis accounted for 8, 4, and 2%, respectively. Myelomeningocele had the highest prevalence at 16%. The overall health scores range from 0.39 to 0.51. Social, cognitive, and physical health scores have mean values of 0.54, 0.50, and 0.48, respectively. The minimum physical health score is 0.17, indicating the most significant impact of hydrocephalus on physical function.

CONCLUSION

This study highlights variations in hydrocephalus severity among pediatric patients, impacting their overall QoL, primarily physical and behavioral functioning. Worse health outcomes were associated with frequent seizures, prolonged hospital stays for diagnosis and treatment, shunt infections, increased number of shunt catheters, and longer travel distances to medical facilities.

Spontaneous regression of migrated ventriculoperitoneal shunt catheter from scrotum to peritoneum: a case-based review

OBJECTIVE

The incidence of scrotal migration of a ventriculoperitoneal shunt (VPS) catheter is rare and may lead to life-threatening visceral complications. Management requires prompt removal of the migrated portion of the shunt and closure of the scrotal sac. We report an interesting case of a young child who presented with asymptomatic unilateral swelling of his scrotum secondary to a migrated VPS catheter. A repeat X-ray prior to his surgery to remove the migrated catheter showed that the entire length of the distal VPS catheter was back in the peritoneal cavity. In view of this unusual phenomenon, the case is discussed in corroboration with published literature.

METHODS AND RESULTS

A systematic search of publications in the English language is performed in PubMed and Google Scholar. Our findings show that there are 49 reported cases (including our patient) of scrotal migration of shunt catheters in patients less than 18 years old. There is only 1 other case of spontaneous resolution of shunt catheter from the scrotum. Favoured management of choice is repositioning the distal shunt catheter back into the peritoneal cavity and herniotomy in the same setting, if possible. Overall, the literature suggests this is a shunt-related complication that has a good prognosis if intervention is timely.

CONCLUSION

Scrotal migration of a VPS catheter is a rare but potentially life-threatening complication in children. Our case report highlights the role of updated preoperative imaging and the need for consistent long-term shunt surveillance in children.